High blood sugar should be considered a symptom. High blood sugar can be caused by:
1) Having enough basal or "baseline" insulin but eating too many carbohydrates. This will lead to a high blood sugar reading but no immediate danger (this will cause long term health issues like kidney failure, blindness, etc if you run a high average blood sugar over time.)
2) Not having enough insulin which is incredibly dangerous. This will often presents with high blood sugar but not always. Your cells are not getting enough glucose. Your body responds by releasing lots of short term energy stores. The stores that become glucose still can't enter your cells since there is not enough insulin so your blood sugar will often read high. Your body also breaks fat into ketones which use a different mechanism to enter the cells and don't require insulin. Ketones can provide the energy your body needs and keep you alive for the short term, but they are acidic and will kill if the concentration gets too high (diabetic ketoacidosis -- your blood pH changes enough that it interferes with the normal chemical reactions your body requires)
So the real test for dangerous situations when experiencing high blood sugars is to test your urine for ketones.
From the FDA article, it sounds like the CGMs were incorrectly reporting low blood glucose values for extended periods of time. The closed loop pumps respond to a low blood glucose by lowering the basal rate of insulin. The is dangerous if done for too long a time. Also note that insulin response varies wildly by individual.
From the pumps I use, there is a maximum basal rate adjustment allowed before the pump alarms and kicks you out of the "insulin auto-adjust mode". This was with both medtronic and tandem pumps.
I haven't used the abbot cgm or pump. I would expect there would also be limits to how much the pump will lower your basal insulin rates before alarming. I haven't seen any specifics, but I bet the software bug is allowing a lowered basal rate for too long under continued false low glucose readings and patients going into DKA. (IMHO bad sensors should be accounted for in software and user alerted under any suspicious circumstances)
Needless to say, this is a horrible situation and my heart goes out to everyone impacted.
The unfortunate part is gimp is intensely useful software with many amazing features...buried under such an awkward interface.
I used it today for doing a color range selection to get an estimate for parameters to use in image magick. It had the easiest dynamic visualization of the matte for the selected range as I was selecting. It did exactly what I needed, very well.
I also tested out krita and nuke. Was easier in gimp.
But gimp is still the tool of last resort as it is just so painful to use. I wish there was a more positive engagement between the graphics community and the gimp devs. It feels very combative and negative compared with tools like krita and blender.
I work in vfx, and we had a lecture from one of the art designers that worked with some formula 1 teams on the color design for cars. It was really interesting on how much work goes into making the car look "iconic" but also highlight sponsors, etc.
But for your point, back during the pal/ntsc analog days, the physical color of the cars was set so when viewed on analog broadcast, the color would be correct (very similar to film scanning).
He worked for a different team but brought in a small piece of ferrari bodywork and it was more of a day-glo red-orange than the delicious red we all think of with ferrari.
If you want a book that is more technical and really gives a sense of what the scope of the project was, I'd highly recommend The Los Alamos Primer by Serber which was the intro lecture given to scientists when they would arrive. Serber did a great job of annotating the lecture to explain in more accessible detail each section. A quick read, and well worth it.
I remember seeing a very similar system at wright-patterson afb in ohio that was used for a flight simulator. The model was mounted vertically on a wall and at a much smaller scale. This was in the early 80's and it was no longer in use. But the model detail was incredible. They had the camera hooked up to a monitor and seeing the camera "fly" through the scene at an appropriately scaled speed was amazing -- even on a tv screen. You could see the camera moving over the model...but on the monitor the view looked real.
I really love Guy Ritchie's tip of the hat in The Gentlemen from Hugh Grant's character where when talking about watching a conversation through a telephoto lens he says, "But I filmed it, had it lip-read, translated, and transcribed. Rather like the classic 1974 film The Conversation starring Gene Hackman and John Cazale. You know, Coppola slipped that one out between the Godfathers. It wasn't really for me. It's a bit boring to be honest...."
I don't know why but that makes me laugh every time. (And I agree w/ The Conversation being underrated)
I have a love/hate relationship as well, mostly because I grew up within bicycling distance and spent way too much time at the museum.
The XB-70 used to be parked outside right in front of the main entrance. The cool thing is they also have the X-3, which seems like the same design family so you can see the test article then the attempt at a usable aircraft.
It was also the location of one of the most bonkers thing I've ever seen which was when they relocated an SR-71 to the museum and landed it on this very short old runway at the site. That thing was so big and so fast and that runway even at the time seemed so short. Here's a vid. I saw it from the road off the end of the threshold and it looked like it was going to hit the fence on the landing pass.
we lived in rona hills for about 4 years. not biking distance, but close enough to visit frequently. and as a youngster they let me conduct the AF orchestra there at the AF 25th anniversary. Very good memories.
As a funny aside, I had applied to lucas arts around 1996 and never heard back from them. I ended up getting a job at industrial light and magic (as they were both companies under lucas digital) thinking I could then transfer over to lucas arts.
But we would visit for the company store, and I would be nosy and go talk to people. This was during production of grim fandango and there was a tangible ramp up of stress in that building as the release approached. I remember one of the testers sitting there staring at the manny character on his screen and bemoaning, "I used to love playing games".
And the voice acting was amazing. Especially for a game.
I think I have rose colored glasses as I remember the game being difficult in the sense of lots of walking around trying to find the solution to the last couple of puzzles. Having played the remaster, it was clear how clunky the controls were. But wow, I still love that game.
Ack --> I misread your article and thought your child was 14 years old, not 4. I don't believe kids that young qualify for any of the auto-adjusting toolkits. The medtronic has a minimum age of 14 (I think). In any case, the best advice I can give is to get your child on something like medtronic's pump + cgm + smartguard as soon as you can. Ideally the minimum age limits will drop and the quality of the treatment will keep improving.
I left the no-longer-relevant-to-you comment below in case it would be interesting to others.
This is a different suggestion than you were talking about in your article, but:
If possible, I would highly suggest trying out the medtronic minimed 780g with guardian 4 or simplera using the "smartguard" feature. This is the first out of the box solution I've ever tried that almost (but not quite) felt like magic in terms of achieving good control that was mostly automated.
This setup provides 3 things not yet available in the dexcom associated systems:
1) auto adjusts your basal rate (via a weighted average or 6ish days)
2) aggressively adjusts basal rate to avoid lows
3) aggressively micro boluses to help prevent highs.
I have recently switched from a tandem x2 with dexcom g6 and g7 and used with xdrip+ android phone app (similar or same as the nightscout you mention, depending on where you get it.)
The dexcom cgm with the tandem auto correct would typically take (for me) 6 hours to correct a high from something like too low meal bolus. The medtronic usually takes less than 2 hours and doesn't peak nearly as high.
More importantly, the hypoglycemia prevention is a complete game changer. I have not had a severe low blood sugar since switching -- and this means avoiding the hypoglycemia followed by 24-48 hours of higher insulin resistance.
The out of the box systems are getting really good, and are advancing at a quick pace now (which until recently hasn't been the case). The quality of control I have now is much better than with xdrip+ and the auto controls available in the tandem x2.
I used to eyeball my android phone many times during the day to follow trends and try and catch highs or lows early. Now, I don't need to adjust basal rates. If I miss calculate the carb counting for a meal, the auto correct takes care of it. Now I only need to pay attention to longer trends relating to meals boluses and relying more on a1c values to double check that the control is really ok.
We looked at the Medtronic 780g system, there are a bunch of problems for a four year old. Most obvious is the tube, it gets in the way, the omnipod is waterproof and just works. The next is inserting the guardian sensors used to be horrific (as I understand it they have an applicator now) but my son barely feels the dexcom G7 insertion.
AAPS is good, it could be better, but it has a complete set of features we need. Just need a phone
In the US and EU, children that young are authorized to use CGM and Omnipod. It’s functionally equivalent to the tube based systems, expect that it only lasts 3 days. Ugh.
But the total automation of basal based on realtime CGM is a lifesaver.
with Medtronic, I am always concerned about the tube as you've to carry it around and with kids, it becomes difficult, so we're opting for Omni Pod. I hope they make it tubeless some how and CGM + Pump in 1 system . With Med, you still have to manage the dose prior - no ?
1) Having enough basal or "baseline" insulin but eating too many carbohydrates. This will lead to a high blood sugar reading but no immediate danger (this will cause long term health issues like kidney failure, blindness, etc if you run a high average blood sugar over time.)
2) Not having enough insulin which is incredibly dangerous. This will often presents with high blood sugar but not always. Your cells are not getting enough glucose. Your body responds by releasing lots of short term energy stores. The stores that become glucose still can't enter your cells since there is not enough insulin so your blood sugar will often read high. Your body also breaks fat into ketones which use a different mechanism to enter the cells and don't require insulin. Ketones can provide the energy your body needs and keep you alive for the short term, but they are acidic and will kill if the concentration gets too high (diabetic ketoacidosis -- your blood pH changes enough that it interferes with the normal chemical reactions your body requires)
So the real test for dangerous situations when experiencing high blood sugars is to test your urine for ketones.
From the FDA article, it sounds like the CGMs were incorrectly reporting low blood glucose values for extended periods of time. The closed loop pumps respond to a low blood glucose by lowering the basal rate of insulin. The is dangerous if done for too long a time. Also note that insulin response varies wildly by individual.
From the pumps I use, there is a maximum basal rate adjustment allowed before the pump alarms and kicks you out of the "insulin auto-adjust mode". This was with both medtronic and tandem pumps.
I haven't used the abbot cgm or pump. I would expect there would also be limits to how much the pump will lower your basal insulin rates before alarming. I haven't seen any specifics, but I bet the software bug is allowing a lowered basal rate for too long under continued false low glucose readings and patients going into DKA. (IMHO bad sensors should be accounted for in software and user alerted under any suspicious circumstances)
Needless to say, this is a horrible situation and my heart goes out to everyone impacted.