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Kariyawasam D, Morin C, Casteels K, Le Tallec C, Sfez A, Godot C, Huneker E, Garrec N, Benhamou PY, Polak M, Charpentier G, Franc S, Beltrand J. Hybrid closed-loop insulin delivery versus sensor-augmented pump therapy in children aged 6–12 years: a randomised, controlled, cross-over, non-inferiority trial. Lancet Digit Health 2022; 4:e158-e168. [DOI: 10.1016/s2589-7500(21)00271-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 10/22/2021] [Accepted: 11/23/2021] [Indexed: 12/14/2022]
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Lawton J, Blackburn M, Rankin D, Allen J, Campbell F, Leelarathna L, Tauschmann M, Thabit H, Wilinska ME, Hovorka R. The impact of using a closed-loop system on food choices and eating practices among people with Type 1 diabetes: a qualitative study involving adults, teenagers and parents. Diabet Med 2019; 36:753-760. [PMID: 30575114 PMCID: PMC6510609 DOI: 10.1111/dme.13887] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2018] [Indexed: 01/11/2023]
Abstract
AIMS We explored whether, how and why moving onto and using a hybrid day-and-night closed-loop system affected people's food choices and dietary practices to better understand the impact of this technology on everyday life and inform recommendations for training and support given to future users. METHODS Twenty-four adults, adolescents and parents were interviewed before commencing use of the closed-loop system and following its 3-month use. Data were analysed thematically and longitudinally. RESULTS While participants described preparing and/or eating similar meals to those consumed prior to using a closed-loop, many described feeling more normal and less burdened by diabetes in dietary situations. Individuals also noted how the use of this technology could lead to deskilling (less precise carbohydrate counting) and less healthy eating (increased snacking and portion sizes and consumption of fatty, energy-dense foods) because of the perceived ability of the system to deal with errors in carbohydrate counting and address small rises in blood glucose without a corrective dose needing to be administered. CONCLUSIONS While there may be quality-of-life benefits to using a closed-loop, individuals might benefit from additional nutritional and behavioural education to help promote healthy eating. Refresher training in carbohydrate counting may also be necessary to help ensure that users are able to undertake diabetes management in situations where the technology might fail or that they take a break from using it.
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Affiliation(s)
- J. Lawton
- Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghEdinburghUK
| | - M. Blackburn
- Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghEdinburghUK
| | - D. Rankin
- Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghEdinburghUK
| | - J. Allen
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
| | | | - L. Leelarathna
- Manchester Diabetes CentreManchester University NHS Foundation Trust and University of ManchesterManchester Academic Health Science CentreManchesterUK
| | - M. Tauschmann
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
| | - H. Thabit
- Manchester Diabetes CentreManchester University NHS Foundation Trust and University of ManchesterManchester Academic Health Science CentreManchesterUK
| | - M. E. Wilinska
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
| | - R. Hovorka
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
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Ambassadors of hope, research pioneers and agents of change-individuals' expectations and experiences of taking part in a randomised trial of an innovative health technology: longitudinal qualitative study. Trials 2019; 20:289. [PMID: 31133076 PMCID: PMC6537378 DOI: 10.1186/s13063-019-3373-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 04/19/2019] [Indexed: 11/10/2022] Open
Abstract
Background While a growing body of research has explored why people take part in clinical trials, this research has not considered how people’s understandings, motivations and agendas might influence their conduct during a trial. This is an important area of enquiry because it is now widely recognised that an intervention might lead to different clinical outcomes when delivered as part of a trial than when implemented in routine clinical practice; however, the reasons for this are not fully understood. Methods/design We interviewed 24 individuals who took part in a trial of an innovative health technology under development for people with type 1 diabetes which automatically regulates blood glucose: the closed-loop system. Participants were interviewed following randomisation to a closed-loop and at trial closeout. Results Participants provided complex agendas for taking part in which altruistic and self-interested considerations were often inseparable. Many described belonging to a wider diabetes community and being beneficiaries of others’ participation in research and how this had given rise to attendant citizenship obligations. Participants also shared the excitement and pride they experienced from contributing to research which situated them at the forefront of technological innovation and enabled them to present themselves to others, by virtue of their trial participation, as ambassadors of hope and research pioneers. Given their desire to support the progression of a potentially life-changing technology, and be part of that innovation, participants, at follow-up, described having made extra effort during the trial. Specifically, participants described having been more focused on their diabetes management to help create conditions in which the closed-loop could work most effectively to optimize their blood glucose control. Conclusions Our findings contribute a new dimension to understandings of trial effects; specifically, we argue that, to aid interpretation of trial outcomes, participants’ understandings and motivations for participation need to be considered. We highlight the potential pertinence of our findings in the contemporary era of bio-citizenship where, increasingly, people are driving research agendas and see themselves as co-producers of knowledge. We also recommend a new concept be introduced into the literature—‘the altruselfish agenda’—to recognise potential inseparability of self-interested and altruistic motivations. Trial registration ClinicalTrials.gov, NCT02523131. Registered on 14 August 2015.
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Lawton J, Blackburn M, Rankin D, Werner C, Farrington C, Hovorka R, Hallowell N. Broadening the Debate About Post-trial Access to Medical Interventions: A Qualitative Study of Participant Experiences at the End of a Trial Investigating a Medical Device to Support Type 1 Diabetes Self-Management. AJOB Empir Bioeth 2019; 10:100-112. [PMID: 30986113 DOI: 10.1080/23294515.2019.1592264] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Increasing ethical attention and debate is focusing on whether individuals who take part in clinical trials should be given access to post-trial care. However, the main focus of this debate has been upon drug trials undertaken in low-income settings. To broaden this debate, we report findings from interviews with individuals (n = 24) who participated in a clinical trial of a closed-loop system, which is a medical device under development for people with type 1 diabetes that automatically adjusts blood glucose to help keep it within clinically recommended ranges. Individuals were recruited from UK sites and interviewed following trial close-out, at which point the closed-loop had been withdrawn. While individuals were stoical and accepting of the requirement to return the closed-loop, they also conveyed varying degrees of distress. Many described having relaxed diabetes management practices while using the closed-loop and having become deskilled as a consequence, which made reverting back to pre-trial regimens challenging. Participants also described unanticipated consequences arising from using a closed-loop. As well as deskilling, these included experiencing psychological and emotional benefits that could not be sustained after the closed-loop had been withdrawn and participants reevaluating their pre- and post-trial life in light of having used a closed-loop and now perceiving this life much more negatively. Participants also voiced frustrations about experiencing better blood glucose control using a closed-loop and then having to revert to using what they now saw as antiquated and imprecise self-management tools. We use these findings to argue that ethical debates about post-trial provisioning need to be broadened to consider potential psychological and emotional harms, and not just clinical harms, that may result from withdrawal of investigated treatments. We also suggest that individuals may benefit from information about potential nonclinical harms to help make informed decisions about trial participation.
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Affiliation(s)
- J Lawton
- a Usher Institute of Population Health Sciences and Informatics , University of Edinburgh , Edinburgh , United Kingdom
| | - M Blackburn
- a Usher Institute of Population Health Sciences and Informatics , University of Edinburgh , Edinburgh , United Kingdom
| | - D Rankin
- a Usher Institute of Population Health Sciences and Informatics , University of Edinburgh , Edinburgh , United Kingdom
| | - C Werner
- a Usher Institute of Population Health Sciences and Informatics , University of Edinburgh , Edinburgh , United Kingdom
| | - C Farrington
- b Cambridge Centre for Health Services Research , University of Cambridge , United Kingdom
| | - R Hovorka
- c Wellcome Trust-MRC Institute of Metabolic Science , University of Cambridge , Cambridge , United Kingdom.,d Department of Paediatrics , University of Cambridge , Cambridge , United Kingdom
| | - N Hallowell
- e Wellcome Centre for Ethics and Humanities and the Ethox Centre, Nuffield Department of Population Health, Big Data Institute , University of Oxford , Oxford , United Kingdom
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Tauschmann M, Thabit H, Bally L, Allen JM, Hartnell S, Wilinska ME, Ruan Y, Sibayan J, Kollman C, Cheng P, Beck RW, Acerini CL, Evans ML, Dunger DB, Elleri D, Campbell F, Bergenstal RM, Criego A, Shah VN, Leelarathna L, Hovorka R. Closed-loop insulin delivery in suboptimally controlled type 1 diabetes: a multicentre, 12-week randomised trial. Lancet 2018; 392:1321-1329. [PMID: 30292578 PMCID: PMC6182127 DOI: 10.1016/s0140-6736(18)31947-0] [Citation(s) in RCA: 260] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 07/26/2018] [Accepted: 08/15/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The achievement of glycaemic control remains challenging for patients with type 1 diabetes. We assessed the effectiveness of day-and-night hybrid closed-loop insulin delivery compared with sensor-augmented pump therapy in people with suboptimally controlled type 1 diabetes aged 6 years and older. METHODS In this open-label, multicentre, multinational, single-period, parallel randomised controlled trial, participants were recruited from diabetes outpatient clinics at four hospitals in the UK and two centres in the USA. We randomly assigned participants with type 1 diabetes aged 6 years and older treated with insulin pump and with suboptimal glycaemic control (glycated haemoglobin [HbA1c] 7·5-10·0%) to receive either hybrid closed-loop therapy or sensor-augmented pump therapy over 12 weeks of free living. Training on study insulin pump and continuous glucose monitoring took place over a 4-week run-in period. Eligible subjects were randomly assigned using central randomisation software. Allocation to the two study groups was unblinded, and randomisation was stratified within centre by low (<8·5%) or high (≥8·5%) HbA1c. The primary endpoint was the proportion of time that glucose concentration was within the target range of 3·9-10·0 mmol/L at 12 weeks post randomisation. Analyses of primary outcome and safety measures were done in all randomised patients. The trial is registered with ClinicalTrials.gov, number NCT02523131, and is closed to accrual. FINDINGS From May 12, 2016, to Nov 17, 2017, 114 individuals were screened, and 86 eligible patients were randomly assigned to receive hybrid closed-loop therapy (n=46) or sensor-augmented pump therapy (n=40; control group). The proportion of time that glucose concentration was within the target range was significantly higher in the closed-loop group (65%, SD 8) compared with the control group (54%, SD 9; mean difference in change 10·8 percentage points, 95% CI 8·2 to 13·5; p<0·0001). In the closed-loop group, HbA1c was reduced from a screening value of 8·3% (SD 0·6) to 8·0% (SD 0·6) after the 4-week run-in, and to 7·4% (SD 0·6) after the 12-week intervention period. In the control group, the HbA1c values were 8·2% (SD 0·5) at screening, 7·8% (SD 0·6) after run-in, and 7·7% (SD 0·5) after intervention; reductions in HbA1c percentages were significantly greater in the closed-loop group compared with the control group (mean difference in change 0·36%, 95% CI 0·19 to 0·53; p<0·0001). The time spent with glucose concentrations below 3·9 mmol/L (mean difference in change -0·83 percentage points, -1·40 to -0·16; p=0·0013) and above 10·0 mmol/L (mean difference in change -10·3 percentage points, -13·2 to -7·5; p<0·0001) was shorter in the closed-loop group than the control group. The coefficient of variation of sensor-measured glucose was not different between interventions (mean difference in change -0·4%, 95% CI -1·4% to 0·7%; p=0·50). Similarly, total daily insulin dose was not different (mean difference in change 0·031 U/kg per day, 95% CI -0·005 to 0·067; p=0·09) and bodyweight did not differ (mean difference in change 0·68 kg, 95% CI -0·34 to 1·69; p=0·19). No severe hypoglycaemia occurred. One diabetic ketoacidosis occurred in the closed-loop group due to infusion set failure. Two participants in each study group had significant hyperglycaemia, and there were 13 other adverse events in the closed-loop group and three in the control group. INTERPRETATION Hybrid closed-loop insulin delivery improves glucose control while reducing the risk of hypoglycaemia across a wide age range in patients with suboptimally controlled type 1 diabetes. FUNDING JDRF, NIHR, and Wellcome Trust.
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Affiliation(s)
- Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Hood Thabit
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Manchester University NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Lia Bally
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Janet M Allen
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Sara Hartnell
- Department of Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Malgorzata E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Yue Ruan
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | | | | | | | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL, USA
| | - Carlo L Acerini
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Mark L Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David B Dunger
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | | | | | | | - Amy Criego
- International Diabetes Center, Minneapolis, MN, USA
| | - Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lalantha Leelarathna
- Manchester University NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK.
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Benhamou PY, Huneker E, Franc S, Doron M, Charpentier G. Customization of home closed-loop insulin delivery in adult patients with type 1 diabetes, assisted with structured remote monitoring: the pilot WP7 Diabeloop study. Acta Diabetol 2018. [PMID: 29520615 DOI: 10.1007/s00592-018-1123-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AIMS Improvement in closed-loop insulin delivery systems could result from customization of settings to individual needs and remote monitoring. This pilot home study evaluated the efficacy and relevance of this approach. METHODS A bicentric clinical trial was conducted for 3 weeks, using an MPC-based algorithm (Diabeloop Artificial Pancreas system) featuring five settings designed to modulate the reactivity of regulation. Remote monitoring was ensured by expert nurses with a web platform generating automatic Secured Information Messages (SIMs) and with a structured procedure. Endpoints were glucose metrics and description of impact of monitoring on regulation parameters. RESULTS Eight patients with type 1 diabetes (six men, age 41.8 ± 11.4 years, HbA1c 7.7 ± 1.0%) were included. Time spent in the 70-180 mg/dl range was 70.2% [67.5; 76.9]. Time in hypoglycemia < 70 mg/dl was 2.9% [2.1; 3.4]. Eleven SIMs led to phone intervention. Original default settings were modified in all patients by the intervention of the nurses. CONCLUSION This pilot trial suggests that the Diabeloop closed-loop system could be efficient regarding metabolic outcomes, whereas its telemedical monitoring feature could contribute to enhanced efficacy and safety. This study is registered at ClinicalTrials.gov with trial registration number NCT02987556.
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Affiliation(s)
- Pierre Yves Benhamou
- Department of Endocrinology, Pôle DigiDune, Grenoble University Hospital, Grenoble Alpes University, CS 10217, 38043, Grenoble, France.
| | | | - Sylvia Franc
- CERITD (Centre d'Études et de Recherches pour l'Intensification du Traitement du Diabète), Bioparc-Génopole Évry-Corbeil, Évry, France
- Department of Diabetes, Sud-Francilien Hospital, 91106, Corbeil-Essonnes, France
| | - Maeva Doron
- Univ. Grenoble Alpes, 38000, Grenoble, France
- CEA LETI MlNATEC Campus, 38054, Grenoble, France
| | - Guillaume Charpentier
- CERITD (Centre d'Études et de Recherches pour l'Intensification du Traitement du Diabète), Bioparc-Génopole Évry-Corbeil, Évry, France
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Abstract
Development of truly useful wearable physiologic monitoring devices for use in diabetes management is still in its infancy. From wearable activity monitors such as fitness trackers and smart watches to contact lenses measuring glucose levels in tears, we are just at the threshold of their coming use in medicine. Ultimately, such devices could help to improve the performance of sense-and-respond insulin pumps, illuminate the impact of physical activity on blood glucose levels, and improve patient safety. This is a summary of our experience attempting to use such devices to enhance continuous glucose monitoring-augmented insulin pump therapy. We discuss the current status and present difficulties with available devices, and review the potential for future use.
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Affiliation(s)
- Frank L. Schwartz
- Center for Diabetes and Endocrine Diseases, West Virginia University Medicine Camden Clark Medical Center, Parkersburg, WV, USA
- The Diabetes Institute, Ohio University, Athens, OH, USA
| | - Cynthia R. Marling
- The Diabetes Institute, Ohio University, Athens, OH, USA
- School of Electrical Engineering and Computer Science, Russ College of Engineering and Technology, Ohio University, Athens, OH, USA
- Cynthia R. Marling, School of Electrical Engineering and Computer Science, Russ College of Engineering and Technology, Ohio University, 321D Stocker Center, Athens, OH 45701, USA.
| | - Razvan C. Bunescu
- The Diabetes Institute, Ohio University, Athens, OH, USA
- School of Electrical Engineering and Computer Science, Russ College of Engineering and Technology, Ohio University, Athens, OH, USA
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Rigla M, Pons B, Rebasa P, Luna A, Pozo FJ, Caixàs A, Villaplana M, Subías D, Bella MR, Combalia N. Human Subcutaneous Tissue Response to Glucose Sensors: Macrophages Accumulation Impact on Sensor Accuracy. Diabetes Technol Ther 2018; 20:296-302. [PMID: 29470128 DOI: 10.1089/dia.2017.0321] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Subcutaneous (s.c.) glucose sensors have become a key component in type 1 diabetes management. However, their usability is limited by the impact of foreign body response (FBR) on their duration, reliability, and accuracy. Our study gives the first description of human acute and subacute s.c. response to glucose sensors, showing the changes observed in the sensor surface, the inflammatory cells involved in the FBR and their relationship with sensor performance. METHODS Twelve obese patients (seven type 2 diabetes) underwent two abdominal biopsies comprising the surrounding area where they had worn two glucose sensors: the first one inserted 7 days before and the second one 24 h before biopsy procedure. Samples were processed and studied to describe tissue changes by two independent pathologists (blind regarding sensor duration). Macrophages quantification was studied by immunohistochemistry methods in the area surrounding the sensor (CD68, CD163). Sensor surface changes were studied by scanning electron microscopy. Seven-day continuous glucose monitoring records were considered inaccurate when mean absolute relative difference was higher than 10%. RESULTS Pathologists were able to correctly classify all the biopsies regarding sensor duration. Acute response (24 h) was characterized by the presence of neutrophils while macrophages were the main cell involved in subacute inflammation. The number of macrophages around the insertion hole was higher for less accurate sensors compared with those performing more accurately (32.6 ± 14 vs. 10.6 ± 1 cells/0.01 mm2; P < 0.05). CONCLUSION The accumulation of macrophages at the sensor-tissue interface is related with decrease in accuracy of the glucose measure.
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Affiliation(s)
- Mercedes Rigla
- 1 Endocrinology Department, Parc Taulí Sabadell University Hospital, Institut d'Investigacio i Innovació Parc Taulí, Autonomous University of Barcelona , Barcelona, Spain
| | - Belén Pons
- 1 Endocrinology Department, Parc Taulí Sabadell University Hospital, Institut d'Investigacio i Innovació Parc Taulí, Autonomous University of Barcelona , Barcelona, Spain
| | - Pere Rebasa
- 2 General Surgery Department, Parc Taulí Sabadell University Hospital, Institut d'Investigacio i Innovació Parc Taulí, Autonomous University of Barcelona , Barcelona, Spain
| | - Alexis Luna
- 2 General Surgery Department, Parc Taulí Sabadell University Hospital, Institut d'Investigacio i Innovació Parc Taulí, Autonomous University of Barcelona , Barcelona, Spain
| | - Francisco Javier Pozo
- 3 Pathology Department, Parc Taulí Sabadell University Hospital, Institut d'Investigacio i Innovació Parc Taulí, Autonomous University of Barcelona , Barcelona, Spain
| | - Assumpta Caixàs
- 1 Endocrinology Department, Parc Taulí Sabadell University Hospital, Institut d'Investigacio i Innovació Parc Taulí, Autonomous University of Barcelona , Barcelona, Spain
| | - Maria Villaplana
- 1 Endocrinology Department, Parc Taulí Sabadell University Hospital, Institut d'Investigacio i Innovació Parc Taulí, Autonomous University of Barcelona , Barcelona, Spain
| | - David Subías
- 1 Endocrinology Department, Parc Taulí Sabadell University Hospital, Institut d'Investigacio i Innovació Parc Taulí, Autonomous University of Barcelona , Barcelona, Spain
| | - Maria Rosa Bella
- 3 Pathology Department, Parc Taulí Sabadell University Hospital, Institut d'Investigacio i Innovació Parc Taulí, Autonomous University of Barcelona , Barcelona, Spain
| | - Neus Combalia
- 3 Pathology Department, Parc Taulí Sabadell University Hospital, Institut d'Investigacio i Innovació Parc Taulí, Autonomous University of Barcelona , Barcelona, Spain
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Lawton J, Blackburn M, Allen J, Campbell F, Elleri D, Leelarathna L, Rankin D, Tauschmann M, Thabit H, Hovorka R. Patients' and caregivers' experiences of using continuous glucose monitoring to support diabetes self-management: qualitative study. BMC Endocr Disord 2018; 18:12. [PMID: 29458348 PMCID: PMC5819241 DOI: 10.1186/s12902-018-0239-1] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 02/08/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Continuous glucose monitoring (CGM) enables users to view real-time interstitial glucose readings and provides information on the direction and rate of change of blood glucose levels. Users can also access historical data to inform treatment decisions. While the clinical and psychological benefits of CGM are well established, little is known about how individuals use CGM to inform diabetes self-management. We explored participants' experiences of using CGM in order to provide recommendations for supporting individuals to make optimal use of this technology. METHODS In-depth interviews (n = 24) with adults, adolescents and parents who had used CGM for ≥4 weeks; data were analysed thematically. RESULTS Participants found CGM an empowering tool because they could access blood glucose data effortlessly, and trend arrows enabled them to see whether blood glucose was rising or dropping and at what speed. This predicative information aided short-term lifestyle planning and enabled individuals to take action to prevent hypoglycaemia and hyperglycaemia. Having easy access to blood glucose data on a continuous basis also allowed participants to develop a better understanding of how insulin, activity and food impacted on blood glucose. This understanding was described as motivating individuals to make dietary changes and break cycles of over-treating hypoglycaemia and hyperglycaemia. Participants also described how historical CGM data provided a more nuanced picture of blood glucose control than was possible with blood glucose self-monitoring and, hence, better information to inform changes to background insulin doses and mealtime ratios. However, while participants expressed confidence making immediate adjustments to insulin and lifestyle to address impending hypoglycaemia and hypoglycaemia, most described needing and expecting health professionals to interpret historical CGM data and determine changes to background insulin doses and mealtime ratios. While alarms could reinforce a sense of hypoglycaemic safety, some individuals expressed ambivalent views, especially those who perceived alarms as signalling personal failure to achieve optimal glycaemic control. CONCLUSIONS CGM can be an empowering and motivational tool which enables participants to fine-tune and optimize their blood glucose control. However, individuals may benefit from psycho-social education, training and/or technological support to make optimal use of CGM data and use alarms appropriately.
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Affiliation(s)
- J. Lawton
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - M. Blackburn
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - J. Allen
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | | | - D. Elleri
- Royal Hospital for Sick Children, Edinburgh, UK
| | - L. Leelarathna
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - D. Rankin
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - M. Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - H. Thabit
- Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R. Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
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Phillips BE, Garciafigueroa Y, Trucco M, Giannoukakis N. Clinical Tolerogenic Dendritic Cells: Exploring Therapeutic Impact on Human Autoimmune Disease. Front Immunol 2017; 8:1279. [PMID: 29075262 PMCID: PMC5643419 DOI: 10.3389/fimmu.2017.01279] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/25/2017] [Indexed: 12/22/2022] Open
Abstract
Tolerogenic dendritic cell (tDC)-based clinical trials for the treatment of autoimmune diseases are now a reality. Clinical trials are currently exploring the effectiveness of tDC to treat autoimmune diseases of type 1 diabetes mellitus, rheumatoid arthritis, multiple sclerosis (MS), and Crohn's disease. This review will address tDC employed in current clinical trials, focusing on cell characteristics, mechanisms of action, and clinical findings. To date, the publicly reported human trials using tDC indicate that regulatory lymphocytes (largely Foxp3+ T-regulatory cell and, in one trial, B-regulatory cells) are, for the most part, increased in frequency in the circulation. Other than this observation, there are significant differences in the major phenotypes of the tDC. These differences may affect the outcome in efficacy of recently launched and impending phase II trials. Recent efforts to establish a catalog listing where tDC converge and diverge in phenotype and functional outcome are an important first step toward understanding core mechanisms of action and critical "musts" for tDC to be therapeutically successful. In our view, the most critical parameter to efficacy is in vivo stability of the tolerogenic activity over phenotype. As such, methods that generate tDC that can induce and stably maintain immune hyporesponsiveness to allo- or disease-specific autoantigens in the presence of powerful pro-inflammatory signals are those that will fare better in primary endpoints in phase II clinical trials (e.g., disease improvement, preservation of autoimmunity-targeted tissue, allograft survival). We propose that pre-treatment phenotypes of tDC in the absence of functional stability are of secondary value especially as such phenotypes can dramatically change following administration, especially under dynamic changes in the inflammatory state of the patient. Furthermore, understanding the outcomes of different methods of cell delivery and sites of delivery on functional outcomes, as well as quality control variability in the functional outcomes resulting from the various approaches of generating tDC for clinical use, will inform more standardized ex vivo generation methods. An understanding of these similarities and differences, with a reference point the large number of naturally occurring tDC populations with different immune profiles described in the literature, could explain some of the expected and unanticipated outcomes of emerging tDC clinical trials.
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Affiliation(s)
- Brett Eugene Phillips
- Allegheny Health Network Institute of Cellular Therapeutics, Allegheny General Hospital, Pittsburgh, PA, United States
| | - Yesica Garciafigueroa
- Allegheny Health Network Institute of Cellular Therapeutics, Allegheny General Hospital, Pittsburgh, PA, United States
| | - Massimo Trucco
- Allegheny Health Network Institute of Cellular Therapeutics, Allegheny General Hospital, Pittsburgh, PA, United States.,Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, United States
| | - Nick Giannoukakis
- Allegheny Health Network Institute of Cellular Therapeutics, Allegheny General Hospital, Pittsburgh, PA, United States.,Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, United States
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