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Ware J, Boughton CK, Allen JM, Wilinska ME, Tauschmann M, Denvir L, Thankamony A, Campbell FM, Wadwa RP, Buckingham BA, Davis N, DiMeglio LA, Mauras N, Besser REJ, Ghatak A, Weinzimer SA, Hood KK, Fox DS, Kanapka L, Kollman C, Sibayan J, Beck RW, Hovorka R, Hovorka R, Acerini CL, Thankamony A, Allen JM, Boughton CK, Dovc K, Dunger DB, Ware J, Musolino G, Tauschmann M, Wilinska ME, Hayes JF, Hartnell S, Slegtenhorst S, Ruan Y, Haydock M, Mangat J, Denvir L, Kanthagnany SK, Law J, Randell T, Sachdev P, Saxton M, Coupe A, Stafford S, Ball A, Keeton R, Cresswell R, Crate L, Cripps H, Fazackerley H, Looby L, Navarra H, Saddington C, Smith V, Verhoeven V, Bratt S, Khan N, Moyes L, Sandhu K, West C, Wadwa RP, Alonso G, Forlenza G, Slover R, Towers L, Berget C, Coakley A, Escobar E, Jost E, Lange S, Messer L, Thivener K, Campbell FM, Yong J, Metcalfe E, Allen M, Ambler S, Waheed S, Exall J, Tulip J, Buckingham BA, Ekhlaspour L, Maahs D, Norlander L, Jacobson T, Twon M, Weir C, Leverenz B, Keller J, Davis N, Kumaran A, Trevelyan N, Dewar H, Price G, Crouch G, Ensom R, Haskell L, Lueddeke LM, Mauras N, Benson M, Bird K, Englert K, Permuy J, Ponthieux K, Marrero-Hernandez J, DiMeglio LA, Ismail H, Jolivette H, Sanchez J, Woerner S, Kirchner M, Mullen M, Tebbe M, Besser REJ, Basu S, London R, Makaya T, Ryan F, Megson C, Bowen-Morris J, Haest J, Law R, Stamford I, Ghatak A, Deakin M, Phelan K, Thornborough K, Shakeshaft J, Weinzimer SA, Cengiz E, Sherr JL, Van Name M, Weyman K, Carria L, Steffen A, Zgorski M, Sibayan J, Beck RW, Borgman S, Davis J, Rusnak J, Hellman A, Cheng P, Kanapka L, Kollman C, McCarthy C, Chalasani S, Hood KK, Hanes S, Viana J, Lanning M, Fox DS, Arreaza-Rubin G, Eggerman T, Green N, Janicek R, Gabrielson D, Belle SH, Castle J, Green J, Legault L, Willi SM, Wysham C. Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial. Lancet Digit Health 2022; 4:e245-e255. [PMID: 35272971 DOI: 10.1016/s2589-7500(22)00020-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 12/10/2021] [Accepted: 01/25/2022] [Indexed: 02/07/2023]
Abstract
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.
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Norrish G, Chubb H, Field E, McCleod K, Till J, Stuart G, Hares D, Linter K, Bhole V, Bowes M, Uzun O, Sadagopan S, Rosenthal E, Mangat J, Kaski J. Clinical outcomes and programming strategies of implantable cardioverter defibrillator (ICD) devices during childhood in hypertrophic cardiomyopathy: a UK national cohort study. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Sudden cardiac death (SCD) is the most common mode of death in childhood hypertrophic cardiomyopathy (HCM). ICDs have been shown to be effective at terminating malignant ventricular arrhythmias but at the expense of a high incidence of complications. The optimal device and programming strategies to reduce complications in this patient group are unknown.
Purpose
To describe the programming strategies and clinical outcomes of ICD implantation in childhood HCM.
Methods
Anonymised, non-invasive clinical data were collected from a retrospective, longitudinal multi-centre cohort of children (<16 years) with HCM (n=687) and an ICD in-situ from the United Kingdom.
Results
96 patients (61 male (64%), 6 non-sarcomeric (6%)) underwent ICD implantation at a median age 14yr (IQR 11–16, range 3–16) and weight 52.3 kg (IQR 34.8–63.1). Indication for ICD was primary prevention in 72 (75%). 82 (85%) had an endovascular system, 3 (3%) epicardial and 11 (12%) subcutaneous system. 61 patients (74%) were receiving one or more cardioactive medications at implantation [B blockers n=66, 70%, disopyramide n=14, 15%, amiodarone n=7, 7%, calcium channel blocker n=7, 9%, other n=5, 6%]. Programming practices varied: all had VF therapies activated (median 220bpm, IQR 212–230); 70 (73%) had a VT zone programmed (median rate 187 bpm, SD 20.9), of which 26 (27%) had therapies activated. 50 patients (61%) had antitachycardia pacing (ATP) activated. Over a median follow up of 53.6 months (IQR 27.3,108.4), 4 patients (4.2%) died following arrhythmic events despite a functioning device. 25 patients had 53 appropriate therapies (ICD shock n=47, ATP n=8), incidence rate 5.22 (95% CI 3.5–7.8). On univariable analysis, secondary prevention indication for ICD implantation was the only predictor of therapy [16 (64%) vs 8 (11.3%), p value <0.001]. 8 (8.3%) patients had 9 inappropriate therapies (ICD shock n=4, ATP n=5), incidence rate 1.37 (95% CI 0.65–2.8), caused by T wave oversensing (n=2), lead migration (n=1), supraventricular tachycardia (n=1). Device complications were seen in 30 patients (31%), including lead complications (n=16) and infection (n=10). No clinical characteristics predicted time to inappropriate therapy or lead complication.
Conclusions
In a contemporary cohort of children with HCM, the incidence of inappropriate therapies is lower than previously reported, yet complication rates remain higher than reported in adult patients. No clinical, device or programming strategies were associated with inappropriate therapies or lead complications.
Funding Acknowledgement
Type of funding source: Other. Main funding source(s): British Heart Foundation
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Affiliation(s)
- G Norrish
- Great Ormond Street Hospital for Children, Inherited Cardiovascular Disease, London, United Kingdom
| | - H Chubb
- Stanford University Medical Center, Paediatric Heart Centre, Stanford, United States of America
| | - E Field
- Great Ormond Street Hospital for Children, Inherited Cardiovascular Disease, London, United Kingdom
| | - K McCleod
- Royal Hospital for Children, Glasgow, United Kingdom
| | - J Till
- Stanford University Medical Center, Paediatric Heart Centre, Stanford, United States of America
| | - G Stuart
- Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - D Hares
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - K Linter
- Glenfield Hospital, Leicester, United Kingdom
| | - V Bhole
- Birmingham Children's Hospital, Birmingham, United Kingdom
| | - M Bowes
- Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - O Uzun
- Children's Hospital for Wales, Cardiff, United Kingdom
| | - S Sadagopan
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - E Rosenthal
- Guy's and St Thomas' NHS Foundation Trust, Greater London, United Kingdom
| | - J.P Mangat
- Great Ormond Street Hospital for Children, Inherited Cardiovascular Disease, London, United Kingdom
| | - J.P Kaski
- Great Ormond Street Hospital for Children, Inherited Cardiovascular Disease, London, United Kingdom
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Mangat J, Morgan J, Benson E, Båth M, Lewis M, Reilly A. A STUDY OF THE IMAGE QUALITY OF COMPUTED TOMOGRAPHY ADAPTIVE STATISTICAL ITERATIVE RECONSTRUCTED BRAIN IMAGES USING SUBJECTIVE AND OBJECTIVE METHODS. Radiat Prot Dosimetry 2016; 169:92-99. [PMID: 27103646 DOI: 10.1093/rpd/ncw084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 02/26/2016] [Indexed: 06/05/2023]
Abstract
The recent reintroduction of iterative reconstruction in computed tomography has facilitated the realisation of major dose saving. The aim of this article was to investigate the possibility of achieving further savings at a site with well-established Adaptive Statistical iterative Reconstruction (ASiR™) (GE Healthcare) brain protocols. An adult patient study was conducted with observers making visual grading assessments using image quality criteria, which were compared with the frequency domain metrics, noise power spectrum and modulation transfer function. Subjective image quality equivalency was found in the 40-70% ASiR™ range, leading to the proposal of ranges for the objective metrics defining acceptable image quality. Based on the findings of both the patient-based and objective studies of the ASiR™/tube-current combinations tested, 60%/305 mA was found to fall within all, but one, of these ranges. Therefore, it is recommended that an ASiR™ level of 60%, with a noise index of 12.20, is a viable alternative to the currently used protocol featuring a 40% ASiR™ level and a noise index of 11.20, potentially representing a 16% dose saving.
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Affiliation(s)
- J Mangat
- Cardiac CT Department, Barts Heart Centre, Bartshealth NHS Trust, London, UK
| | - J Morgan
- Radiography Department, School of Health Sciences, City University, London, UK
| | - E Benson
- Medical Engineering and Physics Department, Kings College Hospital, London, UK
| | - M Båth
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Lewis
- Medical Physics Department, Guy's and St. Thomas' Hospital, London, UK
| | - A Reilly
- Department of Radiotherapy Physics, Altnagelvin Hospital, Londonderry, UK
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