Glycemic control in children with type 1 diabetes treated with the advanced hybrid closed loop system 2-year prospective, observational, two-center study

Background and aims

MiniMed 780G is the first Advanced Hybrid Closed Loop (AHCL) system in Poland, approved in the EU in 2020. To date, observations of glycemic control up to 12 months have been published. This study aimed to analyze glycemic control and anthropometric parameters in children and adolescents with type 1 diabetes (T1D) after two years of using the AHCL system.

Materials and methods

We prospectively collected anthropometric data, pump, and continuous glucose records of fifty T1D children (9.9 ± 2.4 years, 24 (48%) boys, T1D for 3.9 ± 2.56 years) using an AHCL system. We compared the two-week AHCL records obtained after AHCL enrollment with data 6, 12, and 24 months after starting AHCL.

Results

Time in range (70-180 mg/dl) and BMI z-score did not change during the 2 years of observation (p>0.05). The percentage of autocorrection in total daily insulin increased significantly (p<0.005).

Conclusion

Glycemic control in the investigated group of children with T1D treated with the AHCL system for 2 years remained stable. Children in this group maintained weight and optimal metabolic control, most likely due to autocorrection boluses.

MiniMed 780GTM in children with type 1 diabetes under seven years of age: Prospective open-label, single-arm, double-center, follow-up study

BACKGROUND

Given the steadily rising incidence of type 1 diabetes (T1D), particularly among the youngest preschool children, coupled with well-documented challenges of achieving and maintaining optimal metabolic control in this age group, there is a growing need for advanced technological devices.

OBJECTIVE

To evaluate glycaemic control in children below the age of seven with type 1 diabetes (T1D) and assess the safety of the advanced hybrid closed loop (AHCL) system in comparison to the previous treatment method, a sensor-augmented pump with predictive low-glucose suspend (SAP-PLGS).

METHOD

Data from 10 children (aged 2.60-6.98 years) with T1D who transitioned to the AHCL system from SAP-PLGS were analysed. SAP-PLGS records from two weeks prior to the initiation of AHCL were compared with records from the initial four weeks post-switch (excluding the training period). These data were examined at two 2-week intervals and compared with records from two weeks post six-month usage of the AHCL.

RESULTS

A significant decrease in the average nighttime glucose concentration was observed compared to pre-AHCL values (p= 0.001, concordance W = 0.53). The Glucose Management Indicator (GMI) value significantly decreased from 6.88 ± 0.37% to 6.52 ± 0.32% (p= 0.018, rbc = 0.93) immediately following the device switch and stabilized at 6.50 ± 0.28% (p= 0.001, W = 0.53) and 6.55 ± 0.41% (p= 0.001, W = 0.53) at subsequent stages of the study. An improvement was also observed in mean glucose values for time spent < 54 mg/dl, while the proportion of time within this range was maintained, both during the day (p< 0.001, W = 0.58) and at night (p= 0.002, W = 0.83).

CONCLUSION

The AHCL MiniMed 780GTM system improved glycaemic control in the studied group of children under seven years of age with T1D compared to previous SAP-PLGS therapy. It proved to be safe for delivering insulin in this age group.

The role and need for psychological support in the treatment of adolescents and young people suffering from type 1 diabetes

Psychological support might be perceived as one of the most important factors in the treatment of people suffering from type 1 diabetes, particularly among vulnerable groups such as adolescents and young people. Problems arising from extreme pressure put on young patients, high expectations, and specific limitations associated with diabetes often reflect in negative wellbeing and affect patients' behavior, resulting in lower self-esteem, mood swings, depression, or even eating disorders. Therefore, the need for a more holistic approach to the treatment of diabetes and caring about psychological support can be observed, which may contribute to better functioning and management of the disease. Differentiation of certain approach methods such as the positive approach (PA) discussed in the text may help young patients in motivation and coping with their disease as well as accepting limitations caused by type 1 diabetes. This would decrease the risk of potential revolt against medical recommendations, common for patients at the mentioned age, and help raise awareness of the problem. Maintaining life balance through undertaking regular physical activities and being open to new strategies such as telenursing can also result in the improvement of glycemic control. The studies presented have proven the great effectiveness of personalized care adjusted to the patient with psychological support, as well as the invaluable role of education in diabetes, which includes not only standard procedures such as calculating an appropriate insulin dose but also the invention of effective coping mechanisms, which influence patients' performance and wellbeing.

Commercial hybrid closed-loop systems available for a patient with type 1 diabetes in 2022

Technological advances offer the opportunity to improve glycemic control and reduce the risk of complications and burden of type 1 diabetes while improving patient quality of life. Closed-loop insulin delivery systems take the technology to a larger scale by integrating CGM systems with an insulin pump and an algorithm that automates insulin delivery (HCL systems). Several systems using hybrid closed loop technology are currently offered in the global marketplace: the MiniMed™ 670G and MiniMed™ 780G (SmartGuard™) system from Medtronic; the T slim x2 Control IQ from Tandem; the Omnipod5 automated mode (HypoProtect™)5 from Insulet; and the CamAPS FX DanaRS or Ypso pump. Insulet's Omnipod5 automated mode (HypoProtect™) is currently in clinical trials. As technology moves forward, advanced systems are being developed that include an elaborate algorithm with individualization of major target points, automated correction bolus functionality, and increased stability of the automated mode (Advanced Hybrid Closed-Loop - AHCL systems). The AHCL systems include: MiniMed™ 780G (SmartGuard™); Tandem's T slim x2 Control IQ; Insulet's Omnipod5-Automated mode (HypoProtect™); and CamAPS FX. The purpose of this paper is to present commercial devices using HCL and AHCL in 2022, also from a scientific point of view. It is an undeniable fact that "auto-mode" systems represent a new stage that can be confidently called a revolution in diabetology.

Prospective Open-Label, Single-Arm, Single-Center Follow-Up Study of the Application of the Advanced Hybrid Closed Loop System in Well-Controlled Children and Adolescents with Type 1 Diabetes

Background: The aim of this prospective open-label single-arm single-center follow-up study was to analyze glycemic control in children and adolescents with type 1 diabetes treated with the advanced hybrid closed loop (AHCL) system in relation to a sensor-augmented pump with low-glucose suspend (SAP-LGS) or predictive low-glucose suspend (SAP-PLGS). Materials and Methods: The data for 50 children and adolescents (age 5.5-19.6 years) with type 1 diabetes, receiving insulin through an AHCL system after being switched from SAP-LGS/PLGS systems, were included in the analysis. The SAP-LGS/PLGS records from 2 weeks preceding the AHCL connection were compared with the records from the first 4 weeks of AHCL use, represented as two separate 2-week intervals. Results: Significant improvements in most of the parameters, namely time spent in the range of 70-140 mg/dL (from 53.80% ± 12.35% to 61.70% ± 8.42%, P < 0.001) and 70-180 mg/dL (from 76.17% ± 10.28% to 81.32% ± 7.71%, P < 0.001), average sensor glucose (from 138.61 ± 16.66 to 130.02 ± 10.91 mg/dL, P < 0.001), and glucose management indicator (from 6.54% ± 0.45% to 6.27% ± 0.29%, P = 0.001), were observed within 2 weeks of switching to the AHCL. More evident improvements were observed for the parameters monitored at night than during the day. The potential limitations of this study were the short observation time, lack of glycated hemoglobin measurements, and no control arm. Conclusion: The AHCL system can significantly improve glycemic control even in well-controlled children and adolescents with type 1 diabetes by increasing the proportion of time spent in the narrower range of 70-140 mg/dL and decreasing the mean glucose concentration, especially during the night.

Diabetic ketoacidosis incidence among children with new-onset type 1 diabetes in Poland and its association with COVID-19 outbreak-Two-year cross-sectional national observation by PolPeDiab Study Group

BACKGROUND

There are several observations that the onset of coronavirus 19 (COVID-19) pandemic was associated with an increase in the incidence of diabetic ketoacidosis (DKA). However, due to heterogeneity in study designs and country-specific healthcare policies, more national-level evidence is needed to provide generalizable conclusions.

OBJECTIVE

To compare the rate of DKA in Polish children diagnosed with type 1 diabetes (T1D) between the first year of COVID-19 pandemic (15 March 2020 to 15 March 2021) and the preceding year (15 March 2019 to 15 March 2020).

METHODS

Reference centers in 13 regions (covering ~88% of Polish children) retrospectively reported all new-onset T1D cases in children from assessed periods, including DKA status at admission, administered procedures and outcomes. Secondly, we collected regions' demographic characteristics and the daily-reported number of COVID-19-related deaths in each region.

RESULTS

We recorded 3062 cases of new-onset T1D (53.3% boys, mean age 9.5 ± 4.3 years old) of which 1347 (44%) had DKA. Comparing pre- and post-COVID-19 period, we observed a significant increase in the rate of DKA (37.5%-49.4%, p < .0001). The fraction of moderate (+5.4%) and severe (+3.4%) DKA cases increased significantly (p = .0089), and more episodes required assisted ventilation (+2.1%, p = .0337). Two episodes of DKA during 2020/2021 period were fatal. By region, change in DKA frequency correlated with initial COVID-19 death toll (March/April 2020) (R = .6, p = .0287) and change in T1D incidence (R = .7, p = .0080).

CONCLUSIONS

The clinical picture of new-onset children T1D in Poland deteriorated over a 2-year period. The observed increase in the frequency of DKA and its severity were significantly associated with the overlapping timing of the COVID-19 epidemic.

Has the COVID-19 Pandemic Affected the Prevalence of Diabetic Ketoacidosis in Polish Children with Newly Diagnosed Type 1 Diabetes? An Example of the Largest Polish Pediatric Diabetes Center (Upper Silesia—Katowice, Poland)

Purpose: The aim of this study was to analyze the prevalence of diabetic ketoacidosis (DKA) in children with newly disclosed type 1 diabetes (T1D) during the COVID-19 pandemic in 2020 compared to 2019. Methods: A retrospective analysis of the history database of all hospitalized children in our department. The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines were used for the diagnosis of DKA. Results: The database of children with newly disclosed T1D included 196 patients (89 girls and 107 boys) from 2019, and 223 patients (113 girls and 110 boys) from 2020 (a total of 419 patients—202 girls and 217 boys) aged 0 to 18 years. A significantly higher percentage of DKA was observed in 2020 compared to the previous year (47.53% vs. 35.2% [p = 0.005]). The percentage of severe DKA increased in 2020 compared to 2019 (18.39% vs. 14.07% [p = 0.118]). Compared to 2019, the average HbA1c level was higher in 2020 (12.57 ± 2.75% vs. 11.95 ± 2.89% [p < 0.025]), and the average pH level (7.26 vs. 7.31 [p = 0.002], and average HCO3 level (16.40 vs. 18.66 [p = 0.001]) were lower, respectively. Conclusions: During the COVID-19 (2020) pandemic, the incidence of DKA increased in Polish children with newly diagnosed T1D. The conclusions from the analysis of the functioning of health systems during the pandemic should be used in the future to prevent, in similar periods, an increase in severe complications of delayed diagnosis of T1D.

Body mass index, basal insulin and glycemic control in children with type 1 diabetes treated with the advanced hybrid closed loop system remain stable - 1-year prospective, observational, two-center study

BACKGROUND

Information on the influence of insulin treatment using advanced hybrid closed loop systems (AHCL) on body weight of young patients with type 1 diabetes (T1D) is scarce. The aim of this study was to observe whether there were any changes in body mass index (BMI) of children and adolescents with T1D treated using the Medtronic Minimed 780G AHCL after 1 year of follow up and to analyze potential associations between these changes and the insulin doses.

MATERIALS AND METHODS

For 50 children and adolescents (age 5.4-16.8 years, 24 (48%) boys, T1D for 3.9 ± 2.56 years) using an AHCL system anthropometric and AHCL data were collected prospectively. BMI Z-scores and two-week AHCL records obtained after AHCL enrollment were compared with data after 6 months and also 1 year after starting AHCL.

RESULTS

The BMI Z-score of the patients at 1 year follow-up did not change from time of AHCL initiation (0.51 ± 2.79 vs 0.57 ± 2.85, p>0.05). There was a slight increase in total daily insulin per kg of body weight (0.67 ± 0.21 U/kg vs 0.80 ± 0.21 U/kg, p <0.001), but the percent of basal insulin was unchanged (34.88 ± 6.91% vs 35.08 ± 6.30%, p>0.05). We observed also no change (AHCL start vs after 1 year) in glycemic control parameters: average sensor glucose (131.36± 11.04 mg/dL vs 132.45 ± 13.42 mg/dL, p>0.05), coefficient of variation (34.99± 5.17% vs 34.06 ± 5.38%, p>0.05), glucose management indicator (6.45 ± 0.26% vs 6.48 ± 0.32%, p>0.05), and time spent in the range of 70-180 mg/dL (79.28 ± 8.12% vs 80.40 ± 8.25%, p>0.05).

CONCLUSION

During the 1 year of follow-up the BMI of children and adolescents with T1D treated with an AHCL system remained stable. Although there was a slight increase in the total daily insulin dose, the percent of basal insulin was unchanged. The patients maintained recommended glycemic control.

Can the AHCL System Be Used in T1D Patients with Borderline TDDI? A Case Report

(1) Background: Intensive insulin therapy using continuous subcutaneous insulin infusion (CSII) with continuous real-time glucose monitoring (rt CGM) is the best option for patients with T1D. The recent introduction of a technology called Advanced Hybrid Closed Loop (AHCL) represents a new era in the treatment of type 1 diabetes, the next step towards better care, as well as improving the effectiveness and safety of therapy. The aim is to present the case of a T1D patient with a borderline total daily dose of insulin being treated with the Medtronic AHCL system in automatic mode. (2) Materials and Methods: A 9-year-old boy, from October 2020, with type 1 diabetes in remission was connected to the Minimed™ 780G (AHCL) system in accordance with the manufacturer’s recommendations (daily insulin dose > 8 units, age > 7). Records of the patient’s history were collected from visits to The Department of Children’s Diabetology, as well as from the Medtronic CareLink™ software and the DPV SWEET program from October 2020 to April 2021. (3) Results: The patient’s total daily insulin requirement decreased in the first 6 weeks after the AHCL was connected, which may reflect the remission phase (tight glycemic control with a healthy lifestyle). The lowest daily insulin requirement of 5.7 units was also recorded. In a three-month follow-up of the patient treated with AHCL, it was found that for almost 38% of the days the insulin dose was less than 8 IU. (4) Conclusions: The AHCL system allows safe and effective insulin therapy in automatic mode, as well as in patients with a lower daily insulin requirement. The AHCL system should be considered a good therapeutic option for patients from the onset of T1D, as well in the remission phase.

The Problem of Abnormal Body Weight and Dyslipidemia as Risk Factors for Cardiovascular Diseases in Children and Adolescents with Type 1 Diabetes

Diabetes is a disease that affects many people around the world. Its complications are the cause of cardiovascular diseases (CVD) and increased mortality. That is why the search for predictive biomarkers is so important. The aim of the study was to show the prevalence of the problem and risk factors in children and adolescents with type 1 diabetes. These patients are often overweight and obese, and the percentage of lipid disorders is particularly high. The discussed markers of CVD risk in type 1 diabetes include apolipoproteins (apo-B and apo-C3), modified forms of LDL, and the role of high-density lipoprotein (HDL). Recently, a new look at the vasoprotective effect of HDL has appeared, which due to its dysfunctional form in type 1 diabetes may not protect against cardiovascular risk. The HDL proteome in type 1 diabetes has an altered protein composition compared to the healthy population. Another direction of research is determining the importance of trace elements (mainly Mg) in the development of diabetes complications.

The Quality of Life and Satisfaction with Continuous Glucose Monitoring Therapy in Children under 7 Years of Age with T1D Using the rtCGM System Integrated with Insulin Pump-A Caregivers Point of View

Quality of life (QoL) is an important parameter that affects the choice of therapy. Assessment of QoL and satisfaction with therapy using the rtCGM in children with T1D aged < 7 years was conducted. The study group consisted of 38 children with T1D aged < 7 years (34% aged 2–4, 66% aged 5–7 years), HbA1c: 6.53 ± 0.63%, duration of diabetes: 2.6 ± 1.6 years, treated with an rtCGM-augmented insulin pump for 1.92 ± 1.15 years. Two anonymous surveys were conducted: a. PedsQL3.0 diabetes standardized questionnaire—QoL assessment among age groups: 2–4/5–7 years. b. An original survey assessing the CGM use satisfaction. The mean scores in PedsQL3.0: communication 75%, worries 30%, treatment 70%, and problems associated with diabetes 65%. The QoL scale is: 0–19% very low, 20–39% low, 40–59% moderate, 60–79% high, 80–100% very high. The most frequently reported concerns were long-term diabetes complications and prick pain. Satisfaction with CGM use was high (68% in group aged 5–7 and 92% 2–4 years). Twenty-seven (71%) caregivers confirmed the positive effect of CGM on sleep. During the use of rtCGM a high quality of life was reported, and the quality of sleep in their caregivers was increased.

Bacterial strains colonizing the sensor electrodes of a continuous glucose monitoring system in children with diabetes

INTRODUCTION

The higher frequency of infections in diabetic patients is caused by a hyperglycemic environment, which promotes immune dysfunction. People with diabetes are more prone to skin infections. A continuous glucose monitoring (CGM) system provides information on changes in blood glucose (BG) levels throughout the day. Its use facilitates optimal therapeutic decisions for a diabetic patient. One of the factors limiting the use of CGM is inflammation at the insertion site.

AIM OF THE STUDY

The aim of the study was the microbiological identification of the bacterial strains which are found on CGM sensor electrodes.

MATERIAL AND METHODS

We performed microbiological tests on patients' CGM Enlite Medtronic electrodes, which were removed after 6 days of usage according to the manufacturer's instructions. 31 sensors were examined from 31 children (14 girls) aged from 0.5 to 14.6 years. The microbiological analysis was routinely performed at the Department of Children's Diabetology Medical University of Silesia in Katowice, Poland.

RESULTS

12 (39%) of the electrodes were colonized. In 11 (92%) cases the electrodes were colonized by one bacteria strain. 7 times methicillin-sensitive coagulase negative staphylococcus (MSCNS) was detected. We also found one case of Klebsiella pneumoniae, Ochrobactrum tritici, Bacillus sonorensis and methicillin-resistant coagulase-negative Staphylococci (MRCNS) colonization. One electrode was colonized by the mixed flora Enterococcus faecalis, methicillin-susceptible coagulase-negative Staphylococci (MSCNS), Pseudomonas stutzeri, methicillin-susceptible Staphylococcus aureus (MSSA). The median HbA1c in the group with colonization of electrodes was 6, 85% (6, 3-7, 6%) versus 6, 3% (5, 8-7, 5%) in the group without colonization. The median BMI in the group with colonization of the electrodes was 17.10 kg/m² (16.28-18.62 kg/m²) versus 15.98 kg/m² (15.14-17.96 kg/m²) in the group without colonization. Statistically, significantly more frequently electrodes are colonized in older children (median age in the group with colonization of electrodes 11.43 years (6.52-12.27 years), without colonization 8.42 years. (3.098-9.375 years); (p = 0.033).

CONCLUSIONS

It seems that older children are more likely to have their sensor electrode colonized by bacterial strains.

ATP4A autoimmunity in pediatric patients with type 1 diabetes and its relationship to blood count, iron metabolism, and vitamin B12

OBJECTIVE

We aimed to assess the prevalence of autoantibodies against the 4A subunit of the gastric proton pump (ATP4A) in pediatric type 1 diabetes (T1D) patients and explore the relationship between ATP4A positivity and blood cell count, iron turnover, and vitamin B12 concentration.

SUBJECTS

The study included 94 (59% female) T1D children (aged 12.5 ± 4.1 years, T1D duration 4.2 ± 3.6 years, HbA1c 7.3 ± 1.5% (57 ± 12.6 mmol/mol) with no other autoimmune diseases.

METHODS

ATP4A antibodies were measured in T1D patients using a radioimmunoprecipitation assay. Blood cell count, iron concentration, total iron binding capacity, ferritin, transferrin, hepcidin, and vitamin B12 concentration were measured in all the study participants.

RESULTS

A total of 16 (17%) children were ATP4A positive. Serum concentrations of ferritin were significantly lower in ATP4A positive than in antibody negative subjects (P = .034). Overall the levels of ATP4A antibodies (ATP4A Index) correlated positively with the age at T1D diagnosis (r = 0.228, P = .026) and negatively with ferritin levels (r = -0.215, P = .037). In ATP4A positive patients, the ATP4A Index correlated positively with age at diagnosis (r = 0.544, P = .032) and negatively with vitamin B12 levels (r = -0.685, P = .004).

CONCLUSIONS

ATP4A antibodies were present in a significant proportion of children with T1D. Higher ATP4A levels in T1D children are associated with lower, yet still fitting within the normal range, levels of vitamin B12, and ferritin. Routine screening of T1D children for gastric autoimmunity (ATP4A) should be considered with follow-up of those positive for vitamin B12 and iron deficiency.

Markers of Anemia in Children with Type 1 Diabetes

AIM

The aim of the study was to assess markers of anemia in type 1 diabetes (T1D) children, compare them to results obtained in the control group, and estimate their relation to BMI SDS.

METHODS

94 (59% ♀) T1D children without other autoimmune disorders, aged 12.5 ± 4.1 years, T1D duration: 4.2 ± 3.6 years, HbA1c 7.3 ± 1.5% (57 ± 12.6 mmol/mol). Sex- and age-matched controls (43 children). In all children, anthropometric measurements, the blood count, iron turnover parameters, and vitamin B12 concentration were taken.

RESULTS

T1DM children had significantly higher red cell distribution width (RDW) (13.6 versus 12.6%; p < 0.001), hepcidin (0.25 versus 0.12 ng/ml; p < 0.001), and vitamin B12 concentrations (459 versus 397 pg/ml; p < 0.01) and lower TIBC (59.09 versus 68.15 μmol/l; p < 0.001) than in the control group. Logistic regression revealed that RDW, TIBC (both p < 0.001), and hepcidin (p < 0.05) significantly differentiated both groups. In T1DM children, BMI SDS negatively correlated with vitamin B12 (p < 0.01) concentration and mean corpuscular hemoglobin concentration (p < 0.05) and positively with TIBC (p < 0.01) and HbA1c (p < 0.001).

CONCLUSIONS

Patients and controls differed especially in terms of RDW and TIBC. In studied T1DM children, BMI SDS was associated to iron metabolism parameters and vitamin B12 concentration.

Anti-parietal cell antibodies - diagnostic significance

Anti-parietal cell antibodies (APCA) are an advantageous tool for screening for autoimmune atrophic gastritis (AAG) and pernicious anemia (PA). The target for APCA is the H+/K+ ATP-ase. It has been demonstrated, that APCA target both, the alpha, and beta subunits of the proton pump, although the major antigen is the alpha subunit. Circulating serum APCA can be detected by means of immunofluorescence, enzyme-linked immunosorbent assay - currently the most commonly used method, and radioimmunoprecipitation assay (RIA) - the 4A subunit has been optimized as a molecular-specific antigen probe. RIA is the most accurate method of antibody assessment, characterized by highest sensitivity. APCA can be found in 85-90% of patients with PA. Their presence is not sufficient for diagnosis, because they are not specific for PA as they are also found in the circulation of individuals with other diseases. APCA are more prevalent in the serum of patients with T1D, autoimmune thyroid diseases, vitiligo, celiac disease. People with autoimmune diseases should be closely screened for AAG/PA. The anemia develops longitudinally over many years in APCA-positive patients, symptomless, slowly promotes atrophy of the gastric mucosa and parietal cells. APCA are present in 7.8-19.5% of the general healthy adult population. A fraction of these sero-positive people, will never develop AAG or PA. An interesting and not fully explained question is whether APCA presence is related to Helicobacter pylori infection. APCA are found in up to 20.7% of these patients. H. pylori is implicated as one of the candidates causing AAG.