 Tendom also helps with the sensor readings and goes up and down as we discussed. There are different thresholds for different glucose levels, but it basically always takes the whatever is set by your colonization in terms of the basal rate. So if your basal rate is not enough for example at night, the moment your blood sugar starts going up, let's say you go to bed at 10 o'clock and your blood sugar starts going up at 11, your tendon pump will still be able to correct that because it estimates that your blood sugar is going to be keep going up and it keeps giving you more insulin, but the cycle continues to happen pretty much every day. So I think from the basal standpoint both pumps get the job done. It's just a technical difference that I see there. Now the third thing we can talk about is the insulin, active insulin time. Now that is modifiable with Metronic. And then to be honest with you based on the insulin that you are using in the pump and based on your personal active insulin time can be different. So sometimes a novel log for example can last four hours for one person. It may not even last three hours for another person. So as a result being able to change that even in the auto mode is I think a good feature. On tandem side that is not modifiable. It is set at five hours. And I think they did that as a safety feature because they are giving insulin bolus. Remember that Metronic does not. So when tandem gives an insulin bolus on top of what you already have given, they want to prevent something called insulin stacking. So as a result active insulin time is more put as a more like a safety feature. On the other hand you can of course change your sensitivity factor anytime you are not in the auto mode. So in this case they call that a control IQ. So there is some confusion between the terminology they use but the bottom line they mean the same thing. They are all called closed loop systems as sensor talks to your pump bottom line. So Metronic calls that 670G closed hybrid loop system and the tandem calls that a control IQ. So what else we have? So in terms of modifiable factors we talked about the sensitivity factor we talked about. So the other thing that we mentioned in the beginning that your set blood sugar is 120 versus it changes in tandem pump. It has different thresholds like 112, 160, 160, 180. Below 112 and below 70 tandem will make different changes based on the incoming data. So with that we will also talk about the exercise settings that the tandem has as well as sleep settings. So as you know when you are sleeping you are more sensitive to insulin and then when you are exercising you also are more sensitive to the insulin. So on the other hand everybody wants to wake up with a nice blood sugar so tandem thought about this and they came up with a sleep profile. And you can auto set that, you don't have to push a button every time you go to sleep. So if you are sleeping from 10 to 6 every day you can actually put that in your pump as a sleep setting. So everybody's sleep is different but what the tandem does here is that it actually reduces your 160 threshold to 120 for the high. Just because when you are sleeping it's a lot easier to control your blood sugar because you are not really active which affects your blood sugars and you are also not eating which also affects your blood sugar. So it's more of a stable environment so as a result keeping your blood sugar right at 120 is easy for both metronic and the tandem. To be honest with you with any pump or a closed lip system it will be a lot easier when somebody is sleeping. Now metronic doesn't have the sleep pattern but they have it set at 120 which is very similar to tandem pumps so I think there is not much difference there. But you know having a sleep pattern for tandem can help you wake up with better blood sugars in my opinion. Now on the other hand the exercise is important because a lot of people are scared that the blood sugar sometimes go really high, sometimes crash out later after the exercise. So when you're exercising basically your tandem pump will allow your blood sugar to be at 120 so instead of keeping your normal steady basal rate between 112 and 160 blood sugars your tandem will actually only start giving you more basal insulin if you go above 140. Again that is a safety feature because when you're exercising your body uses glucose and if you get a lot of insulin that can definitely cause a low blood sugar. So I'm glad that the tandem thought about this and they increased their basal insulin delivery rate at 160. And it will actually cut down on the insulin if you're going below 140 which is important because if you're exercising and your blood sugar is going below 140 it is just a matter of minutes sometimes for you to find yourself at down to 50. So as a result I think it is an important feature that start cutting the insulin when you are going below 140. Again remember your blood glucose is going down due to exercise anyways so I think that's a good important feature. Now with Metronic you are still set at 120 although what Metronic does it will you can set your low setting if you're a very avid exercise person you can set your low glucose setting a little bit higher which is modifiable with the Metronic sensor which is not modifiable with the DEXCOM that works with tandem. So you can always say okay well I don't want to go low so I'm going to set my low threshold at 80 or 90 and then your pump will start cutting back on your insulin right around 110 and if it goes really down fast it will totally cut your insulin off. So these are the tweaks that you can make in Metronic versus in tandem pump you can just push a button for exercise saying that I'm exercising right now so keep me a little bit higher versus Metronic you just basically need to keep your low threshold a little bit higher. So these are the important features again now we are going to talk about when actually you get kicked out from the automode and that is a fact because these are designed to be safe and you may be kicked out in both closed loop systems to open loop system which is requiring you to basically check your finger stick if there's a problem with the sensor and so forth which we will discuss that in a second. Okay so let's talk about the kick out process. Now one thing that I like about guys with tandem pumps is that you do not necessarily get kicked out unless you do not have any sensor data coming in that is because DEXCOM is approved to make clinical decisions as long as you see a number on the DEXCOM as long as you see an arrow up or down you can make a clinical decision. Now the basic problem with the Metronic sensor unfortunately it is still not approved by the FDA to make clinical decisions. So you will find yourself doing finger sticks multiple times it could be at least two but if not four or more you may end up doing three, four, five finger sticks a day in order to be able to stay within the closed loop system and if you do not do the finger stick since the sensor data is not approved just for the clinical decision making you will be forced to be out of the closed loop system. So closed loop system will adjust your basal insulin delivery but anytime in Metronic if the sensor thinks that the sensor is kind of off you will be asked to enter a blood sugar. If you do not do a finger stick then you're gonna be out you're gonna be in a basal safe basal mode which gives you you know the standard basal rate and if you are really not following the instruction within I think 90 minutes you're out and until you enter a blood sugar you're not getting back in to the closed loop system. Now the problem with the systems is if you're not in the closed loop and if your basal insulin is not being adjusted you're not really going to get the benefit so just remember that. Now also the Metronic will kick you out if your blood sugar is more than 300 for more than an hour that means that the pump basically failed to keep your blood sugar down or the pump does not trust the sensor readings eventually it's gonna ask you to say hey what's your blood sugar if your blood sugar is really 300 more than an hour you should do something about it if you check your pump check your infusion set check your blood sugar make sure you don't have any ketones Metronic just panics on on that regard it's just built extremely safely but it can be annoying sometimes to be extremely safe and so the the other feature with the Metronic is that you know if you are more than 250 for a couple hours again I believe that's three hours again for the safety they make sure that you check your ketones they make sure you check your blood sugar and if you don't do blood sugar check and enter it you may not be able to get back in and if your blood sugars are remaining high if you're not able to control that with a infusion set change or an subcutaneous injection of some sort of correction that brings your blood sugar down then you're not just going to be able to get back in and if your blood sugars are rapidly changing that's one time that you don't want to do calibration so if there is more than 35% change between the sensor reading and the blood sugar reading your pump will not accept that we'll say this is way too confusing I'm out and it's gonna kick you out and then you're gonna be in the dark then you have to handle yourself the pump is not helping you they are doing that for a safety feature but you really be actively hands on involved in following what the pump says and if you're not the type of person who is willing to do finger sticks and blood sugar checks Metronic pump is not gonna be the best pump for you just so you know if you're motivated it can be a good pump but if you're not at this point blood sugar checks are required for you to make a clinical decision and as a rule of thumb guys you always calibrate with any CGM device you always calibrate when your blood sugars are stable don't try to calibrate after you eat or don't try to calibrate when you feel like you're low you're sweating or something that you have symptoms of low blood sugars you don't want to really make calibrations when the blood sugars are rapidly changing in your system