Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Monetary reinforcement for self-monitoring of blood glucose among young people with type 1 diabetes: evaluating effects on psychosocial functioning

AIMS

To explore the auxiliary psychosocial effects of a monetary reinforcement intervention targeting self-monitoring of blood glucose among young people with Type 1 diabetes.

METHODS

Sixty young people with Type 1 diabetes, HbA_1c concentrations between 58 and 119 mmol/mol (7.5-13.0%), and average self-monitoring of blood glucose <4 times per day were randomized to either enhanced usual care or a 24-week intervention of monetary rewards for self-monitoring of blood glucose and associated behaviours (e.g. uploading glucose meters). Data were collected from the young people and their parents at baseline, during the intervention (6, 12 and 24 weeks) and after the intervention (36 weeks).

RESULTS

Linear mixed models were used to evaluate the intervention effects on psychosocial outcomes, adjusting for corresponding baseline levels and potential moderation by baseline level. The intervention reduced diabetes distress at week 6 among young people who had average and high baseline distress. It also reduced diabetes distress at weeks 12 and 24 among those with low baseline distress. The intervention also reduced young person-reported diabetes-related family conflict and diabetes-related interference among those with high baseline scores in these areas; however, the intervention worsened young person-reported diabetes interference among those with low baseline interference. Effects were medium-sized and time-limited.

CONCLUSIONS

Findings indicate predominantly positive impacts of monetary reinforcement interventions on psychosocial outcomes, although effects varied by outcome and time point. Whereas early improvements in diabetes distress were observed for all who received the intervention, improvements in other areas varied according to the level of psychosocial challenge at baseline. Incorporating psychosocial interventions may bolster and maintain effects over time.

K Shell Fluorescence Parameters by Impact of 5.96 keV Photons on Ti and Its Compounds

K shell fluorescence parameters of pure Ti and some of its compounds have been determined experimentally using an Ultra-LEGe detector with resolution 150 eV at 5.9 keV. The samples were excited 5.96 keV photons emitted from a (55)Fe radioisotope source with 50 mCi activity. The experimental values of the K shell fluorescence parameters have been compared with the experimental and theoretical values available in the literature for pure Ti.

Measurement of L(III) Subshell Absorption Jump Parameters of Hafnium

The L(III) subshell absorption jump ratio and jump factor of hafnium have been measured using two different ways which are X-ray attenuation method and Energy Dispersive X-ray Fluorescence technique. The results obtained both ways have been compared with theoretical values. They are in good agreement with each other.

Closer to ideal insulin action: ultra fast acting insulins

Mimicking physiologic insulin action has been the main goal of diabetes therapy since the discovery of insulin. The evolution of insulin therapy from animal insulin to recombinant insulin analogs has improved diabetes treatment significantly over the course of years. Nevertheless, the rapid-acting insulin analog pharmacokinetics and pharmacodynamics are still far from replicating physiologic insulin action resulting in poorly controlled after meal blood glucose levels. The slow action of insulin analogs has been a stumbling block for the development artificial pancreas systems that require a fast responding insulin to blood glucose changes. This review explains the rationale behind the undeniable need for ultra-fast acting insulins from a clinical and research perspective and summarizes ongoing and future projects to accelerate insulin action.

Apoptosis-Mediated Cytotoxic Effects of Ibandronic Acid on Hormone- and Drug-Refractory Prostate Cancer Cells and Human Breast Cancer Cells

Over 80% of patients with advanced breast and prostate cancer ultimately develop bone metastases. Ibandronic acid has proven efficacy for treatment of bone metastasis secondary to breast cancer. This study was designed to investigate the cytotoxic and apoptotic effects of ibandronic acid on hormone- and drug-refractory prostate carcinoma DU-145 and human breast cancer MCF-7 cell lines. Cytotoxicity was evaluated using an XTT cell proliferation kit, and apoptosis was assessed by enzyme-linked immuno sorbent assay (histone-DNA fragmentation) and measurement of caspase 3/7 activity. With increasing concentrations of ibandronic acid there was a dose- and time-dependent decrease in cell numbers. MCF-7 cells were more resistant than DU-145 cells (half maximal inhibitory concentrations of 122 and 90 μM, respectively). Ibandronic acid induced apoptosis in both cell lines. The study showed an apoptosis-mediated cytotoxic effect for ibandronic acid (in addition to the already known osteoclast inhibiting effect) in breast cancer patients with bone metastases; which was also observed in prostate cancer cells. Further clinical studies involving breast and prostate cancer patients with bone metastases are warranted to confirm these findings.

Docetaxel and platinum combination chemotherapy in locally advanced or metastatic head and neck cancer

PURPOSE

To assess the efficacy and toxicity of the docetaxel and platinum combination in patients with locoregionally advanced or metastatic squamous cell carcinoma of the head and neck (SCCHN).

PATIENTS AND METHODS

A total of 24 patients with metastatic or locoregionally advanced SCCHN treated with docetaxel and platinum combination chemotherapy were retrospectively reviewed. All of them had histologically proven SCCHN, measurable disease and ECOG performance status of 2 or less, and were treated with docetaxel 75 mg/m(2) as a 60 min i.v. infusion on day 1, followed by cisplatin 75 mg/m(2) or carboplatin AUC 6 as a 60 min i.v. infusion on day 1 every 3 weeks, until disease progression or unacceptable toxicity. Patients were evaluated for response, survival and toxicity.

RESULTS

Seven (29%) patients showed partial response (PR) and 1 (4%) complete response (CR) for an overall response rate of 33%. Twelve (50%) patients had stable disease (SD). Disease control rate was 83%. The median follow-up time was 26.4 months (range 2-127), the median time to progression 16 months (range 2-20), and the median overall survival 19 months (range 2-22). Grade 3-4 hematologic toxicity occurred in 13 (54%) patients. Febrile neutropenia was seen in 5 (21%) patients.

CONCLUSION

Docetaxel plus cisplatin or carboplatin is an effective regimen with acceptable safety profile for palliation of locally advanced or metastatic SCCHN.

Biofeedback assisted relaxation in essential hypertension: short-term follow-up of contributing effects of pharmacotherapy on blood pressure and heart rate. "Brief communication"

The present study was designed to evaluate the possible beneficial effects of biofeedback-assisted relaxation to pharmacotherapy on blood pressure and heart rate in patients with essential hypertension. Twenty patients with essential hypertension and without any complications or end-organ damage participated in the study. All the patients were using anti-hypertensive drugs. The study protocol consisted of an interview, 10 days baseline, 10 biofeedback-assisted relaxation sessions and a 10-day post-treatment period. Interview blood pressure (BP) and heart rate (HR) measurements, baseline mean values of systolic blood pressure (SBP), diastolic blood pressure (DBP) and HR recorded during the 1st, 10th and 20th minutes of each session and the post-treatment mean values were evaluated. Significant differences were found between the mean values of SBP, DBP and HR after the whole treatment protocol (Wilcoxon signed-ranks test). The mean values of SBP, DBP and HR measurements recorded during the 1st, 10th and 20th minutes of the biofeedback-assisted relaxation sessions, which were evaluated by repeated measures of ANOVA on ranks test, showed a significant decrease only for the 10th minute values at the end of the whole treatment program. Despite a short follow-up, it was suggested that these results were encouraging considering the fact that once the patients are thoroughly instructed in home practice of relaxation and encouraged to develop their own strategies for relaxation, the long term outcome may also be promising.