IntroductionDuring critical illness, dental plaque may serve as a reservoir of respiratory pathogens. This study compared the effectiveness of toothbrushing with a small-headed toothbrush or a foam-headed swab in mechanically ventilated patients.MethodsThis was a randomised, assessor-blinded, split-mouth trial, performed at a single critical care unit. Adult, orally intubated patients with >20 teeth, where >24 hours of mechanical ventilation was expected were included. Teeth were cleaned 12-hourly using a foam swab or toothbrush (each randomly assigned to one side of the mouth). Cleaning efficacy was based on plaque scores, gingival index and microbial plaque counts.ResultsHigh initial plaque (mean=2.1 (SD 0.45)) and gingival (mean=2.0 (SD 0.54)) scores were recorded for 21 patients. A significant reduction compared with initial plaque index occurred using both toothbrushes (mean change=−1.26, 95% CI −1.57 to −0.95; p<0.001) and foam swabs (mean change=−1.28, 95% CI −1.54 to −1.01; p<0.001). There was significant reduction in gingival index over time using toothbrushes (mean change=−0.92; 95% CI −1.19 to −0.64; p<0.001) and foam swabs (mean change=−0.85; 95% CI −1.10 to −0.61; p<0.001). Differences between cleaning methods were not statistically significant (p=0.12 for change in gingival index; p=0.24 for change in plaque index). There was no significant change in bacterial dental plaque counts between toothbrushing (mean change 3.7×104 colony-forming units (CFUs); minimum to maximum (−2.5×1010 CFUs, 8.7×107 CFUs)) and foam swabs (mean change 9×104 CFUs; minimum to maximum (−3.1×1010 CFUs, 3.0×107 CFUs)).ConclusionsPatients admitted to adult intensive care had poor oral health, which improved after brushing with a toothbrush or foam swab. Both interventions were equally effective at removing plaque and reducing gingival inflammation.Trial registration numberNCT01154257; Pre-results.
OBJECTIVE We explored longitudinal changes associated with switching to hybrid closed loop (HCL) insulin delivery systems in adults with type 1 diabetes and elevated HbA1c levels despite the use of intermittently scanned continuous glucose monitoring (isCGM) and insulin pump therapy. RESEARCH DESIGN AND METHODS We undertook a pragmatic, preplanned observational study of participants included in the National Health Service England closed loop pilot. Adults using isCGM and insulin pump across 31 diabetes centers in England with an HbA1c ≥8.5% who were willing to commence HCL therapy were included. Outcomes included change in HbA1c, sensor glucometrics, diabetes distress score, Gold score (hypoglycemia awareness), acute event rates, and user opinion of HCL. RESULTS In total, 570 HCL users were included (median age 40 [IQR 29–50] years, 67% female, and 85% White). Mean baseline HbA1c was 9.4 ± 0.9% (78.9 ± 9.1 mmol/mol) with a median follow-up of 5.1 (IQR 3.9–6.6) months. Of 520 users continuing HCL at follow-up, mean adjusted HbA1c reduced by 1.7% (95% CI 1.5, 1.8; P < 0.0001) (18.1 mmol/mol [95% CI 16.6, 19.6]; P < 0.0001). Time in range (70–180 mg/dL) increased from 34.2 to 61.9% (P < 0.001). Individuals with HbA1c of ≤58 mmol/mol rose from 0 to 39.4% (P < 0.0001), and those achieving ≥70% glucose time in range and <4% time below range increased from 0.8 to 28.2% (P < 0.0001). Almost all participants rated HCL therapy as having a positive impact on quality of life (94.7% [540 of 570]). CONCLUSIONS Use of HCL is associated with improvements in HbA1c, time in range, hypoglycemia, and diabetes-related distress and quality of life in people with type 1 diabetes in the real world.
Problematic hypoglycemia complicates insulin therapy in >25% of adults with type 1 diabetes (T1D). Previous work has identified relationships between cognitive barriers to hypoglycemia avoidance and impaired awareness of hypoglycemia (IAH) with recurrent severe episodes (SH). We investigated fear of hypoglycemia in people with IAH and SH enrolling in a trial of interventions to restore hypoglycemia awareness (“HARPdoc” ClinicalTrials.gov NCT02940873) and compared their data with T1D clinic attenders not enriched for problematic hypoglycemia. Method: Adults with T1D (HARPdoc cohort; n=98, age 54±13 yr, 56% female, T1D duration 40±15 yr) and problematic hypoglycemia (Clarke score 5.5±1.0) completed the Hypoglycemia Fear Survey II (HFS), Hyperglycemia Avoidance Scale (HAS) and anonymous 12 month SH recall forms. The T1D clinic comparator group was n=467, age 46±14 yr, 50% female, T1D duration 30±13 yr. Results: In preliminary analyses, the HARPdoc cohort (n=88) reported higher scores on total HFS (p=0.018) and its worry subscale (p<0.0001) than the comparator. Behavior subscale scores were lower (p<0.0001). In the HARPdoc cohort, 25% (n = 22) reported low worry about hypoglycemia despite high SH risk (vs. 8% in the comparator). People with high worry scored the HAS worry subscale higher (p<0.001). The HARPdoc cohort were grouped by frequency of SH (<2; 2 - 4; 5-12 and >12 SH per yr). Worry scores increased with higher SH rates (p=0.004). Behavior scores increased (p=0.041) but not above the comparator 75th centile. In the ’maintaining high glucose’ subset of HFS behavior items, scores increased between the high SH rate groups (p=0.042) but not the lower rate groups. Conclusion: The majority of people with significant hypoglycemia problems show appropriately increased worry but not corresponding increases in behavior scores. A subgroup show inappropriately low worry. Inability to change behaviors, and worry about hyperglycemia, may be barriers to avoiding SH. Disclosure R.H. Maclean: None. P. Jacob: None. S. Haywood: None. P. Choudhary: Advisory Panel; Self; Abbott, Eli Lilly and Company, Insulet Corporation, Medtronic. Research Support; Self; European Union, JDRF. Speaker’s Bureau; Self; Dexcom, Inc., Novartis AG, Novo Nordisk A/S, Sanofi-Aventis. S.R. Heller: Advisory Panel; Self; Eli Lilly and Company, Novo Nordisk A/S, Zealand Pharma A/S. Speaker’s Bureau; Self; AstraZeneca, Novo Nordisk A/S. Other Relationship; Self; MannKind Corporation. E. Toschi: None. D. Kariyawasam: None. T.C. Anderbro: None. S.A. Amiel: Advisory Panel; Self; Medtronic, Novo Nordisk A/S, Roche Pharma. Other Relationship; Self; Diabetes UK. Funding JDRF (4-SRA-2017-266-M-N)
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