M. Petrina Sweeney

Risk Factors for Chest Infection in Acute Stroke A Prospective Cohort Study

Background and Purpose— Pneumonia is a major cause of morbidity and mortality after stroke. We aimed to determine key characteristics that would allow prediction of those patients who are at highest risk for poststroke pneumonia. Methods— We studied a series of consecutive patients with acute stroke who were admitted to hospital. Detailed evaluation included the modified National Institutes of Health Stroke Scale; the Abbreviated Mental Test; and measures of swallow, respiratory, and oral health status. Pneumonia was diagnosed by set criteria. Patients were followed up at 3 months after stroke. Results— We studied 412 patients, 391 (94.9%) with ischemic stroke and 21 (5.1%) with hemorrhagic stroke; 78 (18.9%) met the study criteria for pneumonia. Subjects who developed pneumonia were older (mean±SD age, 75.9±11.4 vs 64.9±13.9 years), had higher modified National Institutes of Health Stroke Scale scores, a history of chronic obstructive pulmonary disease, lower Abbreviated Mental Test scores, and a higher oral cavity score, and a greater proportion tested positive for bacterial cultures from oral swabs. In binary logistic-regression analysis, independent predictors (P<0.05) of pneumonia were age >65 years, dysarthria or no speech due to aphasia, a modified Rankin Scale score ≥4, an Abbreviated Mental Test score <8, and failure on the water swallow test. The presence of 2 or more of these risk factors carried 90.9% sensitivity and 75.6% specificity for the development of pneumonia. Conclusions— Pneumonia after stroke is associated with older age, dysarthria/no speech due to aphasia, severity of poststroke disability, cognitive impairment, and an abnormal water swallow test result. Simple assessment of these variables could be used to identify patients at high risk of developing pneumonia after stroke.

The mouth and palliative care

Oral complications are common among patients with advanced cancer, though relatively little research has been undertaken in this field. This review article discusses the common problem of xerostomia among the terminally ill, together with an overview of oral candidosis, oral viral infections, chemotherapy- and radiotherapy-associated mucositis, and alterations in taste sensation among those with advanced cancer. Suggested management regimes, based on the limited clinical trial data available, are provided where appropriate.

Provision of mouth care by nursing staff for cancer patients in Scotland: Current status and the role of training:

Oral disease is common in patients with cancer and mouth care is an important element of palliative care. Responsibility for provision of this care usually falls to nursing staff. This study aimed to determine the level of mouth care provided by nurses for patients with cancer in Scottish hospices and in the community within Scotland, and to assess the value of a training pack in oral disease and oral care. Fifteen hospices, 52 Macmillan nurses and 112 district nurses were invited to participate. Responses to an initial questionnaire confirmed the important role of nurses in providing mouth care, but highlighted significant deficiencies in training, particularly for district nurses, and a lack of formal protocols in this area. There was little interaction with professional dental staff. Training packs, including clinical photographs and simple mouth care protocols were sent to 15 hospices, 20 Macmillan nurses and 45 district nurses. A follow-up questionnaire six weeks later showed that the packs had been very well received and had resulted in significant changes to mouth care practices of many of the users. However, 34% of the respondents felt that further training would still be beneficial.

Fluconazole sensitivities of Candida species isolated from the mouths of terminally ill cancer patients.

Oral candidosis is common in advanced cancer and is often treated with the systemic triazole antifungal drug fluconazole. This study examined the species of yeast present in the mouths of 30 patients with advanced cancer and determined their sensitivity to fluconazole. Thirty-five yeast isolates were collected from a total of 25 (83 percent) of the patients sampled. The two most common species were Candida albicans (15 isolates) and C. glabrata (11 isolates)—with smaller numbers of C. tropicalis, C. parapsilosis, C. guilliermondii, C. inconspicua, and Saccharomyces cerevisiae. The minimal inhibitory concentrations (MIC) of fluconazole for the strains of C. albicans were generally low (median 0.19µg/ml) but were considerably higher for C. glabrata (median 2µg/ml). The remaining species demonstrated MICs similar to those for C. albicans, with the exceptions of C. inconspicua and Saccharomyces cerevisiae, which were relatively insensitive. In conclusion, non-albicans yeasts are common in the mouths of patients with advanced cancer and these may have reduced sensitivity to fluconazole. Mycological diagnosis is a valuable aid to management.

Colour teaching aids in oral disease for hospital ward staff

Provision of adequate care for the mouths of patients in hospitals, particularly those such as the elderly in long-stay wards, is frequently overlooked. An important contributing factor is the lack of dental training of the carers. As part of a wider initiative to address this problem a set of encapsulated, full colour illustrated sheets has been designed by a team of dentists for use by medical, nursing and allied staff at ward level. The 20 sheets illustrate features of a healthy mouth together with 16 common oral disorders. Each set is held in a loose-leaf ring binder. Over 100 sets are now in use within the West of Scotland, with an encouraging response to the circulated appraisal forms.