Improving the evidence base for oral assessment in stroke patients

Oral care is essential in maintaining oral hygiene and oral health. When oral care is neglected individuals are at risk of oral and systemic complications affecting general health. Stroke patients are one group who are at risk of poor oral health due to their physical and cognitive dependency. Providing oral care is normally the responsibility of the nurses, and currently there is little evidence to support oral care provided. Through a series of studies this thesis aims to explore oral care in hospitalised stroke patients with the aim of developing an oral assessment to inform oral care. An integrative literature review examining oral assessments developed for use in a dependent population, identified that an oral assessment for use in stroke patients did not exist. The majority of oral assessments had been developed using the empirical literature and/or expert opinion, with a focus to assess oral health and cleanliness. Those assessments that were selected for review were found to be of a poor quality both in development and testing of psychometric properties. Where agreement had been tested, both within and between raters, agreement was variable across all items. The information gathered from the review was used to aid the design of a qualitative study to explore stakeholder’s views of oral care in stroke patients, and the development of a new oral assessment for use in stroke patients. An interpretive approach was utilised to explore the views and experiences of experts in oral health and stroke; health professionals’; patients’ and carers’. Two different methods were used to capture this data: one to one interviews for the experts in oral health and stroke, patients and carers; and focus groups for the health professionals. Eight experts were interviewed, five patients, five carers and the two focus groups with six/seven health professionals. The findings illustrated that oral care is complex, and assessment is only one component of this process. Five concepts relating to oral assessment were identified by all the groups: ability to attend to oral care; oral health and cleanliness of the oral cavity; comfort of the oral cavity; contributing factors; assessment format and layout. The findings from the qualitative interviews, focus groups, and the literature review, were presented to an expert panel that contained a representative from the oral health experts, stroke experts, health professionals, patients and carers. This group reviewed the data and, using a systematic approach, developed the new oral assessment; the Comprehensive Oral Assessment Tool for Stroke (COATS). Following development, the COATS was tested for within and between rater agreement, and diagnostic accuracy, in 82 stroke patients on an acute stroke unit. Agreement was tested, in registered and unregistered nurses, and ranged from fair to very good. The registered nurse showed better agreement than the unregistered nurse. The COATS also demonstrated in this initial testing that it could correctly identify a high proportion of patients either with or without a problem. This thesis has provided some novel findings that will contribute to the existing knowledge of oral care in a stroke and dependent population. It has provided an overview of the quality of oral assessments available to nurses looking after acutely ill patients as well as highlighting all the potential issues that need to be considered when implementing a new oral assessment into clinical practice

Men’s health – the impact of stroke

Stroke is a leading cause of adult death and the most common cause of complex disability in the UK. This article discusses the incidence and impact of stroke, focusing on a range of issues from a male perspective, including stroke prevention, psychological needs, sexuality and return to work. There are some gender differences in modifiable risk factors for stroke, and women have better knowledge of stroke symptomatology. For men, the development of post-stroke depression is associated with greater physical disability. (c) Sherborne Gibbs Limite

‘’It just happens’. Care home residents’ experiences and expectations of accessing GP care.

Background: Care homes provide personal care and support for older people who can no longer be supported in the community. As part of a larger study of integrated working between the NHS and care homes we asked older people how they accessed health care services. Our aim was to understand how older people resident in care homes access health services using the Andersen model of health care access. Methods: Case studies were conducted in six care homes with different socio-economic characteristics, size and ownership in three study sites. Residents in all care homes with capacity to participate were eligible for the study. Interviews explored how residents accessed NHS professionals. The Andersen model of health seeking behaviour was our analytic framework. Findings: Thirty-five participants were interviewed with an average of 4 different conditions. Expectations of their health and the effectiveness of services to mitigate their problems were low. Enabling factors were the use of intermediaries (usually staff, but also relatives) to seek access. Residents expected that care home staff would monitor changes in their health and seek appropriate help unprompted. Conclusions: Care home residents may normalise their health care needs and frame services as unable to remediate these which may combine to disincline older care home residents to seek care. Care access was enabled using intermediaries -either staff or relatives-and the expectation that staff would proactively seek care when they observed new/changed needs. Residents may over-estimate the health-related knowledge of care home staff and their ability to initiate referrals to NHS professionals.Peer reviewedFinal Accepted Versio

Methods for comparing center‐specific survival outcomes using direct standardization

The evaluation of center‐specific outcomes is often through survival analysis methods. Such evaluations must account for differences in the distribution of patient characteristics across centers. In the context of censored event times, it is also important that the measure chosen to evaluate centers not be influenced by imbalances in the center‐specific censoring distributions. The practice of using center indicators in a hazard regression model is often invalid, inconvenient, or undesirable to carry out. We propose a semiparametric version of the standardized rate ratio (SRR) useful for the evaluation of centers with respect to a right‐censored event time. The SRR for center j can be interpreted as the ratio of the expected number of deaths in the total population (if the total population were in fact subject to the center j mortality hazard) to the observed number of events. The proposed measure is not affected by differences in center‐specific covariate or censoring distributions. Asymptotic properties of the proposed estimators are derived, with finite‐sample properties examined through simulation studies. The proposed methods are applied to national kidney transplant data. Copyright © 2014 John Wiley & Sons, Ltd.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106887/1/sim6089.pd

Identification of a BMP inhibitor-responsive promoter module required for expression of the early neural gene zic1

AbstractExpression of the transcription factor zic1 at the onset of gastrulation is one of the earliest molecular indicators of neural fate determination in Xenopus. Inhibition of bone morphogenetic protein (BMP) signaling is critical for activation of zic1 expression and fundamental for establishing neural identity in both vertebrates and invertebrates. The mechanism by which interruption of BMP signaling activates neural-specific gene expression is not understood. Here, we report identification of a 215 bp genomic module that is both necessary and sufficient to activate Xenopus zic1 transcription upon interruption of BMP signaling. Transgenic analyses demonstrate that this BMP inhibitory response module (BIRM) is required for expression in the whole embryo. Multiple consensus binding sites for specific transcription factor families within the BIRM are required for its activity and some of these regions are phylogenetically conserved between orthologous vertebrate zic1 genes. These data suggest that interruption of BMP signaling facilitates neural determination via a complex mechanism, involving multiple regulatory factors that cooperate to control zic1 expression

Oral Care after Stroke: Where are we now?

Purpose There appears to be an association between poor oral hygiene and increased risk of aspiration pneumonia – a leading cause of mortality post-stroke. We aim to synthesise what is known about oral care after stroke, identify knowledge gaps and outline priorities for research that will provide evidence to inform best practice. Methods A narrative review from a multidisciplinary perspective, drawing on evidence from systematic reviews, literature, expert and lay opinion to scrutinise current practice in oral care after a stroke and seek consensus on research priorities. Findings Oral care tends to be of poor quality and delegated to the least qualified members of the caring team. Nursing staff often work in a pressured environment where other aspects of clinical care take priority. Guidelines that exist are based on weak evidence and lack detail about how best to provide oral care. Discussion Oral health after a stroke is important from a social as well as physical health perspective, yet tends to be neglected. Multidisciplinary research is needed to improve understanding of the complexities associated with delivering good oral care for stroke patients. Also to provide the evidence for practice that will improve wellbeing and may reduce risk of aspiration pneumonia and other serious sequelae. Conclusion Although there is evidence of an association, there is only weak evidence about whether improving oral care reduces risk of pneumonia or mortality after a stroke. Clinically relevant, feasible, cost –effective, evidence based oral care interventions to improve patient outcomes in stroke care are urgently needed

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Examining the effectiveness of general practitioner and nurse promotion of electronic cigarettes versus standard care for smoking reduction and abstinence in hardcore smokers with smoking-related chronic disease:protocol for a randomised controlled trial

BACKGROUND: Despite the clear harm associated with smoking tobacco, many people with smoking-related chronic diseases or serious mental illnesses (SMI) are unwilling or unable to stop smoking. In many cases, these smokers have tried and exhausted all methods to stop smoking and yet clinicians are repeatedly mandated to offer them during routine consultations. Providing nicotine through electronic cigarettes (e-cigarettes) may reduce the adverse health consequences associated with tobacco smoking, but these are not currently offered. The aim of this study is to examine the feasibility, acceptability and effectiveness of general practitioners (GPs) and nurses delivering a brief advice intervention on e-cigarettes and offering an e-cigarette starter pack and patient support resources compared with standard care in smokers with smoking-related chronic diseases or SMI who are unwilling to stop smoking. METHODS/DESIGN: This is an individually randomised, blinded, two-arm trial. Smokers with a smoking-related chronic condition or SMI with no intention of stopping smoking will be recruited through primary care registers. Eligible participants will be randomised to one of two groups if they decline standard care for stopping smoking: a control group who will receive no additional support beyond standard care; or an intervention group who will receive GP or nurse-led brief advice about e-cigarettes, an e-cigarette starter pack with accompanying practical support booklet, and telephone support from experienced vapers and online video tutorials. The primary outcome measures will be smoking reduction, measured through changes in cigarettes per day and 7-day point-prevalence abstinence at 2 months. Secondary outcomes include smoking reduction, 7-day point-prevalence abstinence and prolonged abstinence at 8 months. Other outcomes include patient recruitment and follow-up, patient uptake and use of e-cigarettes, nicotine intake, contamination of randomisation and practitioner adherence to the delivery of the intervention. Qualitative interviews will be conducted in a subsample of practitioners, patients and the vape team to garner their reactions to the programme. DISCUSSION: This is the first randomised controlled trial to investigate whether e-cigarette provision alongside a brief intervention delivered by practitioners leads to reduced smoking and abstinence among smokers with smoking-related chronic diseases or SMI. TRIAL REGISTRATION: ISRCTN registry, ISRCTN59404712. Registered 28/11/17

Revised Lithostratigraphy of the Sonsela Member (Chinle Formation, Upper Triassic) in the Southern Part of Petrified Forest National Park, Arizona

BACKGROUND: Recent revisions to the Sonsela Member of the Chinle Formation in Petrified Forest National Park have presented a three-part lithostratigraphic model based on unconventional correlations of sandstone beds. As a vertebrate faunal transition is recorded within this stratigraphic interval, these correlations, and the purported existence of a depositional hiatus (the Tr-4 unconformity) at about the same level, must be carefully re-examined. METHODOLOGY/PRINCIPAL FINDINGS: Our investigations demonstrate the neglected necessity of walking out contacts and mapping when constructing lithostratigraphic models, and providing UTM coordinates and labeled photographs for all measured sections. We correct correlation errors within the Sonsela Member, demonstrate that there are multiple Flattops One sandstones, all of which are higher than the traditional Sonsela sandstone bed, that the Sonsela sandstone bed and Rainbow Forest Bed are equivalent, that the Rainbow Forest Bed is higher than the sandstones at the base of Blue Mesa and Agate Mesa, that strata formerly assigned to the Jim Camp Wash beds occur at two stratigraphic levels, and that there are multiple persistent silcrete horizons within the Sonsela Member. CONCLUSIONS/SIGNIFICANCE: We present a revised five-part model for the Sonsela Member. The units from lowest to highest are: the Camp Butte beds, Lot's Wife beds, Jasper Forest bed (the Sonsela sandstone)/Rainbow Forest Bed, Jim Camp Wash beds, and Martha's Butte beds (including the Flattops One sandstones). Although there are numerous degradational/aggradational cycles within the Chinle Formation, a single unconformable horizon within or at the base of the Sonsela Member that can be traced across the entire western United States (the "Tr-4 unconformity") probably does not exist. The shift from relatively humid and poorly-drained to arid and well-drained climatic conditions began during deposition of the Sonsela Member (low in the Jim Camp Wash beds), well after the Carnian-Norian transition