Scott Hanselman

Open Source Artificial Pancreases will become the new standard of care for Diabetes in 2019

April 23, '19 Comments [12] Posted in Diabetes
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Loop is an open source pancreas for iPhoneI've been a Type 1 diabetic for over 25 years. Diabetes sucks. They actually give you an award for staying alive for years on insulin. Diabetics don't usually die of old age, they die of heart disease or stroke, kidney failure, and while they're at it they may go blind, get nerve damage, amputation, and a bunch of other stuff. It used to be a death sentence but when insulin was introduced as a treatment in 1921, there was a chance for something new.

The idea is if you keep your blood sugars close to normal - if you can simulate your non-working pancreas - you'll get hit by an ice cream truck! At least, that's how I hope I go. :)

  • Early on it was boiling big gauge steel needles and pork insulin to dose, and peeing on a stick to get a sense of sugar levels.
  • Then it was a dozen finger pricks a day and a half dozens manual shots with a syringe.
  • Then it was inserted continuous glucose meters and insulin pumps that - while not automatic - mean less invasive treatment and greater control.

Today, we are closing the loop. What's the loop? It's this:

  1. Consider my glucose levels, what I'm about to eat, and what I'm about to to (and dozens of other environmental factors)
  2. Dose myself with insulin
  3. GOTO 1. Every few hours, or every few minutes, depending on the situation.

I do that. Manually. Every diabetic does, and the mental pressure - the intense background psychic weight of it all - is overwhelming. We want to lower the cognitive load of diabetes. This is a disease where you may not live as long if you're not good at math. Literally. That's unfair.

The community is "looping" by allowing an algorithm to make some of those decisions for me.

I've personally been looping with an open source artificial pancreas for over two years. It's night and day from where I started with finger sticks and a half dozen needle sticks a day. It's not perfect, it's not automatic, but Open Source Pancreas are "Tesla autopilot for diabetes." It doesn't always park the car right or stop at every stop light, but it works very hard to keep me in-between the lines and going straight ahead and now that I have it, I can't imagine living without it.

I sleep through the night while my Loop makes tiny adjustments every five minutes to keep my sugars as flat as possible. I don't know about you but my pancreas sits on my nightstand.

It's happening and it can't be stopped

Seven years ago I wrote about The Sad State of Diabetes Technology in 2012. Three years ago The Promising State of Diabetes Technology in 2016 and last year The Extremely Promising State of Diabetes Technology in 2018. There's a great comment from the first blog post in 2012 where Howard Loop shared his frustration with the state of things. Unlike most commenters on the Internet, amazingly Howard took action and started the Tidepool Organization! Everything in his comment from 7 years ago is happening.
Great article, Scott. You've accurately captured the frustration I've felt since my 12 year old daughter was diagnosed with T1D nine months ago. She also wears a pump and CGM and bravely performs the ritual you demonstrate in your video every three days. The technology is so retro it's embarrassing.

It's 2019 and things are really looking up. The open source DIY diabetes community is thriving. There are SEVERAL open pancreas systems to choose from and there's constant innovation happening with OpenAPS and Loop/LoopKit.

  • OpenAPS runs on devices like Raspberry Pi Zeros and is a self-contained pancreas with the communications and brain/algorithm all on the main device.
  • Loop runs on an iPhone and uses a "RileyLink" devices that bridges the RF (Radio Frequency) insulin pump communications with modern Bluetooth.

The first bad part is I am running a 15 year old out of warranty cracked insulin pump I bought on Craigslist. Most new pumps are locked down, and my old pump is the last version that supported remote control. However, the Loop open source project announced support for a second pump this week, the OmniPod Eros. This is the first time an "in warranty" pump has been supported and it also proves the larger point made by the diabetes community. We Are Not Waiting. We want open choice and open data and open choices that put us in control.

Read about the history of Loop by original developer Nate Racklyeft. As he points out, a thing like Loop or OpenAPS is the result of a thousand little steps and innovation by countless community members who are so generous with their time.

The first system to run it was a Raspberry Pi; the code was a series of plugins, written with the help of Chris Hannemann, to the openaps toolkit developed by Ben West in collaboration with Dana Lewis and Scott Leibrand. I’m still in awe of the elegant premise in Ben’s design: a system of repeatable, recordable, and extendable transform commands, all backed by Git. The central plugin of the toolkit is decocare: Ben’s 5-year magnum opus, a reverse-engineered protocol of the Minimed Carelink USB radio to command insulin pumps.

There's an amazing write up by Pete Schwamb, one of the core members of the community who works on Loop full time now,  on how Software Defined Radios have allowed the community to "sniff" the communication protocols of insulin pumps in the RF spectrum and reverse engineer the communications for the Medtronic and now Omnipod Eros Insulin Pumps. It's a fascinating read that really illustrates how you just need the right people and a good cause and you can do anything.

You can watch my video presentation "Solving Diabetes with an Open Source Artificial Pancreas" where I offer an overview of the problem, a number solutions offered over the year, and two open source pancreas options in the form of LoopKit and OpenAPS.

The community members and organizations like Tidepool and the Nightscout Foundation are working with the FDA to take projects and concepts like an open source pancreas system from a threat based on years of frustration to a bright future based on mutual collaboration!

In March, 2018, the FDA announced a de novo iCGM (integrated CGM) designation. A de novo designation is the FDA process for creating new device classifications, in this case moving qualifying CGMs from Class-III, the highest FDA risk classification, to Class-II with Special Controls. The first CGM to get this designation is the Dexcom G6.

Diabetic Xbox AvatarWhat does this mean? It means the FDA is willing to classify continuous glucose meters in a formal way that paves a path towards interoperable devices. Today we hack devices to build these Loops with out-of-warranty pumps. We are doing this utterly on our own. It can take months to collect the equipment needed, get ancient pumps on the gray market, compile the software yourself - which is a huge hurdle for the non-technical.

Imagine a future where someone could buy a supported and in-warranty "iPump," download an officially supported app or package, and start looping! We could have world of open and interoperable devices and swappable algorithms.

In October of 2018 the non-profit Tidepool organization announced its intent to deliver the Loop app as a supported and FDA-regulated mobile app in the Apple App Store! This is happening, people but we are just getting started.

To learn more, start reading.

Also, if you're diabetic, consider buying a Nightscout Xbox Avatar accessory so you can see yourself represented while you game!


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About Scott

Scott Hanselman is a former professor, former Chief Architect in finance, now speaker, consultant, father, diabetic, and Microsoft employee. He is a failed stand-up comic, a cornrower, and a book author.

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Xbox Avatar accessories for People with Diabetes! Sponsored by Nightscout and Konsole Kingz

March 14, '19 Comments [3] Posted in Diabetes | Gaming
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My Xbox user name is Glucose for a reason.

This is a passion project of mine. You've likely seen me blog about diabetes for many many years. You may have enjoyed my diabetes hacks like lighting up my keyboard keys to show me my blood sugar, or some of the early work Ben West and I did to bridge Dexcom's cloud with the NightScout open source diabetes management system.

Recently Xbox announced new avatars! They look amazing and the launch was great. They now have avatars in wheelchairs, ones with artificial limbs, and a wide variety of hair and skin tones. This is fantastic as it allows kids (and adults!) to be seen and be represented in their medium of choice, video games.

I was stoked and immediately searched the store for "diabetes." No results. No pumps, sensors, emotes, needles, nothing. So I decided to fix it.

NOW AVAILABLE: Go and buy the Nightscout Diabetes CGM avatar on the Xbox Store now!

I called two friends - my friends at the Nightscout Foundation, dedicated to open source and open data for people with diabetes, as well as my friends at Konsole Kingz, digital avatar creators extraordinaire with over 200 items in the Xbox store from kicks to jerseys and tattoos.

And we did it! We've added our first diabetes avatar top with some clever coding from Konsole Kingz, it is categorized as a top but gives your avatar not only a Nightscout T-Shirt with your choice of colors, but also a CGM (Continuous Glucose Meter) on your arm!

Miss USA has a CGMFor most diabetics, CGMs are the hardware implants we put in weekly to tell us our blood sugar with minimal finger sticks. They are the most outwardly obvious physical manifestation of our diabetes and we're constantly asked about them. In 2017, Miss USA contestant Krista Ferguson made news by showing her CGM rather than hiding it. This kind of visible representation matters to kids with diabetes - it tells them (and us) that we're OK.

You can find the Nightscout CGM accessory in a nuimber of ways. You can get it online at the Xbox Avatar shop, and when you've bought it, it'll be in the Purchased Tab of the Xbox Avatar Editor, under Closet | Tops.

You can even edit your Xbox Avatar on Windows 10 without an Xbox! Go pick up the Xbox Avatar Editor and install it (on both your PC and Xbox if you like) and you can experiment with shirt and logo color as well.

Consider this a beta release. We are working on improving resolution and quality, but what we really what to know is this - Do you want more Diabetes Xbox Avatar accessories? Insulin pumps on your belt? An emote to check your blood sugar with a finger stick?

Diabetes CGM on an Xbox avatar

If this idea is a good one and is as special to you and your family (and the gamers in your life with diabetes) please SHARE it. Share it on social media, tell your friends at the news. Profits from this avatar item will go to the Nightscout Foundation!


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About Scott

Scott Hanselman is a former professor, former Chief Architect in finance, now speaker, consultant, father, diabetic, and Microsoft employee. He is a failed stand-up comic, a cornrower, and a book author.

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Lighting up my DasKeyboard with Blood Sugar changes using my body's REST API

February 7, '19 Comments [12] Posted in Diabetes | Open Source
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imageI've long blogged about the intersection of diabetes and technology. From the sad state of diabetes tech in 2012 to its recent promising resurgence, it's clear that we are not waiting.

If you're a Type 1 Diabetic using a CGM - a continuous glucose meter - you'll want to set up Nightscout so you can have a REST API for your sugar. The CGM checks my blood sugar every 5 minutes, it hops via BLE over to my phone and then to the cloud. You'll want your sugars stored in cloud storage that YOU control. CGM vendors have their own cloud, but we can easily bridge over to a MongoDB database.

I run Nightscout in Azure and my body has a REST API. I can do an HTTP GET like this:

/api/v1/entries.json?count=3

and get this

[
{
_id: "5c6066d477b2a69a0a7810e5",
sgv: 143,
date: 1549821626000,
dateString: "2019-02-10T18:00:26.000Z",
trend: 4,
direction: "Flat",
device: "share2",
type: "sgv"
},
{
_id: "5c6065a877b2a69a0a7801ce",
sgv: 134,
date: 1549821326000,
dateString: "2019-02-10T17:55:26.000Z",
trend: 4,
direction: "Flat",
device: "share2",
type: "sgv"
},
{
_id: "5c60647b77b2a69a0a77f381",
sgv: 130,
date: 1549821026000,
dateString: "2019-02-10T17:50:26.000Z",
trend: 4,
direction: "Flat",
device: "share2",
type: "sgv"
}
]

I can change the URL from a .json to a .txt and get this

2019-02-10T18:00:26.000Z    1549821626000    143    Flat    
2019-02-10T17:55:26.000Z 1549821326000 134 Flat
2019-02-10T17:50:26.000Z 1549821026000 130 Flat

The "flat" value at the end is part of an enum that can give me a generalized trend value. Diabetics need to manage our sugars at the least hour by hour and sometimes minute by minute. As such it's super important that we have "glanceable displays." That means anything at all that gives me a sense (a sixth sense, if you will) of how I'm doing.

That might be:

I got a Das Keyboard 5Q recently - I first blogged about Das Keyboard in 2006! and noted that it's got it's own local REST API. I'm working on using their Das Keyboard Q software's Applet API to light up just the top row of keys in response to my blood sugar changing. It'll use their Node packages and JavaScript and run in the context of their software.

However, since the keyboard has a localhost REST API and so does my blood sugar, I busted out this silly little shell script. Add a cron job and my keyboard can turn from orange (low), to green, yellow, red (high) as my sugar changes. That provides a nice ambient notifier of how my sugars are doing. Someone on Twitter said "who looks at their keyboard?" I mean, OK, that's just silly. If my entire keyboard turns red I will notice it. Again, ambient. I could certainly add an alert and make a klaxon go off if you'd like.

#!/bin/sh
# This script colorize all LEDs of a 5Q keyboard
# by sending JSON signals to the Q desktop public API.
# based on Blood Sugar values from Nightscout
set -e # quit on first error.
PORT=27301

# Colorize the 5Q keyboard
PID="DK5QPID" # product ID

# Zone are LED groups. There are less than 166 zones on a 5Q.
# This should cover the whole device.
MAX_ZONE_ID=166

# Get blood sugar from Nightscout as TEXT
red=#f00
green=#0f0
yellow=#ff0
#deep orange is LOW sugar
COLOR=#f50
bgvalue=$(curl -s https://MYSITE/api/v1/entries.txt?count=1 | grep -Eo '000\s([0-9]{1,3})+\s' | cut -f 2)
if [ $bgvalue -gt 80 ]
then
COLOR=$green
if [ $bgvalue -gt 140 ]
then
COLOR=$yellow
if [ $bgvalue -gt 200 ]
then
COLOR=$red
fi
fi
fi

echo "Sugar is $bgvalue and color is $COLOR!"

for i in `seq $MAX_ZONE_ID`
do
#echo "Sending signal to zoneId: $i"
# important NOTE: if field "name" and "message" are empty then the signal is
# only displayed on the devices LEDs, not in the signal center
curl -s -S --output /dev/null -X POST --header 'Content-Type: application/json' --header 'Accept: application/json' -d '{
"name": "Nightscout",
"id": "'$i'",
"message": "Blood sugar is '$bgvalue'",
"pid": "'$PID'",
"zoneId": "'"$i"'",
"color": "'$COLOR'",
"effect": "SET_COLOR"

}' "http://localhost:$PORT/api/1.0/signals"

done
echo "\nDone.\n\"

This local keyboard API is meant to send a signal to a single zone or key, so it's hacky of me (and them, really) to make 100+ REST calls to color the whole keyboard. But, it's a localhost call and it's not that spendy. This will go away when I move to their new API. Here's a video of it working.

You can also hit the volume button on the keyboard an any "signaled" (lit up) key and get a popup with the actual blood sugar value (that's 'message' in the second curl command above). Again, this is a hack but I'm going to make it a formal applet you can just install from the store. If you want to help (I'm slow) head to the code here https://github.com/shanselman/DasKeyboard-Q-NightScout

What are some other good ideas for ambient sugar alerts? An LCD strip around the monitor (bias lighting)? A Phillips Hue smart light?

Consider also that you could use the glanceable display idea for pulse, anxiety, blood pressure - anything in your body you could hook up to in real- or near-realtime.


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About Scott

Scott Hanselman is a former professor, former Chief Architect in finance, now speaker, consultant, father, diabetic, and Microsoft employee. He is a failed stand-up comic, a cornrower, and a book author.

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The Extremely Promising State of Diabetes Technology in 2018

September 7, '18 Comments [6] Posted in Diabetes
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This blog post is an update to these two Diabetes Technology blog posts:

You might also enjoy this video of the talk I gave at WebStock 2018 on Solving Diabetes with an Open Source Artificial Pancreas*.

First, let me tell you that insulin is too expensive in the US.

Between 2002 and 2013, the price of insulin jumped, with the typical cost for patients increasing from about $40 a vial to $130.

Open Source Artificial Pancreas on iPhoneFor some of the newer insulins like the ones I use, I pay as much as $296 a bottle. I have a Health Savings Plan so this is often out of pocket until I hit the limit for the year.

People in America are rationing insulin. This is demonstrable fact. I've personally mailed extra insulin to folks in need. I've meet young people who lost their insurance at age 26 and have had to skip shots to save vials of insulin.

This is a problem, but on the technology side there's some extremely promising work happening, and it's we have really hit our stride in the last ten years.

I wrote the first Glucose Management system for the PalmPilot in 1998 called GlucoPilot and provided on the go in-depth analysis for the first time. The first thing that struck me was that the PalmPilot and the Blood Sugar Meter were the same size. Why did I need two devices with batteries, screens, buttons and a CPU? Why so many devices?

I've been told every year the a Diabetes Breakthrough is coming "in five years." It's been 25 years.

In 2001 I went on a trip across the country with my wife, an insulin pump and 8 PDAs (personal digital assistants, the "iPhones" of the time) and tried to manage my diabetes using all the latest wireless technology...this was the latest stuff 17 years ago. I had just moved from injections to an insulin pump. Even now in 2018 Insulin Pumps are expensive, mostly proprietary, and super expensive. In fact, many folks use insulin pumps in the states use out of warranty pumps purchased on Craigslist.

Fast forward to 2018 and I've been using an Open Source Artificial Pancreas for two years.

The results speak for themselves. While I do have bad sugars sometimes, and I do struggle, if you look at my blood work my HA1c (the long term measurement of "how I'm doing" shows non-diabetic levels. To be clear - I'm fully and completely Type 1 diabetic, I produce zero insulin of my own. I take between 40 and 50 Units of insulin every day, and have for the last 25 years...but I will likely die of old age.

This is significant. Why? Because historically diabetics die of diabetes. While we wait (or more accurately, #WeAreNotWaiting) for a biological/medical solution to Type 1 diabetes, the DIY (Do It Yourself) community is just doing it ourselves.

Building on open hardware, open software, and reverse-engineered protocols for proprietary hardware, the online diabetes community literally has their choice of open source pancreases in 2018! Who would have imagined it. You can choose your algorithms, your phone, your pump, your continuous glucose meter.

Today, in 2018, you can literally change the code and recompile a personal branch of your own pancreas.

Watch my 2010 YouTube video "I am Diabetic" as I walk you through the medical hardware (pumps, needles, tubes, wires) in managing diabetes day to day. Then watch my 2018 talk on Solving Diabetes with an Open Source Artificial Pancreas*.

I believe that every diabetic should be offered a pump, a continuous glucose meter, and trained on some kind of artificial pancreas. A cloud based reporting system has also been a joy. My wife and family can see my sugar in real time when I'm away. My wife has even called me overseas to wake me up when I was in a bad sugar situation.

Artificial Pancreas generations

As the closed-hardware and closed-software medical companies work towards their own artificial pancreases, the open source community feel those companies would better serve us by opening up their protocols, using standard Bluetooth ISO profiles and use security best practices.

Looking at the table above, the open source community is squarely in #4 and moving quickly into #5. But why did we have to do this ourselves? We got tired of waiting.

All in all, through open software and hardware, I can tell you that my life is SO MUCH BETTER than it was when I was first diagnosed. I figure we'll have this all figured out in about five years, right? ;)

THANK YOU!

MORE DIABETES READING

* Yes there are some analogies, stretched metaphors, and oversimplifications in this talk. This talk is an introduction to the space to the normally-sugared. If you are a diabetes expert you might watch and say...eh...ya, I mean, it kind of works like that. Please take the talk in in the thoughtful spirit it was intended.


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About Scott

Scott Hanselman is a former professor, former Chief Architect in finance, now speaker, consultant, father, diabetic, and Microsoft employee. He is a failed stand-up comic, a cornrower, and a book author.

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Visualizing your real-time blood sugar values AND a Git Prompt on Windows PowerShell and Linux Bash

December 17, '17 Comments [4] Posted in Diabetes
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imageMy buddy Nate become a Type 1 Diabetic a few weeks back. It sucks...I've been one for 25 years. Nate is like me - an engineer - and the one constant with all engineers that become diabetic, we try to engineer our ways out of it. ;) I use an open source artificial pancreas system with an insulin pump and continuous glucose system. At the heart of that system is some server-side software called Nightscout that has APIs for managing my current and historical blood sugar. It's updated every 5 minutes, 24 hours a day.

I told Nate to get NightScout set up ASAP and start playing with the API. Yesterday Nate added his blood sugar to his terminal prompt!

I love this. He uses Linux, but I use Linux (Ubuntu) on Windows 10, so I wanted to see if I could run his little node up from Windows (I'll make it a Windows service).

Yes, you can run cron jobs under Windows 10's Ubuntu, but only when there is an instance of bash running (the Linux subsystem shuts down when it's not used) and upstart doesn't work yet. I could run it from the .bashrc or use various hacks/workarounds to keep WSL (Windows Subsystem for Linux) running, but the benefit of running this as a Windows Service is that I can see my blood sugar in all prompts on Windows, like Powershell as well!

I'll use the "non-sucking service manager (NSSM)" to run Nate's non-Windows-service node app as a Windows service. I ran "nssm install nsprompt" and get this GUI. Then I add the --nightscout parameter and pass in my Nightscout blood sugar website. You'll get an error immediately when the service runs if this is wrong.

NSSM Service Installer

From the Log on tab, make sure the service is logged on as you. I login with my MSA (Microsoft Account) so I used my email address. This is to ensure that with the app writes to ~ on Windows, it's putting your sugars in c:\users\LOGGEDINUSER\.

Next, run the service with "sc start NSPrompt" or from the Services GUI.

My sugar updater runs in a Windows Service

Nate's node app gets blood sugar from Nightscout and puts it in ~/.bgl-cache. However, to be clear since I'm running it from the Windows side while changing the Bash/Ubuntu on Windows prompt from Linux, it's important to note that from WIndows ~/ is really c:\users\LOGGEDINUSER\ so I changed the Bash .profile to load the values from the Windows mnt'ed drives like this:

eval "$(cat /mnt/c/Users/scott/.bgl-cache)"

Also, you need to make sure that you're using a Unicode font in your console. For example, I like using Fira Code Light, but it doesn't have a single character ⇈ double-up arrow (U+21C8), so I replaced it with two singles. You get the idea. You need a font that has the glyphs you want and you need those glyphs displaying properly in your .profile text file.

You'll need a Unicode Font

And boom. It's glorious. My current blood sugar and trends in my prompt. Thanks Nate!

My sugars!

So what about PowerShell as well? I want to update that totally different prompt/world/environment/planet from the same file that's updated by the service. Also, I already have a custom prompt with Git details since I use Posh-Git from Keith Dahlby (as should you).

I can edit $profile.CurrentUserAllHosts with "powershell_ise $profile.CurrentUserAllHosts" and add a prompt function before "import-module posh-git."

Here's Nate's same prompt file, translated into a PowerShell prompt() method, chained with PoshGit. So I can now see my Git Status AND my Blood Sugar. My two main priorities!

NOTE: If you don't use posh-git, you can remove the "WriteVcsStatus" line and the "Import-Module posh-git" and you should be set!

function prompt {
Get-Content $ENV:USERPROFILE\.bgl-cache | %{$bgh = @{}} {if ($_ -match "local (.*)=""(.*)""") {$bgh[$matches[1]]=$matches[2].Trim();}}
$trend = "?"
switch ($bgh.nightscout_trend) { "DoubleUp" {$trend="↑↑"} "SingleUp" {$trend="↑"} "FortyFiveUp" {$trend="↗"} "Flat" {$trend="→"} "FortyFiveDown" {$trend="↘"} "SingleDown" {$trend="↓"} "DoubleDown" {$trend="↓↓"} }
$bgcolor = [Console]::ForegroundColor.ToString()
if ([int]$bgh.nightscout_bgl -ge [int]$bgh.nightscout_target_top) {
$bgcolor = "Yellow"
} ElseIf ([int]$bgh.nightscout_bgl -le [int]$bgh.nightscout_target_bottom) {
$bgcolor = "Red"
} Else {
$bgcolor = "Green"
}

Write-Host $bgh.nightscout_bgl -NoNewline -ForegroundColor $bgcolor
Write-Host $trend" " -NoNewline -ForegroundColor $bgcolor
[Console]::ResetColor()

$origLastExitCode = $LASTEXITCODE
Write-Host $ExecutionContext.SessionState.Path.CurrentLocation -NoNewline
Write-VcsStatus
$LASTEXITCODE = $origLastExitCode
"$('>' * ($nestedPromptLevel + 1)) "
}

Import-Module posh-git

Very cool stuff.

Blood Sugar and Git in PowerShell!

This concept, of course, could be expanded to include your heart rate, FitBit steps, or any health related metrics you'd like! Thanks Nate for the push to get this working on Windows!


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About Scott

Scott Hanselman is a former professor, former Chief Architect in finance, now speaker, consultant, father, diabetic, and Microsoft employee. He is a failed stand-up comic, a cornrower, and a book author.

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Disclaimer: The opinions expressed herein are my own personal opinions and do not represent my employer's view in any way.