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.

The information needs and understanding of 5-10-year old children with epilepsy, asthma or diabetes

This exploratory study compared the information needs and understanding of 25 5-10-year olds with epilepsy with those of 10 children with asthma and 10 with diabetes (of the same age range). The children were interviewed whilst attending specialist clinics by the first author and were unaware of her professional status. All the children had access to specialist nurses and their families had received literature about their condition. The interview covered five main areas: knowledge of their condition, psychological effects, medication, restrictions on lifestyle, where they obtained their information and if they had unanswered questions. The children with epilepsy had far more unanswered questions and felt excluded from discussions with doctors. They also appeared reluctant to tell their friends their diagnosis and, at such a young age, felt stigmatized by their condition. The results highlight a contrast in the understanding of children with epilepsy when compared with those with asthma or diabetes. It is proposed that if a simple biological model were used to explain epilepsy this could aid children's understanding and reduce their reluctance to disclose their diagnosis.

Phenotypic variation and diversity among Trichomonas vaginalis isolates and correlation of phenotype with trichomonal virulence determinants

The extent and nature of heterogeneity among representative Trichomonas vaginalis isolates were evaluated by flow cytofluorometry analysis. Monoclonal antibody and monospecific antiserum to an immunodominant trichomonad surface glycoprotein with a molecular weight of 267,000 (267K glycoprotein) were used to evaluate fresh isolates (JHH and RU375) and long-term grown isolates (NYH286, IR78, and JH31A) of T. vaginalis. Isolates NYH286, JH31A, and JHH were made up of heterogeneous staining (positive [pos] phenotype) and nonstaining (negative [neg] phenotype) populations of trichomonads, whereas RU375 and IR78 were all neg phenotype parasites. Flow cytofluorometric patterns of agar clones derived from single organisms of heterogeneous isolates such as NYH286 showed populations which were either homogeneous pos or neg and also showed clones which were heterogeneous in nature containing both phenotypes. Fluorescence-activated cell sorting was also accomplished, and subpopulations of defined pos or neg phenotype were purified. Flow cytofluorometry evaluation of all isolates for an extended period revealed a phenotypic variation among all heterogeneous isolates and also for all clones and subpopulations derived from the heterogeneous isolates. On the other hand, IR78 and RU375 did not undergo phenotypic variation and have remained neg for greater than 4 years. Parasites which were nonreactive with either monoclonal antibody or monospecific antiserum to the 267K glycoprotein in flow cytofluorometry did not possess the antigen on their surface. This was determined by radioimmunoprecipitation assays using extracts of iodinated trichomonads. Finally, neg phenotype parasites yielded enhanced rates of contact-dependent cytotoxicity of host cell monolayers as compared with the pos phenotype trichomonads.