OBJECTIVES: The primary objective of this study was to evaluate the effectiveness of of oral health promotion interventions on both clinical oral health, and oral opportunistic pathogens in hospitalized patients following acute stroke. Secondary objectives were to investigate the development of infectious complications, as well as health-related quality of life during the hospitalization period, and to monitor clinical oral health, oral opportunistic pathogens, and health-related quality of life following hospital discharge. METHODS: A total of 102 patients were recruited into a clinical trial conducted among stroke patients in a rehabilitation ward. Patients were randomly assigned either: 1) oral hygiene instruction 2) oral hygiene instruction and chlorhexidine mouthrinse or 3) oral hygiene instruction, chlorhexidine mouthrinse, and assisted brushing. Dental plaque, gingival bleeding, oral opportunistic pathogens, health-related quality of life, oral health-related quality of life, and functional status were assessed at baseline and review. The development of infectious complications was also monitored during the clinical trial. Patients completing the clinical trial were assessed at six months following hospital discharge. RESULTS: Eighty-one patients were available for review at the end of the clinical trial. Reductions in dental plaque (PI) scores were significantly greater in the two groups receiving chlorhexidine compared to the group receiving oral hygiene instruction alone (p<0.001). Reductions in gingival bleeding (GBI) scores were three to four-fold greater in groups receiving chlorhexidine. Almost three quarters (72.8%) of patients harbored oral aerobic and facultatively anaerobic Gram-negative bacilli (AGNB) at baseline. Over half of the patients had detectable Staphylococcus aureus (56.8%) and yeasts (59.3%). Percentage frequencies and viable counts of pathogens remained relatively stable during the course of the clinical trial, and no significant differences were observed between groups (p>0.05). No cases of pneumonia were observed during the course of the clinical trial. Health-related quality of life (p<0.001), oral-health related quality of life (p=0.014), general functional disability (p<0.001), and toothbrushing ability (p=0.001) improved significantly during hospitalization. A total of 52 patients were reviewed six months following hospital discharge. PI scores were significantly higher than those observed at the end of the clinical trial (p<0.001), but were still significantly lower than those documented at baseline (p<0.001). Changes in GBI scores did not reach statistical significance (p>0.05). Percentage frequencies of AGNB (p=0.001), and viable counts of both AGNB (p<0.001) and yeasts (p=0.028) were significantly reduced at six months. No significant gains in life quality or oral functional disability were observed following hospital discharge (p>0.05). CONCLUSIONS: The clinical oral health condition of stroke patients may be safeguarded following acute stroke with the use of chlorhexidine mouthrinse in conjunction with a standard mechanical plaque removal regimen. These interventions are acceptable to the majority of patients, and their administration poses a minimal burden to rehabilitation ward staff. There was, however, no significant difference in the effectiveness of the three different oral health promotion interventions in combating oral opportunistic pathogens. Gains in quality of life and oral functional disability were largely limited to the in-hospital rehabilitation period. / published_or_final_version / Dentistry / Doctoral / Doctor of Philosophy

Section A is a review of the literature on psychological adjustment following stroke. Empirical research is critically reviewed with reference to two research questions: (1) What do we understand about adjustment following survival of stroke? (2) What psychosocial interventions have been used to support adjustment post-stroke and what are the outcomes? Theoretical models for adjustment to stroke are drawn upon to illuminate the findings. Gaps within the literature are discussed and future directions for research are suggested. Section B describes a study using mixed methods. The purpose of the study was to evaluate whether narrative group therapy could facilitate psychosocial adjustment in survivors of stroke, and to explore the impact of stroke on survivors’’ lives through their shared narratives. Methods: Ten participants took part in a six-week narrative group therapy intervention for stroke survivors. Quality of life, use of coping strategies and illness representations were measured pre- and post-intervention, and thematic analysis was conducted on the content of the intervention sessions. Results: There was no statistically significant change on the outcome measures post-intervention. However the inductive thematic analysis resulted in the identification of four master themes: ‘using the group’, ‘negative talk’, ‘positive talk’ and ‘relationships’. These themes, respectively, revealed that the social aspects of the group allowed comparing experiences and exchanging information; participants were able to discuss the perceived negative aspects of surviving a stroke; with support, participants could identify the adaptations and achievements made since the stroke; and how the stroke impacted on relationships between the survivor and the systems around them. Conclusion: The findings indicate that narrative therapy requires further evaluation in terms of facilitation of adjustment. However, the thematic analysis supports the utility of group discussions and the provision of information to stroke survivors and their carers, thus indicating potential development of psychoeducation group programmes, provisionally as part of a stepped care model.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / abstract / toc / Medicine / Doctoral / Doctor of Philosophy

Theiler's murine encephalomyelitis virus (TMEV) is classified as a Cardiovirus in the Picornaviridae family. An enteric virus, TMEV, spreads within the mouse population by the fecal-oral route. The neurovirulent GDVII strain of Theiler's virus causes a fatal encephalitis in all strains of mice following intra-cranial infection of the virus. Persistent BeAn strain of Theiler's virus causes a demyelinating disease in susceptible strains of mice, which is similar to the human disease - Multiple Sclerosis (MS). Although a well-recognized model for MS, the route of entry of the virus into the central nervous system (CNS) following natural infection has not been well understood. One of the proposed portals of entry includes the blood-brain barrier (BBB). This report indicates the ability of both the neurovirulent and the persistent strains of Theiler's virus to induce apoptosis in the functional units of the BBB - the cerebrovascular endothelial cells (CVE) both in vitro and in vivo. Induction of apoptosis in CVE was demonstrated by Annexin staining, electron microscopy, DNA fragmentation assay, Hoechst staining and by caspase-3 staining. Corresponding to results by other authors, GDVII is a stronger inducer of apoptosis in CVE compared to BeAn. Induction of apoptosis is dependent on the MOI of the virus. UV-inactivated virus is not capable of inducing apoptosis and induction of apoptosis appears to be an internal event not requiring activation of death receptors. Determining the pathway of induction of apoptosis by TMEV in CVE indicated the involvement of a Ca2+ dependent pathway for apoptosis - the calpain pathway. Involvement of calpain in apoptosis has been reported in MS. Induction of apoptosis in CVE in vivo was also demonstrated following the intra-peritoneal inoculation of Theiler's virus. Induction of apoptosis in CVE following Theiler' virus infection could lead to a breach of the BBB and entry of inflammatory cells as well as virus into the central nervous system. This finding could aid understanding the neuropathogenesis of Theiler's virus.

TRUNK BALANCE AS A PREDICTOR OF MOTOR OUTCOME IN PATIENTS WITH STROKE ABSTRACTBackground: The search for predictors of functional stroke outcome has always been matter of research in Physical Medicine and Rehabilitation. Outcome prediction at an early stage enables clinicians not only to inform patients and their families, but also to set realistic therapeutic goals. A lot of prognostic studies have evaluated several factors, which either individually or in combination claim to predict functional outcome in stroke. The Trunk Control Test (TCT) proposed by Collin & Wade administered at 6 weeks post-stroke is a predictor of the walking ability at 18 weeks. The TCT reliability and validity has been demonstrated in stroke patients, as well as its positive correlation with disability at hospital discharge from in-patient rehabilitation measured with the Functional Independence Measure (FIM). In a previous study, a predictive model which only includes the FIM and the TCT measured at admission of patients to a rehabilitation ward, predicts 66.5% of the variability of the functional level at discharge (total FIM). Objective: To develop an early model to predict motor function (disability, walking ability and balance)at 6 months, taking into account the TCT and other valid predictors evaluated in the first and second week after suffering a stroke.Patients and Methods: Seventy-five consecutive patients with first stroke who were admitted to a rehabilitation hospital were studied. Sex, age, the stroke type, urinary incontinence, the National Institutes of Health Stroke Scales (NIHSS) and the TCT scores (assessed at first and second week post-stroke) as independent variables. Motor function outcome at 6 months after stroke is defined by the use the Rankin score, the motor FIM and the Berg Balance Scale (BBS).Results: Older patients, women and those with initial urinary incontinence and lower TCT and NIHSS scores showed significantly worse motor outcomes at first and six months after the stroke (Rankin, motor FIM and BBS). A multiple regression reveals that only age and the TCT (at 14 days after stroke) accounts for the 61.1% of the variance in the motor FIM score at 6 months after stroke. When the TCT is registered at 7 days after stroke, age and the TCT accounts for the 51.7% of the motor FIM variance. A cluster analysis identifies 12 patients with low outcome scores: Rankin 4-5, motor FIM < 59 and BBS < 5. The ROC curves show a better prediction ability for the TCT than the NIHSS at 14 days after stroke. Logistic regression is used to predict the probability of achieving in this group with low motor scores. The TCT &#61603; 50 at 14 days after stroke is a significant predictive factor of poor motor outcome at 6 months after stroke (Sensibility 83.3%, Specificity 85.7%) (OR=30.0, 95% CI 4.7 - 247.3). The TCT &#61603; 24 at 7 days after stroke is a significant, but obviously worse predictive factor of poor motor outcome (Sensibility 66.7%, Specificity 89.3%) (OR=16.7, 95% CI 3.2 - 97.5). Discussion and conclusions: Age, sex, urinary incontinence, TCT and NIHSS scores are related with disability, balance and walking ability six months after the stroke. It is possible to approach to the motor functional outcome at 6 months after stroke by the early use of data easily recorded as age and the TCT. In this study the TCT even overcomes the NIHSS, a comprehensive neurological measure whose ability to predicts outcome has been well documented in stroke patients. The reproducibility of this model must be cross-validated in future studies. The TCT registered at 14 days provides better prediction values compared with those obtained at 7 days after stroke. This study shows that the TCT early administered predicts motor outcome at six months after stroke.EQUILIBRI DE TRONC: PREDICTOR DE LA FUNCIÓ MOTORA EN L'HEMIPLÈGIC VASCULAR RESUMIntroducció: La cerca de factors predictors del resultat funcional després de patir un ictus és objecte constant d'investigació en Medicina Física i Rehabilitació. Un pronòstic funcional en fases inicials permet al clínic informar als pacients i a la seva familia, però també establir objectius terapèutics realistes. Molts estudis han avaluat la capacitat predictora de diferents factors individual i combinadament. El Test de Control de Tronc (TCT) registrat a les 6 setmanes de l'ictus és un predictor de la capacitat de marxa a les 18 setmanes. La fiabilitat i validesa del TCT s'ha demostrat en pacients amb ictus, així com la seva correlació positiva amb la discapacitat a l'alta hospitalaria. Un model predictiu que inclou només el TCT i el Functional Independence Measure (FIM) registrats a l'ingrés en la unitat de rehabilitació d'hospitalització aguda prediu el 66.5% de la variabilitat del FIM a l'alta.Objectius: Conèixer la relació de les variables predictores amb els resultats de funció motora global al mes i als sis mesos de l'ictus. Construir un model de predicció precoç de la funció motora (discapacitat, capacitat de marxa i equilibri) als 6 mesos, tenint en compte el TCT i altres predictors vàlids avaluats en la primera i en la segona setmana després de patir l'ictus.Pacients i Mètode: estudi longitudinal i prospectiu en 75 pacients consecutius ingressats per un primer episodi d'ictus. Les variables independents van ser: edat, sexe, tipus d'ictus, incontinencia urinària, l'escala d'ictus National Institutes of Health Stroke Scales (NIHSS) i el TCT (recollits en la primera i segona setmanes de l'ictus). Els resultats de funció motora al mes i als 6 mesos de l'ictus es van definir amb l'escala de Rankin, la subescala motora del FIM i l'escala d'equilibri Berg Balance Scale (BBS).Resultats: els pacients de més edat, les dones i els que tenen incontinència urinària inicial i puntuacions més baixes de TCT i NIHSS són els que presenten significativament pitjors resultats de funció motora tant en el primer com en el sisè mes de l'ictus (Rankin, FIM motor i BBS). Una anàlisi de regressió múltipla determina que només amb l'edat i el TCT de la segona setmana s'explica el 61.1% de la variabilitat del FIM motor als 6 mesos de l'ictus. Quan el TCT es registra en el setè dia de l'ictus, l'edat i el TCT expliquen el 51.7% de la variabilitat del FIM motor. Una anàlisi de conglomerats identifica 12 pacients amb resultats baixos de funció motora: Rankin 4-5, FIM motor < 59 i BBS < 5. Les corbes ROC mostren que la millor capacitat predictora correspon al TCT de la segona setmana, per sobre del NIHSS. La probabilitat de tenir un mal resultat motor, es a dir, d'estar entre aquests 12 pacients es calcula mitjançant una anàlisi de regressió logística. Un TCT &#61603; 50 en la segona setmana de l'ictus és un factor predictiu de mal resultat motor als 6 mesos (Sensibilitat 83.3%, Especificitat 85.7%) (OR=30.0, IC 95% 4.7 - 247.3). Un TCT &#61603; 24 en la primera setmana també és un factor predictor significatiu, tot i que menys potent, de obtenir un mal resultat motor als 6 mesos (Sensibilitat 66.7%, Especificitat 89.3%) (OR=16.7, IC 95% 3.2 - 97.5).Conclusions: L'edat, el sexe, la incontinència urinària, el TCT i el NIHSS inicials són factors relacionats amb la discapacitat, equilibri i capacitat de marxa 6 mesos després de l'ictus. És possible aproximar-nos al resultat funcional motor als 6 mesos després de patir l'ictus amb la utilització precoç de dades de fácil recollida com l'edat i el TCT. El TCT recollit en fases inicials prediu el resultat motor als 6 mesos de l'ictus.

The rehabilitation of stroke patients can occur at different settings. These include in-patient settings, such as stroke units or general rehabilitation wards and out-patient settings, such as out-patient departments attached to hospitals, day hospital departments and the patients’ home. In South-Africa, day hospitals have been upgraded and are now referred to as Community Health Centres which provide comprehensive health services to the population. In the Western Cape these centres are faced with the rehabilitation of stroke patients who have been discharged early from hospital during the acute stage or who have never been admitted to hospitals. To date there is a lack of best practice guidelines and formal evaluations in terms of efficacy and effectiveness of rehabilitation at these centres. The aim of the study was therefore to investigate the rehabilitation of stroke patients at Community Health Centres in the Metropole Region of the Western Cape. The structure, process and outcomes (SPO) model was used as a conceptual framework in this study.

A retrospective review was made of the case records, angiograms and computed tomography (CT) relating to a total of 263 patients with subarachnoid haemorrhage (SAH) due to ruptured berry aneurysms who were admitted to the Department of Neurosurgery, Wentworth Hospital during the four years 1983-1986. The part of the thesis concerning vasospasm (VS) includes two independent studies on calcium blocker Nimodipine (NO) in the prevention and treatment of VS done by the author. The aim of the thesis is to analyse the management problems of aneurysmal SAH, and investigate factors influencing outcome in order to establish the best possible management policy. The results are discussed and related to the recent data from literature. The main factors influencing outcome were: clinical condition of the patient, the timing of admission and surgery, hypertension and hyperglycaemia on admission, presence of vasospasm and related CT appearance of a thick layer of blood or clot in subarachnoid haemorrhage (CT-Fisher 3). The systemic administration of the calcium blocker nimodipine did not reverse or prevent delayed vasospasm and caused serious adverse effects i.e. hypotension and hyperglycaemia. The results of the thesis suggest a change in management policy and timing of surgery should depend. on clinical condition of the patient on admission (Hunt & Hess grading)(HH I/II grade (HH as possible regardless of timing of admission and results of radiological investigations (CT, angiography). Early surgery (1-3 days) should be the aim of the effort including referral, transport and hospital organisation. III grade (HH surgery should be performed soon after day 10 post-SAH. Particular attention should be paid to the careful preparation and selection of patients for angiography. IV/V grade (HH in specialised units as s000n as possible, preferably neurological or neurosurgical wards, and operated on as soon as their grade improves or, in selected (by surgeon, radiologist and anaesthetist) cases by delayed surgery ( after day 10 post-SAH). / Thesis (M.Med.)-University of Natal, Durban, 1988.

The outcome of acute stroke in 210 White adult patients admitted to Addington Hospital, Durban in 1983 and 1984 was investigated by means of retrospective case-note review. In addition, the level of functional independence of 35 people who, at the time of this study, were survivors of an initial acute stroke was assessed through household survey. The study was considered relevant and worthwhile for several reasons: 1. Stroke is an important contributor to morbidity and mortality in Whites in South Africa, however, l i t t l e information is available in respect of the outcome of sufferers of stroke who were admitted to the study hospital. 2. Knowledge of the needs of survivors of acute stroke is necessary if appropriate health care is to be provided. 3. Few community studies have been done in South Africa in which the status of stroke survivors has been established. The principle aims of the study were therefore: 1. To establish the survival of patients with acute stroke who were admitted to the study hospital. 2. To determine in survivors of an initial stroke their residual functional loss and hence to identify the supportive health care needs of this group. The most important findings of the study were as follows: 1. Of the 286 stroke admissions identified through the hospital's medical record retrieval system, stroke diagnosis according to the study definition could be confirmed in only 210 (73.4%) cases due to misplaced files or miscoded diagnoses. The need for improvement in the method of recording, storing and retrieving of patient information is indicated by these findings. The overall hospital fatality rate for stroke was 54%. Mortality was highest in the first week after admission (71%). The number of males and females, in respect of whom a final diagnosis of stroke was attributed, was almost equal. A significant difference (p < .000 2) in respect of age was noted between the sexes. The mean age of onset of stroke was 62.9 and 70.0 years for males and females respectively. The major diagnostic categories (haemorrhagic or occlusive) of stroke could only be ascertained in respect of 30% of cases. This was due to incomplete recording of clinical findings, and possibly, due to the absence of resident brain-scanning facilities at the time. Analysis of the results of the household interviews indicated that:-( I ) Of the 35 patients interviewed 13 (37%) were found to be fully independent in self-care and were mobile outside of the home. (ii) The patients' potential for improvement in an appreciable number of cases had been under-estimated by the hospital staff. Patient adjustment following hospital discharge appeared adversely affected by.-(i) Inadequate preparation for discharge, especially where patients were returning to their own homes. (ii) Inadequate explanation given to patients and their families of the meaning and implications of stroke. (iii)The non-involvement of the family during the period of hospitalization. (iv) The absence of appropriate follow-up after discharge. Stroke onset was a traumatic experience in all cases. Amongst the most important reasons given for reduced life-satisfaction post stroke were confinement to the home, reduced independence and unresolved loss (eg death of spouse, forced retirement). 8. In some cases it was f e l t that social isolation, general ill-health and old age were more significant problems in the lives of patients than the stroke itself. The advent of stroke merely exaggerated these problems. 9. The advantage of administering a standardized functional assessment at intervals during the rehabilitation of the patients became increasingly clear as the study progressed. It is proposed that functional assessment be considered as important as clinical assessment in the management of stroke patients. 10. Recommendations have been submitted concerning rehabilitation and the provision of supportive services for stroke patients. As the role of the nurse in short and long-term care is central to successful stroke outcome, emphasis has been placed on her role in the team. The main conclusions formulated in the study were:-1. Mortality from stroke is high but in survivors an appreciable proportion maintained functional independence. 2. Preparation of patients and their families is important to adjustment following discharge from hospital. 3. Supportive services are important to the maintenance of the stroke patient in the home environment. 4. A team approach, consisting of a wide range of health professionals is appropriate to the management of stroke. 5. Functional assessment is an important component of the clinical examination and should be done prior to discharge and subsequently at regular intervals to assess the patient's competence to exist in the current domestic environment. / Thesis (MMed.)-University of Natal, Durban, 1986.