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AIDA Clinical Use

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A number of practitioners have started to make use of the AIDA diabetes simulation approach in lessons or classes with health-care students and / or patients with diabetes.

Some short descriptions are included below - to highlight some of the ways in which such diabetes simulations may be applied for class instruction / education.

Please use the menu below to review some of the descriptions.

If you have been making use of AIDA or 'AIDA on-line' for teaching patients with diabetes, or health-care students, we would be very interested to hear from you. We will be able to learn - and improve AIDA - by understanding how people have been actually applying the software for teaching. Please do take a moment to contact us. We can best be reached by using the on-line AIDA contact form.

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A diabetes educator and nurse write:

AIDA, an educational simulator for insulin dosage and dietary adjustment in diabetes, was recently reviewed by several of the nurse educators and medical staff of the Newcastle Diabetes Education Centre regarding its potential use in diabetes education.

Our initial impression of the program was that it is quite complex; it takes some time to thoroughly review the excellent written manual provided before you can begin using it effectively. In its present form it is not possible to have a quick 'play' with the software unless you are well versed in the mechanics of the program.

Several features of the program were thought to be worthwhile in diabetes education. Once the new user overcomes the problem of grasping the basic concepts of the program it is interesting to alter the inputs for insulin dose and carbohydrate intake and see an immediate change in the blood glucose level as a result of these changes. With practice users tend to become immersed in the program, testing out their ideas. Being able to modify or add case scenarios allows patients to make the program relevant to their particular educational needs.

The software will be useful to many of the adolescents and younger patients that we see at the diabetes centre, but a reasonable level of computer literacy will be necessary for people to get the most out of the program. Many of those in the older age groups might have a problem using the program as they would first have to overcome their aversion to using computers; this problem might be eased a little by developing a Windows-type graphical user interface for the software.

Nevertheless, interpretation of the screen output is not difficult once the basic operational concepts are grasped by the user; overall, the software design is quite sophisticated, and with increasing operator experience the application becomes a pleasure to use. The approach used offers realistic data output following changes in input variables and the often subtle changes that are elicited by the operator make this one of the highlights of the program. Further development of this feature to expand analysis of the effects of exercise and stress on changes in blood glucose levels should be both interesting and useful. We suggest breaking the program up into easy, moderately difficult and difficult levels of interaction. This may prevent the user losing interest in the program before being introduced to its many benefits.

If used in the Newcastle Diabetes Centre as an adjunct to diabetes education it would be essential to have someone conversant with the program give hands-on instructions to the first time user. If the person being shown the program is reasonably computer literate this should not be too difficult. However poor computer literacy could make this an ineffective process. Once the basic concepts of the program are grasped, it is easy to become absorbed in the program and be keen to explore all options available.

Feedback from staff members using the program was positive - they liked the program. They felt that the overall concept was good and the software had some excellent features that were useful for teaching purposes. The software was recently trialled under nurse educator supervision by 4 adolescents attending our Young People's Diabetes Clinic. Again, overall reaction was favourable, with 3 of the 4 expressing an interest to enter their own data and to monitor progress themselves.

Dr. Kerry Bowen, MB BS PhD FRACP
and Jane Scorer, BA RN
Director and Research Nurse
Newcastle Diabetes Education Centre,
New South Wales, Australia

Reproduced from Computer Methods and Programs in Biomedicine 1998 56: 109-132.

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An endocrinologist writes:

The Diabetes Control and Complications Trial has demonstrated the benefits of good blood glucose control, however, achieving these results in the wider type 1 diabetic patient population is a challenge. One definite message is that diabetes education of both patients and healthcare workers needs to go beyond broad guidelines and that a sound understanding of insulin and carbohydrate interaction is fundamental.

AIDA is based on a physiological model and as such provides a realistic simulation of glucose values and can demonstrate the effects of changing carbohydrate or insulin amounts (or timing). When discussing methods of improving blood glucose levels most clinicians concentrate on adjusting the insulin dose. Using AIDA with the different case scenarios provided, it becomes evident that dose adjustment is not always the answer and that changes to type or timing of insulin administration or to the distribution of carbohydrate intake may offer a better solution.

AIDA can be used as an educational tool either individually or in groups. When used as a demonstration/teaching tool it has provided a starting point for discussion on other topics such as the pros and cons of tight blood glucose control, advantages and disadvantages of various insulin regimens, age-related limits, methods of testing and the treatment of hypoglycaemia. As well as having a favourable response when showing patients, AIDA has also been useful for teaching medical students on their diabetes attachments.

Hypoglycaemia is the downside of maintaining tight blood glucose control and with the advisory function in AIDA, resolution of the hypoglycaemia takes priority over all other treatment options, as it does clinically. However, not all hypoglycaemic episodes are recognised clinically and by looking at the simulated glucose curve generated by AIDA potentially vulnerable periods during the day, for a given scenario, can be identified.

No computer program can hope to mimic the full range of factors which influence glucose homeostasis in vivo, and while certain variables like alcohol or exercise have not been included, the effects of these are easier to contemplate once a good grasp of the basics has been obtained.

AIDA provides a risk-free opportunity to experiment with different aspects of blood glucose control. While trial and error are a significant part of any learning curve, the principles acquired from using AIDA are invaluable. I have no hesitation in recommending the program as an educational tool to patients and students, as well as endocrinologists and other healthcare workers.

Dr. Kathleen Hopkins, MD FRACP
Formerly from Division of Endocrinology, Middlesex Hospital, London, U.K.

Reproduced from Computer Methods and Programs in Biomedicine 1998 56: 109-132.

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A postgraduate educator writes:

Thank you for your fine AIDA. The program has been used for teaching audiences of would-be Doctor or Diabetes Specialists, general practitioners, as well as technicians. The program's simulations provide a very convenient 'back to real life' sense for technical lectures.

The non-endocrinologists especially found the demonstration of the need for gradual adjustment of calorie intake, timing and combination of fast- and slow-acting insulins, very instructive. They made use of the adjustable normoglycaemic ranges in a 'competition' between two or three people at a time, switching from low-insulin sensitivity patients to high-insulin sensitivity patients. The nurses here, not accustomed to the need for very regular blood glucose determination, are also going to have a demonstration of the software.

In my experience the program is sufficiently sophisticated to convey the effects of regular insulin-dosage adjustments - yet it is simple enough to be used by non-experts. Furthermore most people will be able to use AIDA on their own. However, my experience is that especially in an audience, say of 6-10 people, this program is ideal because discussions about what to simulate next develop very rapidly.

I recognise the need for the warnings at the start of AIDA, but I believe that a program like this could enhance the knowledge of interested diabetic patients early on in their disease. However I have no personal experience in this matter, having only used AIDA for postgraduate teaching. I agree that patients should not by any means see this as a direct way to adjust their own insulin-doses. Rather allowing patients and health-carers to learn basic rules - as AIDA does - seems a very smart and logical addition to other existing teaching methods.

Dr. Bjørn Søeberg, MD
Kommunehospitalet, University Hospitals of Copenhagen
Copenhagen, Denmark

Reproduced from Computer Methods and Programs in Biomedicine 1998 56: 109-132.

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A pharmacy educator educator writes:

The Pharmacy Undergraduate Curriculum is a 3-year professional program. Our students receive a total of 6 hours of didactic diabetes education during the endocrinology course, taught in the second professional year of the program, at a point when students have not acquired any clinical experience or exposure to patient care activities. The ‘AIDA on-line’ diabetes case simulator was used as a required web assignment for the endocrinology course. Students were divided in groups of two and assigned one of the 40 case scenarios. Students were specifically asked to review and assess the baseline data provided, identify problems, and define glycemic goals. Based on this assessment they were to devise new treatment regimens involving insulin dosing and carbohydrate intake in order to achieve the specified glycemic goals. Students ran several simulations by experimenting with a number of changes in insulin therapy or carbohydrate intake, or both, and identified the best course of action. They summarized their findings and provided graphical simulations of baseline data, and the final course of action. In all cases the recommended regimens resulted in an improvement in glycemia compared to baseline. In the majority of cases student-devised regimens led to 24 hour glycemic control with minimal hypoglycemia.

The ‘AIDA on-line’ diabetes simulation has proved to be a valuable educational tool that complements the didactic portion of the course. The program provides various virtual models of diabetes that differ significantly in presentation and in approaches to treatment. This reinforces the heterogeneous nature of diabetes and emphasizes the need for individualizing treatment. The program allows the interactive simulation of the effects of minute changes in insulin dose and / or carbohydrate intake on the 24 hour blood glucose profile of a patient with diabetes. The Website allows students the opportunity for experimentation and manipulation of insulin therapy including doses, frequency, and types – and the patient’s dietary intake including amounts and frequency – and patient-specific characteristics such as weight, renal or hepatic function status. The simulations help students to understand the dynamic nature of the relationship that exists between blood glucose concentrations, insulin dosing, and dietary regimens. Therefore students can gain an appreciation of the challenges, and difficulties, of achieving an appropriate balance between these variables.

Students were required to provide an evaluation of the assignment. Their comments were extremely positive. From the students’ perspectives the assignment has strengthened, reinforced, and enhanced the didactic information provided during the course. It has also led to a better understanding of the importance of the rather difficult task of achieving normal glycemic control. Students described the assignment as educational, informative, challenging, and enjoyable. Many have indicated that the on-line simulations have allowed the application of knowledge learned in class, by experimentation with several different therapeutic plans, without putting patients at risk. These simulations are particularly useful in understanding the difficulties associated with insulin regimens by exploring the drastic effects of a small change in insulin dose or timing on plasma glucose concentrations, and in advancing students’ knowledge and skills in the cautious and accurate dosing of insulin.

The changing trends in the health care system mandate an expansion of pharmacy practice beyond traditional distributive duties, and pharmacists are increasingly challenged to take more active roles in patient care. Successful diabetes management requires an entire team of healthcare providers, including a pharmacist. In addition, diabetes management is a unique challenge that requires substantial knowledge acquisition, training, and practice. The emphasis on achieving normoglycemia in patients with diabetes has resulted in increasingly complex regimens of insulin, oral hypoglycemic agents, and nutrition requiring more intense monitoring and interpretation of blood glucose data. The ‘AIDA on-line’ diabetes simulation is a worthwhile educational tool that allows the learner to apply new knowledge, and to experiment with various therapeutic regimens, without any risks to patients.

Linda A. Jaber, Pharm.D.
Associate Professor
Department of Pharmacy Practice
Wayne State University
Detroit, Michigan, U.S.A.

Reproduced from Diabetes Technology & Therapeutics 2000; 2(2): 329-342.

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A Past President of the American Association of Diabetes Educators writes:

Educating primary care practitioners regarding the complexities of type I diabetes management is a challenge due to the difficulties of finding practice experience for students. Individual primary care settings may have only a few patients with type I diabetes and opportunities to learn diabetes management principles may be limited. Equally daunting is the concern of students making decisions that can be life threatening to real persons. The 'AIDA on-line' interactive diabetes management simulation has been an exciting tool that alleviates many of these problems. Students are given the opportunity to practice adjusting insulins – including the type, dosage and timing of injections – as well as adjusting carbohydrate intake for simulated patients. The immediate feedback enables them to evaluate their decisions instantly, unlike the real world where it may take weeks before the effect of decisions will be known.

At San Francisco State University’s Family Nurse Practitioner (FNP) Program our students have the opportunity to practice at the ‘AIDA on-line’ Website and learn the principles of type I diabetes management. New trainee FNPs would rarely treat type I diabetic patients independently, however, understanding the principles of glycemic management is an essential component of their education.

Our FNP program utilizes the Internet as an adjunct to in-class instruction and we encourage the use of certain Websites as sources of professional and scientific information. Many professional Websites contain standards of care and full text research articles. Using the Internet for these purposes is useful and their value is in finding current medical information, not unlike reading a journal or textbook. The ‘AIDA on-line’ Website is the first site that we have used which teaches about a complex medical problem and is interactive, engaging the students in the decision-making process with immediate feedback.

In making the assignments to the program, the instructor first makes a decision regarding which of the 40 standard case scenarios at the Website would be appropriate for first time students. The initial cases are selected for their simplicity so that the students can gain an understanding of the many factors that affect the simulated patient’s blood glucose level. Students are instructed in the pathophysiology of diabetes mellitus including the many factors that can influence glycemic control. Treatment principles of nutrition, exercise and medication are presented. Lecture topics include identification and prevention of complications of diabetes, including hypoglycemia and diabetic ketoacidosis. Current research regarding the glycemic levels necessary to prevent the macrovascular and microvascular complications of diabetes are presented with discussions regarding the process of achieving those normoglycemic levels.

Students are guided through their first simulation with instructions to first read the detailed description of the case. They must change the blood glucose to mg/dl and change the insulin types to those most commonly used in the United States. They are given the height of the simulated patient since this is not included in the simulation. They are then required to calculate the simulated patient’s body mass index (BMI) or they may use a standardized chart to determine this. Based on that information, they calculate the simulated patient’s expected nutritional needs, and the total daily number of grams of carbohydrate required. They examine the simulated patient’s carbohydrate intake and determine if it is adequate, and if the distribution of the meals is appropriate in light of the current glycemic profile. Students are encouraged to change the carbohydrate amounts and meal-plan, if that is indicated, based on their calculations.

When choosing the insulin dosages, students are asked to try various regimens including multiple injections of short-acting with intermediate-acting insulin, and then short-acting with long-acting insulin. Premixed (biphasic) insulin preparations are compared with non-premixed regimens. The dosages of insulin and the timing of the injections are changed to determine their effects. Once the predetermined glycemic goals are achieved, students are then asked to change the renal threshold and renal function levels to evaluate those effects on glycemic levels. The same is then done with the insulin sensitivities in the liver and peripheral muscles. When students see the dramatic differences these changes can make to the simulated glycemic levels, it opens discussions as to what exactly is happening. They learn that each patient is an individual and will respond differently to often very subtle changes in their treatment regimen. After completing their assigned cases, they are asked to print out their solutions and the cases are brought to class for discussion and grading.

At San Francisco State University we have found the ‘AIDA on-line’ interactive Website to be an invaluable tool in teaching our FNP students about the complexities of diabetes management. Students find the Internet access to be an asset since they can practice on the simulations on their home computers at a time convenient to them. This program offers a learning experience that is unparalleled in diabetes management education.

Sharon Johnson, Ph.D., FNP, RN, CS
Associate Professor
San Francisco State University, School of Nursing
Family Nurse Practitioner Program
San Francisco, California, U.S.A.

Reproduced from Diabetes Technology & Therapeutics 2000; 2(2): 329-342.

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An overview of a randomised controlled clinical trial evaluating AIDA:

The AIDA software is believed to be of use in recreating clinically realistic diabetes situations for interactive simulation. However, despite its widespread usage, its actual utility for supporting the education of patients with insulin-dependent (type 1) diabetes mellitus remains to be objectively demonstrated in a randomised-controlled clinical trial setting.

This short text overviews a prospective, randomised-controlled trial (RCT) methodology that we have been applying for formally evaluating the educational utility of AIDA.

The protocol makes use of two study arms - each receiving different educational interventions. During lessons, Arm A of the study will be exposed to the AIDA simulator (the active intervention), while Arm B (the control group) will benefit from conventional educational methods using standard presentations with slides and transparencies. Six lessons will be held for each study arm (one per week). Attendance at each lesson will be recorded, as will the incidence of any ‘drop outs’ from the study.

A novel aspect of this study is the fact that the participants will not interact directly with the computer - rather the teacher will serve as a ‘wizard' undertaking all interactions with the computer. This will circumvent any problems if the participants are not fully computer-literate or confident to use a computer themselves. Connected with this, a perceived limitation of the current version of the AIDA software is that it is DOS-based and therefore does not make use of a standard, Windows graphical user interface. Given this - provided the teacher is fully conversant with use of the software - the ‘wizard' approach should help to avoid any ‘learning curve' effect where it takes the study participants a number of lessons simply to become fully familiar with the program's functions. Furthermore using a ’wizard' approach should avoid any language difficulties as the software is written in English, while the participants' mother-tongue will be Italian. In this respect, where required, the ‘wizard’ will also serve as a translator. For all simulation lessons two computer screens will be made available - linked to the same personal computer - ensuring that all study participants will have a good view of the computer displays.

At the beginning and end of the study self-monitoring blood glucose (SMBG) data will be collected, details of any hypoglycaemic episodes recorded, and assessments made of HbA1c. Participants will also be required to complete a detailed questionnaire to assess their self-confidence, quality of life and metabolic control, attitudes towards SMBG, and knowledge about insulin dosage calculation. Comparisons will be made between Arm A and Arm B using unpaired statistical analyses. A partial cross-over study design is also proposed whereby subsequently the control group will be exposed to the AIDA simulator during a further 6-week course of lessons. This will ensure that the maximum number of subjects will eventually receive the active intervention, and will also allow further within group paired analyses to be applied (with greater statistical power).

Initial qualitative experience gained from running this study has highlighted various ways in which it is possible to optimise the use of the simulator for participants during lessons. (i) One of the most important things seems to be to give each participant a role. Therefore limiting the class size of each lesson to 6 subjects (+ teacher) enables each participant to be given a task monitoring one aspect of the simulations. For example the different simulated glucose fluxes (net hepatic glucose balance, peripheral glucose uptake, glucose absorption from the gut, and renal urinary excretion) plus blood glucose and plasma insulin levels can each be monitored by a different person, increasing their individual involvement. (ii) Selection of patients who may benefit most from such computer-assisted teaching sessions may also be important. For instance young, intellectually alert subjects who are willing to participate appear to get the most out of such simulator-based lessons. (iii) It seems useful to let the discussion during each lesson flow freely, but at the same time retain the focus on the chosen topic of the lesson. In this respect - as with all education - it remains important for the teacher to have clearly in mind what the participants are meant to learn, or take away, from each lesson. (iv) Applying the diabetes simulator as an interactive ‘blackboard' - and thereby as a vehicle for discussion - seems to be one of the more profitable ways of making use of the simulations during lessons.

An initial evaluation study using this RCT approach, involving 24 type 1 diabetic patients, is currently underway in the Ospedale di Marino in Marino (Rome), Italy. As well as confirming the feasibility of this evaluation approach - this initial study will also be used to derive data for power calculations for a larger multi-centre study - to investigate the utility of the AIDA diabetes simulation approach for supporting interactive clinician / nurse / educator-led education.

Dr. Patrizio Tatti, MD
Chief of Diabetes Branch
Ospedale di Marino
Marino, Rome


Dr. Eldon D. Lehmann, MB BS BSc
Department of Imaging (MR Unit)
Imperial College of Science Technology & Medicine
NHLI Royal Brompton Hospital
London, U.K.

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If you have been making use of AIDA or 'AIDA on-line' for teaching patients with diabetes, or health-care students, we would be very interested to hear from you. We will be able to learn - and improve AIDA - by understanding how people have been actually applying the software for teaching. Please do take a moment to contact us. We can best be reached by using the on-line AIDA contact form.

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AIDA Website home Return to AIDA Website Home Page AIDA is a freeware diabetes software simulator program of glucose-insulin action + insulin dose & diet adjustment in diabetes mellitus. It is intended purely for education, self-learning and / or teaching use. It is not meant for individual blood glucose prediction or therapy planning. Caveats

This Web page was last updated on 6th January, 2001. (c), 2000. All rights reserved. Disclaimer. For the AIDA US Mirror Site, please click here. For the Diabetes / Insulin Tutorial, please click here.