Diabetes & Endocrine ECHO: Continuous Glucose Monitoring, Part 1 – 7/20/17
Good morning everybody, I want to get started. This is the first, this will be the first of four sessions that Veronica will be leading, to- Can everybody hear me, okay? Okay. to familiarize everyone, and hopefully encourage more of you to consider using continuous glucose monitoring for your patients. We really think this is a great tool that has broad applicability and is very, very doable. And we’re hoping that by doing this in kind of a different way from the way we’ve done things, we can really you know, get you comfortable with the idea of adopting this in your practices. So before we do that I just thought maybe we would go around and make sure we know who everyone is, because there are some names that are unfamiliar, and I just want everybody who’s on board today, to know what everybody else is so, David Cummings, do you want to just say hello if you’re there? Hello. Okay good, so you can follow instructions. (laughter) So, who are you and where are you? Say again? Tell us who you are, where you are, what your role is. All right, I’m a rural family medicine PGY2 in Winnemucca. Great, thank you. Dean Elin. Hi. I am a PA at the (inaudible) clinic, part of (inaudible). Are you hearing us okay? Because your audio is breaking up. Yes, I am hearing you fine. Okay, great. We have Reno-Sparks. (inaudible) Okay. We have Community Health Alliance in Sparks on board Dr. Van Guilder is with us. We have Community Health, Alliance other locations. Jan Boyer. And anyone else? The Center for Complex Care. Okay. Good morning gang. And we’ve got William Bee Ririe, in Ely. Okay. Alright. So, As Dr. Klass said, we are going to do a deeper dive into continuous glucose monitoring. I presented briefly, I think it was last year or the year before, it’s all starting to blur now, but on continuous glucose monitoring. So today we’re going to start out by talking about the first in this four part series. And just by a show of hands, if you’ve got your video on, How many of you are currently using continuous glucose monitoring? I see no hands. So, we got one? One out there, okay, so Janice. So when we talk about continuous glucose monitoring, what we’re going to talk about today is, what is CGM, and personal versus the professional. And then in our second series we’re going to talk about identification of the appropriate candidates for the CGM. Part three is interpretation of the data, and then part four is going to be billing and coding, cost, return on investment, and those types of things. The objectives today, we’re going to define continuous glucose monitoring for you, and kind of go through and identify the different types, and talk about them in some detail. So, continuous glucose monitoring. The first thing that I would do, that they tell you not to do, and that’s read your slide. So, it’s a sensor composed of a microelectrode coated with glucose oxidase beneath a biocompatible membrane, which converts glucose in the interstitial fluid into an electrical signal proportional to the amount of glucose present. So, it’s a glucose detector implanted underneath the skin. So It provides blood glucose readings every 5 minutes, so you get 288 readings a day. Noting that there is, indeed, a lag time of about 5 minutes. It does require -one of them in particular- requires calibration at least every 12 hours. There is another that doesn’t require any calibration, And we’ll get into some of those finer details. And I’ve bolded and put in red for you because it’s only accurate for blood glucosees 40 to 400. And I find that important to say because most recently, I had a patient whose glucose has dropped to 29 and they insisted on trying to enter this blood glucose value into the transmit- the receiver. It will not accept blood glucose values less than 40 or greater than 400. So, if your patient’s blood glucoses are running 500, they cannot calibrate their devices. So between 40 and 400, it will allow you to calibrate. When you can outside that realm, it does not allow. They have to wait until their blood glucoses come up or down in order to enter a calibration number. So CGM at a glance, as you can see here, this is the Medtronic device. That’s not what I’m trying to do. Sorry. So the top one is the Medtronic device, and you see the transmitter, which is sitting on top of the skin. This device has a catheter that is about 9 to 12 millimeters, that sits in the interstitial fluid. And as you can see, it’s sitting in the interstitial fluid, not in the blood vessel. The bottom picture is that of-, I can use it now? Oh okay. So the bottom picture is that of the, the FreeStyle Libre device. It has a much shorter catheter, which is only 5 millimeters. So this one, for people who are thin, this is usually your better device choice. So again, it sits in the interstitial fluid, wicking in that fluid every five minutes to record a blood glucose value. So when we think about CGM, it’s been out there since 1999, and it started with the GlucoWatch. And I don’t know if any of you are familiar with the GlucoWatch. But it was a sensor that was worn on the wrist, and it did check blood sugars every five minutes, But the problem was that patients came away with a lot of bruising and discomfort from that constant probe. So that was discontinued, and currently we have several devices on the market. DexCom has two devices, the G4 Platinum, the G5, and then next year will be their G6 device. Medtronic has the Guardian REAL-Time device, the Paradigm REAL-Time, the 530G with the Enlite, and most recently they have the 630G, as well as the 670G. And then new to the market, is the FreeStyle Libre Pro. And we’ll talk about those in a little bit more detail. The two categories of the devices are your professional, which is the Medtronic iPro2, The FreeStyle Libre, or the DexCom G4 Platinum. Or you can get a personal device. So when we talk about the differences between the professional and the personal CGM, primarily today, we’re going to talk most about the professional CGM. And this is the monitor and device that is owned by the practice, and you use it for clinical decision making. It’s usually used on an intermittent basis. And we’ll talk about billing and coding, but most insurance companies will allow you to place a center on a patient every three months, in order to find out if the changes that you’ve made in their therapy have been effective. So it’s just used on an intermittent basis. It serves as a teaching tool, and can be blinded or unblinded. It used best as a teaching tool in the unblinded mode, but it can also be effective in the blinded mode. For the personal CGMs, these are owned by the patient. And the patient uses them to detect high or low blood glucose levels, with alerts, and bells and whistles that alert them to the fact that they’re having difficulties with their glucoses, It gives them immediate feedback in regards to taking their medications, their food, their activities, and it is an ideal tool for behavior modification in patients who are having some difficulties getting to goal. And it can be used with or without an insulin pump. So when we talk about the professional device, we have the Medtronic iPro2, the FreeStyle Libre, and the DexCom G4. These are the devices that are blinded. So the patient does not get to see what their blood glucose readings are, and there are no alarms or warnings. This is the Retrospective data, that once you remove the device from the patient, you bring them back into the clinic and you review it with them at that time. The only unblinded device on the market currently, is the DexCom G4. So with the DexCom G4, you place in on the patient, and the patient gets to look at those readings, see what’s happening in regards to their blood glucose control, and make immediate changes based on whether they’re running high or low, and there are alarms and warnings that you can set on the device for the patient. (cough) Excuse me. So that’s my slide saying the same thing over. But one of the most important things to think about, I don’t know how many of you work in a pediatric practice, but most of these devices have been tested and available for use in folks over the age of 7 years of age, for the iPro2, and over 18 years of age for the professional CGM. We do some off-label use of the devices, but these are what the FDA has approved them for. (silence) That one’s not my best slide, so I’m going to skip past it. (laughter) So, when we talk about the DexCom G4, were going to talk about that one first. So it comes with three parts. And when you are talking with your patients about it, one of the things that usually gets the patient’s most, is when they look at this sensor over here, and you show them the sensor, and it looks like a huge and complex apparatus. It’s not that intimidating, and I’m going to show you a video about how it’s inserted. So it has to have these three parts with it. You need a sensor, you need your receiver, and you need your transmitter. So, all of those in the practice, what I usually do with my patients is I put them all together in one container, So that when they are using my device, it’s in a big bulky container and it makes it hard for people to kind of escape with it. But you do need all three of these in order to set your patient up on the continuous glucose monitor. For the Medtronic, It’s inserter is a little bit more intimidating. And one of the issues that we’ve had with this one in the past, is that sometimes you can’t get that sensor inserted just right on the first try. So it takes, maybe two tries to get it inserted properly. It also requires a receiver with it, and for the receivers, they need to be within 20 feet of the patient. If they are greater than 20 feet away from the patient they will not report any information. And the problems with the Medtronic device and the DexCom G4, is that even when the patient comes back into the realm of their transmitter or the receiver, It will not retrospectively bring the data back into the device. However, with the newer devices that are coming out, this will no longer be an issue. So if they go away from their receiver for an hour or so, when they come back to within range of the receiver, it will pick up the retrospective data. So I’m kind of looking forward to that one. For the Dexcom, that receiver needs to be charged every 72 hours. I usually tell my patients to plug it in every night, because I don’t want to run the risk of the receiver not holding a charge. For the Medtronic, it does need to be placed back on its base usually every six days, in order for it to be recharged. The freeStyle Libre Pro comes with all the parts that you see here. And as I said, it is the newest device to the market. So what you see for the FreeStyle Libre, you see a little more in the other picture. This is the introducer here, the actual transmitter is in this container. And then the meter is the activation device. And the beautiful thing about this particular device, is that it takes about 2 minutes for it to come online and begin to record blood glucose readings. And I have a slide that will show the various ones, But the DexCom takes about two hours to begin. It had a two hour warmup period before it will actually start to record any blood glucose readings for you, whereas this one will start for you in about two minutes. (silence) So with the FreeStyle Libre, as I said, It’s got a much smaller catheter on it. And as you can see on the screen here, when you’re ready, once you have placed the catheter, it’s a simple matter of pressing this start new sensor button, and it will say, are you ready to activate a new sensor? You tap the “yes” that appears on the screen, It tells you you need a two minute warm-up, so you sit and talk to the patient for two minutes, you wave your magic wand over the sensor, and it activates it. And the patient is good to go. (silence) So the beauty of the sensors is in placement. The thing that I enjoy, about the FreeStyle Libre is that it is placed on the back of the arm, and that is the only place that it is recommended for use by the FDA. It must be the back of the arm. It is not recommended for abdomen and thighs, and all the wonderful things that you see people doing on the YouTube videos. It is arm only. The other sensors, the DexCom G4 and the Medtronic device, are recommended for placement on the abdomen. What you will find a lot of times, is that patients will watch the YouTube video and see that they can place their DexCom and their Medtronic on their arms, on their sides, on the back of their hip, it does transmit in all of those places, but the FDA recommendations are for abdomen only. So when we are placing them in clinic, it is abdomen only. And the usual question that I get, and I’m going to pause and answer here now, is in regards to pregnant women. We know that continuous glucose monitoring is valuable in pregnant women, and one of the women that I went to place a sensor on said to me, well, it’s going to touch my baby. I was like, well, you know, your baby’s got a lot of distance between the sensor and the uterine sack. So what we usually do for pregnant women though, we are lower abdomen only. It’s not up on top, lower abdomen only. And If they have personal sensors that they are going to use in pregnancy, I usually recommend thighs. Because we know that that is safer if they’re doing a whole lot of pressing, and having some difficulty with insertion. We recommend thighs. (silence) So, I’m going to show you a quick video. Insertion of the DexCom G5, (Video Begins) It’s time to learn how to insert a new sensor. After completing this step, you will have chosen a placement site for your sensor, inserted your sensor, attached your transmitter, learned the options for skin preparation or adhesive products. Before starting this process, you should have a sensor applicator, your transmitter, alcohol wipes, and skin preparation or adhesive products if needed. For example, Skintack or Mastisol ready to go. Your first sensor insertion may not feel natural, but once you have done it once or twice, it should become more familiar. The process of inserting the sensor is as follows: on the applicator barrel, the white plunger inserts the introducer needle and sensor under your skin. When the collar is pulled back completely, the introducer needle is removed, and the tiny flexible sensor remains under your skin. First, wash your hands with soap and water before opening the sensor package. After opening the package, avoid touching the adhesive area. Next, choose a sensor placement site on your belly. An alternative for users aged 2 through 17, is the upper buttocks. No other sensor insertion sites have been tested. When you choose which site to place your sensor, here are a few things to keep in mind. The best areas to insert your sensor are usually flat and pinchable. The placement site should be out of the way of your waistband. Avoid areas that are likely to be bumped, pushed, or pressed against, or areas of your skin with scarring, tattoos, or irritation. Place the sensor at least three inches away from your insulin pump infusion set or injection site. Make sure there are no traces of lotions, perfumes, or medications on the skin where you place the sensor. Change the site where you place your sensor with each new sensor. The ideal sensor insertion site for you may be based on your body type, activity, sensitivities, and other personal traits. For more help on choosing the ideal sensor insertion sites for you, contact your health care provider. (silence) Once you have chosen your site to place your sensor, you’ll then clean the placement site on your body with alcohol, and let it dry. To help the sensor stick to your body, you can also use skin preparation or adhesive products. For example, Skintack or Mastisol. These products are optional, and should be used prior to inserting your sensor on your body. If you choose to use a skin preparation or adhesive product, place it on the skin in a doughnut shape, where you will place the sensor adhesive patch. The center area of the doughnut should be free of skin preparation or adhesive products, and is where you will insert your sensor. Let the skin preparation or adhesive product dry before inserting your sensor. Once the placement site is clean and the optional skin preparation or adhesive product has been placed on your skin and dry, remove the adhesive tabs from the bottom of the sensor pod. (silence) Place the sensor horizontally on the placement site on your body, not vertically. Rotate your fingers around the adhesive to secure the adhesive tape to the body. Remove the safety lock by pulling straight out. Save the safety lock, as you’ll be using it to remove your transmitter from your sensor after your sensor session is done. Using the thumb and forefinger on your non-dominant hand, you may want to pinch up on the tips of the white adhesive on your skin at the base of the sensor pod. With your dominant hand, place two fingers above the sensor application collar. Put your thumb on the plunger, and push down completely. You should hear two clicks. Using your thumb as a base, move your fingers from above the collar to below the collar, and pull the collar up completely towards your thumb, until you hear two clicks or cannot pull back any more. You might feel pressure as you pull back the collar, but continue to pull it back completely as shown. While still holding the sensor applicator, use your other hand to squeeze the rib tabs on the sides of the sensor pod. Rock the sensor applicator forward and out, away from your body. Once your sensor has been inserted, it’s time to attach the transmitter. First, if you haven’t already done so, clean your transmitter with an alcohol wipe and let it dry. Once it’s dry, place your transmitter into the sensor pod flat side down, thinner side away from the transmitter latch. With one hand, you may want to pinch up on your skin at the front tips of the white adhesive. Use a finger to hold the transmitter in place, with your other hand, move the transmitter latch forward until you hear two clicks. This may take some force. To remove the transmitter latch, hold the sides of the sensor pod with one hand, and the transmitter latch with the other. Twist off the latch. Your sensor insertion is now complete. You are now ready to go on to the next step. (silence) So the sensor insertion, I like that to clicks, so everything comes in twos. And I will tell you, most patients will give you that funny face when you go to push down on the plunger, because it is- It does pinch quite a bit. I inserted one for myself. Just because I wanted to see how it was. Yeah, it smarts just a wee bit. And then the other piece that’s a little bit difficult, when you go to sit down the transmitter into that face, you really do have to apply quite a bit of pressure, And sometimes that feels like, “Eh this may not be going very well”, but it does take quite a bit of pressure, and there must be the two clicks. Because if the transmitter is not seated properly, you will not get communication with your receiver. So it has to be fully seated or it will not respond. So once you’ve got it inserted, as I said, there are some differences between the devices. With the FreeStyle Libre, there is no warmup, because in essence it happens in the office in about two minutes. The FreeStyle Libre requires no calibrations. So the patient does not have to do anything. You put it on them, two minutes, you activate it, they are out the door. They wear the FreeStyle for 14 days. Which is really nice. Because, although you can get some good information in six to seven days, you get a lot of information in 14 days. So the 14 day wear is fantastic. You get, so for restrictions, they should not go through scanners. So if they’re going to the airport to jump on a plane, I always ask them to have them do the wanding over them, instead of going through the x-ray. They should not get cat scans and things like that. The device is waterproof. So they can swim, and bathe, and shower and do all those things that they normally do. And one of the limitations of this, it is a single patient use. So once that patient has worn the device, they take it off, you take it off and download it, you’re done. So that one is disposable. For the DexCom G4, there is a two-hour warmup period. And when we get into talking about patient wear, you’ll see that there’s a little hourglass or clock on the screen that the patient has to be tuned into, and when it is fully green they’ll get two drops, but it does take two hours. And I’ve had those patients that will call back to the office in an hour, and say “this thing is not working”. Okay, they didn’t really listen to the fact that I said it will take two hours before it begins to transmit any data. So it does take that full two hours. it also does require two calibrations a day. And usually those calibrations need to be within twelve hours of each other. If they’re not done within those twelve hours, the device will give them a warning, and instead of them seeing any readings on their screen, they see a big red drop that will not allow them to go any further. So it’s got a great reminder. It is a seven-day wear. Again, the transmitter that is on their body is indeed water proof, the receiver is not. They should not go through scanners, x-rays, and things like that. And this one is multiple patient use. So although the sensor is one patient use, the transmitter and the receiver are multiple patient use, and are usually good for- they tell you six months, but they will last up to a year, for that transmitter. The receiver, I’m going on two years with my current receivers, so you can get at least two years out of it. The Medtronic iPro does not require a warmup period. At this point it does not require any calibrations. In the past it required two to four calibrations, but it does not require any calibrations and it is blinded mode. It is a six to seven day wear, and the device is waterproof for up to 30 minutes at 8 feet. Again, should not go through x-rays, and CT scans, and things like that. And it is multiple patient use. Veronica, for the days of wear, for 14, which is quite a bit longer than the other two, do you find that it actually, adhesive maintains for 14 days? So for the number of patients that I put it on, I’ve only had one patient who it has come off, and it came off in seven days. But this was a patient, and I freely admit, the patient was reluctant to wear a device. And I convinced them, and I think they got to the point where they were like “you know what, no more. Thank you very much”. So I will tell you I put it on one of the residents, and when she went to take it off, she was a little miserable. She was like “this kind of hurts, and do you have anything-“, So sometimes you need some of that adhesive remover because it adheres pretty good. So one of the other nice things about the devices, and I’ll talk about this a little bit more in my talk about patient use, but they do have remote applications. So if any of you thinking of jumping into it right away, and patients want a personal device, one of the things to think about, that I love about the DexCom Share, in particular. For patients who are not wearing a insulin pump, it does have the ability, if you have a G5 device, it talks to a smart phone, a smart watch, it will talk to up to five of your closest friends, and tell them what your blood glucoses are doing. So, I tell you, I use this for some of my patients, and I had a patient whose wife was out of town and when he came into the office, his phone started ringing. And I’m like, he said “can I get this?”, it was his wife, letting him know that his blood sugar was dropping. So he was like, “I understand that, and I’m here in the doctor’s office right now, and I’ll take care of it”. But it was really neat to kind of see it in action. So you’ve got a patient who, you know, five of their friends need to know what’s going on with them, they travel a lot, that sort of thing, there are some really wonderful options for those patients. Those come up with parents watching their kid’s blood sugars. That’s, you know, a nice security feature for parents. It is, and I have a couple of college students, whose parents are still watching their blood sugars, even though they are 23, 24 years old. And the parents are still needing that security blanket. So it’s also a great tool for them. And again, as I said five of your closest friends can watch you. I’m going to skip past that. So one of the things that often comes up, is okay, you want to use a CGM, and what does the literature say about it? What the recommendations around the use? Who’s going to cover it? That sort of thing. So I just want to go over with you a little bit, the ACE and the AACE guidelines. Their consensus statement from 2015 about who can, and who should, use CGM devices. So, CGM by them, is approved for people who have type 1 diabetes. They say it should be available for people with type 2 diabetes on multiple dose insulin, basal insulin, or sulfonylureas. Because we know that it improves the clinical outcomes, by reducing the episodes of hypoglycemia. It’s also very useful in patients with type 2 diabetes when we’re attempting to identify postprandial glycemic excursions. So I get that patient who comes into the office, and says “all of my blood sugars-” I had this patient the other day, every single blood glucose reading that they captured, was below 180. But you get an A1c of 10. So there’s something else that is going on here. So we know, and the general consensus is, the device is useful in these patients, because I suspect that that patient was having a lot of postprandial hyperglycemia. Also, they state that the intermittent use of a CGM, usually one to two weeks for patients with type 2, it might be more effective than their daily fasting glucose, which is what most people are willing to do. They’re willing to check once a day in the morning, and what I usually tell them, that’s fantastic and that tells me one thing: what your blood glucoses are doing in the morning. So it is useful in that population, especially when you’re considering advancing therapy. In 2017, they took a step back a little bit, and still recommend it for patients with type 1 diabetes with a history of severe hypoglycemia, hypoglycemia unawareness, or frequent hyperglycemia. And I will tell you, for this population, Medicare is covering. And we’ll get into more of the details of that. Medicaid now, is covering for patients under the age of 21. So if they’re under the age of 21 there is very little resistance to getting a CPM device. Over the age of 21, then it becomes a little bit more of a struggle. For type 1 only? For type 1 only, this is type 1 only. There is insufficient evidence according to the AACE and the ACE guidelines of ACE consensus, there’s insufficient evidence to recommend CGM on patients with type 2 diabetes at this time. And data on CGM during pregnancy is unclear. So for the ADA standards of care from 2017, the CGM in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults. And as you can see there, they say adults greater than or equal to 25 years of age with type 1. Part of the reason that is said, when they did it in younger patients, younger patients have a tendency not to pay as much attention to the bells and whistles, so they did not get as much benefit. But over the age of 25, the device has been shown to be extremely beneficial. And although the evidence for the A1C lowering is less in children, teens, and younger adults, they say it may be helpful in this group. Success does correlate to adherence to ongoing use of the device. Part of the reason for that being said, I have multiple patients have been started on CGM, and they get alarm fatigue. If they can never get their blood glucoses under control, because they have consistently ignored the alarms, and where you set the alarms. So if you set a high alarm at 200, for a patient who’s consistently had blood sugars over 400, they are going to get alarm fatigue, because that thing is going to go off constantly. And so what they end up doing is taking off the device. So when we talk about choosing patients, we’re going to talk about choosing how to set those alarms, because it can be very annoying. I wore the device, and I don’t have diabetes, but I sometimes get a little hypoglycemic because I forget eat. So I’m sitting in the room with a patient, and as I start to talk this thing is buzzing. (imitates buzzing noise) I’m like “excuse me just a second”. So I glanced down, and it said my blood sugar is 67. I’m like, “okay, I’m alright”. But, if you don’t fix it, it will blow up every five minutes, until the blood sugar is above or below the targets that has been set. So needless to say, I had to leave out of that appointment and fix that, because it would not stop making noise. And that’s the thing that the patient’s experience. Depending on where you set those alarms, it can be very, very annoying. And that would be a reason for them not to adhere. They also say that CGM may be a useful tool in those with hypoglycemia unawareness, or frequent hypoglycemic episodes. I don’t need to read all this to you. But one of the things to think about, is the last point there. People who have been successfully using CGM should have continued access after they turned 65 years of age. The prior recommendations, were that you didn’t need CGM in people who are over the age of 65. That was very discriminatory. And so there was a serious uprising in regards to that statement. So in 2017 they changed it, so people over the age of 65 can now continue to use their device. And that was a thing with Medicare in particular. So some of the benefits. Again, that patient that is only testing once a day, you get to see what’s happening at that one time that they test. But the CGM will provide you with a movie, as opposed to just that snapshot of what’s happening with the blood glucose readings. Some of the, the Diamond Study that was sponsored by Dexcom, what they did show, in people with CGM, they had a 9% improvement or 9% reduction in their A1C. They spent less time in hypoglycemia, they also spent less time in severe hypoglycemic episodes, less time again, with glucoses greater than 180, and their glycemic variability decreased by 4%. And one of the things we know about blood glucose control, and some of the adverse events associated with that, is that glycemic variability. If you’ve got that patient who’s riding the roller coaster, that patient who’s going from 40 to 400 on a consistent basis, they have more adverse effects. So this was very helpful in decreasing that variability. Reasons to use it in your practice, and we’ll talk about this again in a little bit more detail. But one of the particular things, is that it provides some insight into the trending and pattern management for your patients. It will help you to find those patterns that you cannot detect with finger stick alone. And also for those patients who you’re not exactly sure what’s going on with them, and their A1Cs are above target. It will really help you to find out if they’re having problems with dawn phenomenon, if they are also having some nocturnal hypoglycemia, causing them to have some rebound hyperglycemia. So it helps to detect this information, and to better target and manage their diabetes medications. So in summary, what does CGM do for you? Tells that glucose is rising or falling, provides immediate feedback on the impact of diet and exercise, the alarms are there if glucoses are too high or too low, and it does help with improving glycemic control in your patients who you’re having some difficulty getting them to target. It does not replace blood glucose finger sticks if glucoses are less than 40 or over 400. Again, as I said, it maxes out at 400. So if they’re 593, the only way to know is if they test that blood sugar. And it does not replace the need for training in diabetes management. So they should still go to diabetes education classes. (silence) I said that all already. And can be used with or without an insulin pump. So for our next three courses, Next, in two weeks we’re going to talk about the appropriate candidate for CGM, then we’ll talk about interpretation of data, and then we’ll talk about billing and coding. Questions about that? Questions about the things that I just discussed? (silence) Wow that means that I covered everything. Yes, Jan? Sorry. Are you going to record the sessions, or is there a way that we can access them? Can you hear me? Yes. They are being recorded. And then they will be on the Project ECHO site. Did you hear us? So, can you hear me now? Yep, I can hear you. Okay, so the sessions are being recorded, and they will be on the Project ECHO site. Great, thanks. You’re welcome. Other questions? There’s a question… Community Health Alliance. Yes? Un-mute them. In your practice using CGMs, have you seen any, has it caused infections and stuff with the CGMs placed with any of your patients? So I will tell you, I have seen one site infection, and It was pretty remarkable, but it was a person who had their personal device, and it is recommended for wear for seven days. The reason is, if you wear it longer than seven days, the body has attempted to recognize it as a foreign object. It will treat it as such, and you end up at day 14, which is where my patient was, with a rip-roaring skin infection, you know, it gets really nasty. But it was from prolonged wear. If you follow the instructions, seven-day wear, I have never seen a site infection. The only other risk with CGM, and it is a 1% risk, is sensor fracture. I have never had a sensor fracture. But when you go to remove the device, if you don’t- you should see your full catheter when you remove the device- if you don’t, likely that sensor has fractured, and you need to go in and remove it. I have never seen a sensor fracture. Thank God. (laughter) So for professional use, I have never seen a site infection. other questions? (silence) You know, let me just- so we’re all now, I think, pretty used to looking at patient’s glucose logs. They write- almost everybody is using glucose monitoring to some degree. They bring their logs in, and we accept them as truth. And just like the news is now fake, sometimes the glucose logs are fake. And, you know, my- I’ve said this before- you know, unless I see dried blood on the glucose log, I never believe that the patients are really testing, but that’s another story. But this is a way of obtaining reliable, really meaningful data. And, you know, there’s a learning curve for everything. But we have the opportunity here, I think, to to provide enormous- or to gain enormous insight into how our patients are responding to our therapies. And finding the areas where are happening that we didn’t know about. And you know, people’s lives tend to follow fairly predictable patterns. So, you know, a 14-day observation period is very predictive of what the patient’s life is actually like. So you can you can just get enormous insight and start to- remember everything we do is incremental, right? So we want to try a narrower ischemic range, we want to smooth things out, we want to eliminate the hypo’s, because they distort everything. This is an incredibly valuable thing, that doesn’t add enormously to our work burden, that we could actually get reimbursed for doing it. So, join us again in two weeks, and we’ll- Talk more. We’ll talk more. (laughter) Any other questions? Okay, see you in a couple weeks. Thank you.