When I started to research oral care–brushing and flossing–for stroke, I found advice all over the world. But first a little background on how I was reacting to oral care when I had the stroke and even after, until I read the literature on mouth hygiene.
I didn’t think oral care mattered, and because I was so f’ed up from the stroke, I tended not to brush my teeth and floss if fatigue had already set in. It happened 11 years ago, random times, at least twice a month, until this research began to sink in. Now I think different and so might you, in post-stroke care and even in pre-stroke care of, as the Urban Dictionary says, that pie hole!
In the U.S., a Finnish-inspired study published by the Journal of the American Heart Association found that bacteria commonly seen in parts of the mouth migrated to the brains of people who had an ischemic stroke between 2013 and 2017.
With an ischemic stroke, caused by a blockage in a blood vessel in the brain, 59 people in the study had streptococci normally found in the mouth that can inspire infections in the bloodstream.
The research professor in the Department of Oral Medicine at Carolinas Medical Center in Charlotte, North Carolina, Dr. Peter B. Lockhart, said, “We now know that bacteria exist throughout the body, including in the blood,” [previously thought to be sterile].
In the reverse, Web MD says, in an article by Karen Pallarito, says, “Adults with gum disease may be twice as likely as people with healthy gums to suffer a stroke.” I was stunned.
In a recent study, it was 1.9 times, 2.1 times and 2.2 times higher for people with mild, moderate and severe gum disease, respectively. The conclusion? People who neglect their teeth are also less likely to go to the doctor for any type of medical risk. They simply don’t want to know.
In the European Stroke Journal, there appears to be an association between poor oral hygiene and increased risk of aspiration pneumonia – a leading cause of mortality post-stroke.
“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.” From a social perspective, with bad breath, one is more likely to be overlooked.
In the European Union, the cost of dental care is expected to go up significantly. So people would be more likely to skip the dentist’s office, especially for older people with a fixed income.
For example, in the UK stroke is the third most common cause of death and ranks #1 in people with severe disability. Stroke costs the National Health Service (NHS) as well as the economy 7 billion a year. So we’re talking a lot of people.
In a recent study, the UK found these patients who often experience depression, anxiety, and fatigue to be less compliant with oral hygiene needs. Stroke, the study went on to say, sometimes results in confusion and the inability to recognise a toothbrush or floss in the early months.
The National Clinical Guidelines for Stroke in Australia emphasize the need for mouth hygiene following a stroke and the need for staff to be cognizant of the fact. Managing oral health post stroke is necessary, the guidelines go on to say, “and there is a need for an appropriate integrated oral care service in Australia.”
In Japan, a recent study found that tooth loss was related to stroke including not only ischemic but also hemorrhagic ones as well.
“It may be concluded that the association between stroke and tooth loss can be explained by common stroke risk factors associated with lifestyle such as hypertension, diabetes, smoking and alcohol intake.”
In addition, the key issue addressed in this study is determining whether dental treatment for tooth loss can be associated in preventing a second and more recurrent strokes. The jury is still out on that one. But with fewer teeth and ignoring dental visits, my mind is made up. What else can it be!
To conclude, watch this video to know my opinion! It might have been created before you were born! The 50s jingle goes like this:
When I visited Scotland people were wearing t-shirts and shorts when it was 68 degrees F because they thought it was hot. For the 1st time I understood why I sweat when it hits 70 degrees. My Norwegian ancesters who emmigrated to northern Scotland gave me muscular calves and thighs you would see on a soccer player. Big muscles create heat. I am a polar bear living with the gazelles in New Jersey.
After my stroke I did not go to a gym because it has machines that require 2 good arms or 2 good legs. Doing half of a yoga posture while sitting felt stupid and reinforced the asymmetrical strength my stroke created. I freak out about walking barefoot without my leg brace on slippery ceramic tile at a pool. I also do not want to learn how to put on and take off a swimsuit one-handed. So for
16 years I have exercised by pushing a shopping cart through large stores 2 to 3 times a week.
I would buy only $20 of merchandise so I had to make many returns trips. Now stores may have covid-19 virus in the air and on surfaces.
I switched to walking around my neighborhood while the weather was mild, but now the summer heat is here. I have to walk in the early morning when it is cool. The catch is that I have never been a morning person. All I can do is grunt if a person talks to me during the 1st hour I am up.
I felt groggy and sluggish so I decided to drink 16 ounces of water before I walked. Surprisingly it helped. I wore my pedometer and was pleased to see a high number. I do not know what I will do when snow covers the street, but I will worry about that later. homeafterstroke.blogspot.com
The last perspectives in medicine was about sudden changes. This post is on more insidious changes and the diagnostic challenge.
There is an interesting challenge that I notice in clinical medicine. It is a situation when someone’s health is not quite right but the diagnostic test and the clinical condition has not yet materialized to allow the physician to make a diagnosis. There is certainly a sweet spot in timing of the diagnosis: long enough to discern one cause from another and confirm it; not too long that a person is left with discomfort or a health risk.
In the inpatient setting, a patient may come in with a nonspecific series of complaints: fatigue, chills, jaundice. There may be nonspecific test results: elevated liver tests, a low white blood cell count, low platelets and a high bilirubin. This very circumstance happened in a patient that I evaluated. This series of findings is described as a mononucleosis syndrome. The challenge is that there are many things, infectious, rheumatologic, and neoplastic, that can cause these findings besides Epstein Barr Virus (EBV), the virus that causes “mono”.
The patient developed the symptoms over a period of three weeks. She noticed jaundice and increased fatigue. She had no flu-like symptoms, sore throat, lymph node swelling, or sick contacts. A battery of infectious diseases tests were performed, but none of them singled out one process. She may have had a positive antibody for EBV, but so does 80% of the population. The EBV DNA Polymerase chain reaction test (PCR), a marker of active infection, did not detect any copies. A CT scan showed an enlarged liver and spleen. Over a period of several days, she improved to the point that she was able to be discharged – without a diagnosis.
We discussed the next steps, which included a liver biopsy. The pathology of the liver sample suggested a process that is a result of many possible causes. It suggested a rare finding known as hemophagocytic lymphohistiocytosis (HLH), which is caused by autoimmune, neoplastic, or infectious causes. No telling findings otherwise were seen. Fortunately, she was feeling better.
We had a discussion about the results. I brought up strategy to address diagnostic challenges.
In medicine, seldom is a condition diagnosed on the spot. An astute physician can evoke a diagnosis like they are conjuring up magic. One of my mentors in infectious diseases, while rounding with us on a particularly vexing patient, walked in the room, looked at the patient face and skin (he had some ulcers on his lips and a generalized rash), and almost immediately said “he has Mycoplasma. And that is what he had. All other tests were negative, but he had the typical X-ray finding of Mycoplasma, a cause of “walking pneumonia,” and all his tests HIV, syphilis, etc were otherwise negative. We were spellbound, as we reviewed about this less common presentation of Mycoplasma.
A disease process sometimes takes time to present, time to grow and enable a safe way to diagnose it. Some diseases can be diagnosed fairly reliably by looking at the skin, our bodies largest organ. In fact, there is an app for that. The skin houses a network of vessels that mirror what is going on the in the entire body. Occasionally, systemic diseases can present with skin findings, that facilitate a less invasive way of making a diagnosis. This includes conditions such as sarcoidosis, T-cell lymphoma, malignant melanoma, metastatic squamous cell carcinoma of the lung, and lupus vasculitis.
When the disease is confined to the deeper vessels and lymphatic system, often there will be nonspecific changes in the GI tract. The tests may be nonspecific, such as elevated liver enzymes, white blood cell changes, and anemia. Since there are a multitude of infections that can present similarly, a shot-gun approach isn’t always high-yield or cost-effective. The radiologic imaging may also be nonspecific, such as a large liver and spleen, and mildly enlarged lymph nodes. At that point, the next step becomes a decision between watchful waiting or more aggressive, invasive testing.
The imaging and tests can only hint at the possibilities. Sometimes, there is a need of tissue, and sometimes there is a need to treat while not being completely sure. It reminds me of a patient that I saw from Africa who presented in the US with peritoneal fluid, lymph nodes, and thickening changes of the peritoneal lining. These changes usually occur when there is inflammation. The pathology report of the peritoneal biopsy was that of non-caseating granulomas, a feature of sarcoidosis but certainly not exclusive to it. She was from a part of Africa, where an article was published on cases of sarcoidosis.
It was also a high prevalence country for tuberculosis, which can present as non-caseating granulomas (though are more known for caseating changes). Her blood test (quantiferon) was positive for tuberculosis, but it wasn’t clear if it was latent infection (and had sarcoidosis) or if this was peritoneal tuberculosis. I saw her in the hospital; a different one from where she was being seen. She just had a biopsy there. I called the pathologist told him that I found it worrisome for tuberculosis. He looked at the smears before (tuberculosis stains with acid fast stain) and did not find anything. My call was enough to get him to go back and look. He called me a few hours later saying that he found “one acid fast bacillus.” We started her on four drug tuberculosis and after about one week, she had already felt better. None of the cultures ever grew; none of the genetic tests were ever positive. Yet, she had peritoneal tuberculosis.
Although ultimately it goes back to the service that physicians provide to the patient, a vague but concerning presentation can get a physician concerned about whether something is missing, and even if he or she is skilled enough. Hovering around is a concern of malpractice. As many as 39% of medical malpractice lawsuits come from failure to make a diagnosis, missed diagnosis, or delay. There is a point when the nonspecific, mild symptoms start to escalate to more specific, acute symptoms. Ideally, the time to diagnose a disease is before it can cause a threat on health.
Fortunately, there are some important aspects to addressing a challenging diagnosis, for patient and doctor alike. I approached the patient with the diagnostic dilemma with these points in mind:
Go back to the History and Physical Exam
This is one of the physician’s most important tool. Whenever I get into a situation of a diagnostic challenge, I go back to the patient and really listen to his/her words and determine the development of symptoms. A dying art in the era of advanced medical technology, a good history can still assist greatly in making a diagnosis; from some estimates, 70-90% of the time.
A follow-up physical examination while reviewing the history is critical. I often find that the best exam includes a second visit. It gives clarity on the history: the patient may have had a chance to think about the symptoms or questions more; the exam may have been changed or a physician may have missed something on the prior exam. There was a time that after a fourth genital exam, in my stubborn fashion, I found the source of the patient’s fever – a penile abscess.
It is important to keep the channels open and to feel comfortable to discuss any questions or concerns. I like to reassure the patient that I will continue to search for a the person can contact me and inform me of their health. We can keep visits at closer intervals to review progress.
Go toward the place where there is the greatest change
A blood test can sometimes show changes, for instance in the white blood count or the liver tests. A patient may have localizing symptoms, for instance, localized abdominal pain. If there is a concern, an imaging test may be ordered, such as a CT scan. Where an abnormality is encountered is the place that a more invasive test can be used to assist in the diagnosis. This often requires a scope or interventional radiology to take a sample.
Watchful waiting requires diligence
If a person is not suffering from severe symptoms, they may be safe enough to monitor over time. This requires careful planning and setting goals. This could be ensuring that the patient is seen frequently or receives additional testing, such as an imaging study or diagnostic test, in a timely fashion.In the infectious diseases clinic, I once diagnosed a patient with atrial fibrillation, but needed to confirm it on an ECG, which we didn’t have. I sent him to the cardiovascular lab; it was closed. He wasn’t able to get the test for one week, which confirmed the clinical exam. Was that too long to wait? Maybe.
Consider collaborative discussions and second opinions
Occasionally bias can obfuscate the ability to draw objective conclusions. There are always going to be knowledge gaps, as well. I used to think that being a specialist would have a more confined and manageable knowledge foundation than a generalist. I though wrong. It is just as complex and ever-changing.
It’s common that a patient’s information is discussed by multiple providers involved. In fact, it is a disservice to not have this collaboration otherwise. It isn’t unusual and sometimes helpful to walk down to the radiology reading rooms, review slides in microbiology or the biopsies with a pathologist, or to scrub in on a surgery. These perspectives enhance care.
I discuss cases with other infectious diseases specialist as well, if I can’t find a satisfactory answer from my knowledge base or from a brief literature review. Sometimes, one can be treated while closely watching and considering other causes. Other times, it is necessary to wait until a definitive diagnosis is made. It all depends on the acuity.
All anti-depressants do not just come in a pill so I am glad I found a way to garden after my stroke. However, each year I forget the tricks I discovered so I took photos and described them.
At first I pulled plants out of their containers one-handed. The moist dirt balls broke apart. I learned to let the plants dry out a little. The photo shows a child size spade I slide down the sides of each container to loosen the roots.
I use a big plastic pot that is lighter than clay. After I partially fill the pot, I put a ring on top of the dirt. I made this ring out of a disposable plastic cutting board. The ring keeps plants away from the rim and gives me something to lean the 1st row of plants against. A small cup helps me fill the narrow space between the ring and the edge of the pot. I make sure the plants are touching each other so they grow into a thick ball that prevents water evaporation. I drop fistfuls of dirt in the small spaces between the plants. Then I pull out the ring.
I use my hemiplegic (paralyzed) hand to hold the watering can still so it will not tip over as I fill it with the hose. I use the garden hose to wash off the dirt I have spilled on my concrete patio.
I lower the pot onto a bench and carefully slide it next to the chair I sit in to watch the sunset and drink a cup of coffee. I also get to enjoy these beautiful flowers every time I come home.
P.S. Rebecca you only need four 4-packs. homeafterstroke.blogspot.com
Aphasia is not having a senior moment every once in awhile. Rather, aphasia is the loss of ability to comprehend or express speech caused by brain damage, one of negatives for winding up with a malfunctioned brain from stroke and Traumatic Brain Injuries (TBI). Sometimes you get better with aphasia from stroke or TBI, but few get better completely.
I make a self-deprecating joke with aphasia when I often say, stumbling to find the exact word, “This here is aphasia in action,” naming it before people think I’m slow. But naming it or not, aphasia really sucks.
I’ve come up with a list the insensitives among us say when, after a few seconds, they lose my thread and start talking about something else. I want to say, “C’mon, guys, can’t you wait while I think of the word,” but I never say it. Why bother? I saw that now. But early on, I wanted to change the world’s thinking about aphasia. What a dud I was.
Here’s the list of the top ten reactions people have for those with aphasia:
1. I can’t understand you.
This statement cuts right into my soul. You’re speaking English. I’m speaking English. “So what’s the problem?” I say silently. To my ear, it sounds good enough, but to the person’s ear, it sounds incomplete, which it probably is. But even though….
2. Supplying the right word
Oh, no! I want to be part of the conversation, and if you’d just hang on for a sec or three, the word will come to me. Or they won’t.But my aphasia is different from some, because the word that I’ll come up with, though in the ballpark of correctness, a word I’ve rarely used before. Example, we took a ride to the coast and when we arrived, I described the houses as “ramshackle.” I never know what’s going to come out of my mouth because I lost the filters when I had a stroke in 2009.
3. People finishing your thought
I can honestly say, “What the F is wrong with them?” Sheesh. Give a gal a chance. They think they’re doing me a favor, but the exact opposite happens. I resent them, and fairly soon, I want to leave the room.
4. Speaking sentences that NO ONE understands
I’ve improved, but early on in the first three I spoke sentences that even after I was finished, I couldn’t understand. People just stopped listening soon after.
5. Making up words
I used words, back in the beginning, that weren’t really words at all, like “clockfer,” “greenac,” and “withand.” I know that I said them because early on (wanting to escape the aphasia which I still have not done completely), I used to tape conversations on my phone and recognize the errors. I was embarrassed but given the condition I was in, a little empathy please?
6. Inability to understand someone else’s conversation
In the first year after my stroke, I went to an art lecture on Picasso, and with the visuals right there in front of me, I had severe trouble following that talk. I hadn’t heard of aphasia, but I’m satisfied that other people had trouble following other lectures at first with strokes, too. But people were annoyed that I “didn’t get it.” Remember when I said strokes suck?
7. Pronunciation suffers
On the first round, even after eleven years, I still, like a little child, say “bisquetti” for spaghetti when I don’t remember to slow down my speech. It is also useful to say every part of the word in isolation and put it all together, slowly at first. Thus, I had the inability to pronounce words correctly, and some words not due to muscle weakness or paralysis because I could pronounce them if I slowed the heck down. Some people laughed. It wasn’t funny though.
8. Loss of reading and/or writing skills
In some patients with aphasia, reading and/or writing skills (usually both at first) are lost. This means that the patient is no longer able to comprehend written language or even express themselves through writing, all of which are necessary to communicate to emotion, language, and information using symbols, and even emojis. You can imagine what that loss does for self esteem. They have to start over. I’m extremely fortunate, as a writer, I didn’t have that affliction.
9. Spontaneous speech is rare for aphasiacs
I gave a speech to a stroke support group a year after the stroke in the Hershey Medical Canter in Pennsylvania, and though it appeared spontaneous, I simply read off the bullet points so fast, it seemed that the neural pathways were on fire for somebody in the back row who was simply listening and not watching the presentation. Spontaneous speech, also called off-the-cuff, is speech that happens without any planning having taken place, and the majority of aphasics, though they want to do it, simply are unable.
10. The facial expressions
I saw the frowns, and sneers, when I talked to people, even now, if the minds are already made up that this is a person (me) whom they won’t understand. I detest it though I can’t have any control over so I don’t worry about it like in the early years. I can try and talk slower and who cares what they think? If they call me slow and dimwitted, who cares?
Alexander Hamilton said it best: We must make the best of those ills which cannot be avoided. He may have been talking economics, but I’m talking stroke and TBI. Different causes; same result.
Also, as it turns out, when you freeze bananas and puree them in a blender, something magical happens. Due to their naturally high pectin content (a type of fiber), pureed bananas obtain a texture similar to custard-y ice cream!
The steps are simple:
First, cut your ripe bananas into coins and then freeze them. Once frozen, put the coins into a blender or food processor. Blend them, while scraping the sides down often, until you achieve a smooth, ice cream consistency. If the bananas continue to stay in chunks, you can add some milk or soy milk tablespoon by tablespoon until it blends smoothly. Scrape out and enjoy!
In this book, Pepe says “I think it’s worth a try.” In this simple sentence lies the bridge toward new behaviors. Pepe steps out of his comfort zone by changing his diet, managing his feelings, and walking with his family. He takes one step at a time in forging a path toward improved health. From these changes come more opportunities, as Pepe plants the seed for his future self.
Whether you are a child who has some challenges with your health or are interested in learning some skills that can strengthen a feeling of wellness, Pepe Find His Way provides tools that are sure to be useful. Please be sure to enter your email on the right to become a member of Your Health Forum for access to more books, carefully researched articles and virtual and physical community events.
What a great way to use eggplant in place of dough for snacks that are healthy AND tasty!
Actually considered a fruit, the eggplant was originally from China and made its way East. It is popularly used in Middle Eastern and Greek dishes. At one point from the 14th century to the 1700’s in Italy, eggplant was not regularly eaten. A member of the nightshade family, it was believed to be a cause of fever, epilepsy and insanity. Not to mention it has a very unappealing, bitter taste that requires soaking prior to cooking.
Eggplant has a lot of fiber and is packed with vitamins and minerals like potassium, Vitamin B6, Vitamin A, magnesium and folic acid. It is a versatile food and is a great staple for a plant-based diet.
In this recipe provided by Lucia of Lalu, Inc, the eggplant slices become the small snacks in the form of pizza. If you are a fan of Eggplant Parmesan, you’ll like this preparation! This could even be the kids go-to snack. It might be fun to have the children design their own mini-pizzas with their favorite pizza toppings.
Hope you enjoy it! Don’t forget to check out the website of Lalu, Inc. for recipes and nutrition information in Spanish and English.
I had an annoying, dry cough in the beginning of February. Then the cough roared like a hungry beast. No fever. Just the cough, with shortness of breath and fatigue that escalated quickly over a two-week period. Was it COVID-19, I asked myself repeatedly? I don’t know now, and maybe I wouldn’t ever know, unless the testing starts very shortly to all people, rich or poor, healthy (for the asymptomatics amongst us) or sick, despite what Jared Kushner, as a spokesman for President Trump, says about enough tests now. I haven’t had one at the peak of coughing/shortness of breath/fatigue. Have you? Just to make sure?
But with Trump in charge, forget that option. “Coming up shortly,” or “Within the next two weeks,” or, my favorite, “Soon” is Trump-speak, when most people, after the passage of time, forget he made those promises in the first place. But I remember. You can count on that.
WIRED had an article written by Megan Molteni who says that scientists are running like crazy to comprehend why some patients also develop neurological ailments like confusion, stroke, seizure, or loss of smell. Stories of other, stranger symptoms like headaches, confusion, seizures, tingling and numbness, the loss of smell or taste have been going on for weeks.
“The medicines we use to treat any infection have very different penetrations into the central nervous system,” says S. Andrew Josephson, chair of the neurology department at the University of California, San Francisco. He is saying that most drugs can’t pass through the blood-brain barrier, a living wall around the brain. He also says if the coronavirus is penetrating the barrier and infecting neurons, that could make it more difficult to find appropriate treatments.
When the virus first started in Wuhan, China, health records indicate that 214 patients admitted to the Union Hospital of Huazhong University of Science and Technology, 36.4 percent of the patients showed signs of nervous-system-related issues, including headaches, dizziness, confusion, strokes, prolonged seizure, and a slowly disappearing sense of smell, some before the fever and cough were apparent.
“We’ve been telling people that the major complications of this new disease are pulmonary, but it appears there are a fair number of neurologic complications that patients and their physicians should be aware of,” says Josephson.
Without that information, datasets in particular, there’s no way to know how to interpret reports on patients, and “single cases are tantalizing, but they can be fraught with coincidence,” says Josephson.
COVID-19’s horrendous death toll, 61, 656 as of this writing, is other-worldly, science fiction-like worthy, and not many autopsies are being done. Only some pictures of the lungs, but a good chance that there’s some viral invasion of the brain.
A paper in the New England Journal of Medicine examining 58 patients in Strasbourg, France, found that more than half were confused or agitated, with brain imaging suggesting inflammation.
“You’ve been hearing that this is a breathing problem, but it also affects what we most care about, the brain,” says Josephson. “If you become confused, if you’re having problems thinking, those are reasons to seek medical attention,” he added.
Viruses affect the brain, explained Michel Toledano, a neurologist at Mayo Clinic in Minnesota. The brain is protected by something called the blood-brain-barrier, something that Josephson says, too, which blocks foreign substances but could be penetrated if compromised.
Since loss of smell is one of the symptoms of COVID-19, some have hypothesized the nose might be the pathway to the brain. But in the case of the novel coronavirus, doctors hold on to current evidence that the neurological impacts are more likely the result of overactive immune response rather than brain invasion.
Jennifer Frontera, who is also a professor at NYU School of Medicine, explains documenting notable cases including seizures in COVID-19 patients with no prior history of the episodes, and new patterns of small brain hemorrhages.
“We’re seeing a lot of consults of patients presenting in confusional states,” said Rohan Arora, a neurologist at the Long Island Jewish Forest Hills hospital, adding that more than 40 percent of recovered virus patients. “Returning to normal,” added Arora, “appears to be taking longer than for people who suffer heart failure or stroke.” [Apparently, Dr. Arora hasn’t worked extensively with stroke patients. After 11 years, I’m still recovering. Just sayin’.]
Anyway, good advice if you have any of those symptoms–headaches, dizziness, confusion, prolonged seizure, and a disappearing sense of smell–go to the doctor. Many doctors are seeing patients through tele-conference now. If you had a stroke as a result of COVID-19, you probably have already gone to the hospital where there are tests but not too many of them.
One more thing. How about Trump supporters try injecting or swallowing disinfectants to see if they work or this headline: Online demand for hydroxychloroquine surged 1,000% after Trump backed it, study finds. I say that statement with sarcasm, but unlike Trump, he said it confidently when he recommended Lysol, Clorox, and hydroxychloroquine, despite his walkback when people were alarmed and others broke into peals of laughter. It’s on tape, Mr. President.