Guide to diabetes technology Patch pumps with the enticement of a much smaller, hopefully cheaper insulin pump that can be worn on any area of the body are part of the new gadgets available now. The technology and behind-the-scenes regulatory, legal and engineering genius of these developments are mind blowing lt is easy to envisage the benefits that safe, simple delivery devices could offer to thousands of people with diabetes. We await the introduction of these new technologies as eagerly as we await the inclusion of artificial ntelligence algorithms that would make the attainment of euglycaemia safer and easier. However, hypoglycaemia remains a clear and present danger to the attainment of perfect glycaemic control. Fear of hypoglycaemia leads patients to run higher sugars and adopt avoidance behaviours that sabotage long-term control. lt is now well recognised that hypoglycaemia may account for between 4 and 10% of the mortality in diabetes, with many of the deaths being attributed to cardiac arrhythmias rather that hypoglycaemic seizures and coma. While an attempt was made to reach a consensus of the exact value that defines hypoglycaemia, this has greater relevance for regulatory authorities and clinical trials than it does for real-world patient care. A value of 3.9 mmo/l may be too high for clinical trials, but provides a buffer zone for people with diabetes. lt must however be pointed out that there is not much scientific support for this value. Hypoglycaemia and its symptoms and consequences vary from time to time in any given patient and probably are best defined by a range of blood sugars rather than an absolute value This range needs to be tailored to the clinical situation, the age of the patient, the duration of disease and concomitant medical problems. Lessons learned from both inpatient (l\llCE-SUGAR) and outpatient (ACCORD, VADT) clinical trials targeting very strict glucose control have resulted in unexpected increases in morbidity and mortality. A particular concern is the entity of hypoglycaemia-associated autonomic failure and hypoglycaemia unawareness. In elegant PET scan studies of humans with and without hypoglycaemia unawareness, there appears to be a loss in perception of any noxious stimulus related to hypoglycaemia in those with hypo-unawareness. The net effect is that these individuals do not feel their hypos but in particular will take no evasive action to avoid such episodes, even if they are made aware of them, because they do not feel bad with them. This helps to explain the difficulties faced in trying to ‘re-train’ these individuals to run higher sugars and feel their lows, and the high rate of refractory hypo-unawareness. A particularly interesting session on multi-modal treatment of type 2 diabetes covered the use of leptin combined with amylin in reducing glycaemic variability, possibly through the regulation of gastric emptying and incretin hormone induction. A brief but interesting mention of the role of glucagon in maintenance of dysglycaemia again raised the notion that glucagon targeting may be a therapeutic option. However, the most interesting notion lies on the possibility, or better yet the probability of curing type 2 diabetes with surgery. The benefits of gastric bypass procedures were presented to look like a treatment panacea for the myriad of disorders associated with obesity and insulin resistance, or rather should we say that stem from hyperinsulinaemia. The concept of a gastric diabetogenic factor’ (GDP) was raised and supported. lt certainly sounds plausible that the contact of food with enterocytes in the gastric mucosa could lead to the release of this GDP, which results in a state of hyperinsulinaemia and with it all of the well described consequences of hyperinsulinaemia.