Assessment and management of chronic pressure ulcers in the elderly

Associations of Age and Sex with the Efficacy of Inpatient Cancer Rehabilitation: Results from a Longitudinal Observational Study Using Electronic Patient-Reported Outcomes

Cancer rehabilitation is thought to increase the quality of life (QOL) and functioning of cancer survivors. It remains, however, uncertain whether subgroups benefit equally from rehabilitation. We wished to investigate the outcomes of multimodal rehabilitation according to age, sex and functioning. Patients of an Austrian rehabilitation center routinely completed the EORTC QLQ-C30 and the hospital anxiety and depression scale (HADS) questionnaires prior to (T1), and after rehabilitation (T2). To compare the outcomes between age groups (i.e., <40, 41–69, and ≥70 years), sex, and the Norton scale risk status, repeated measures of analyses of variance were calculated. A total of 5567 patients with an average age of 60.7 years were included, of which 62.7% were female. With T1 indicating the cancer survivors’ needs, older and high-risk patients reported lower functioning (all p < 0.001) and a higher symptom burden for most scales (all p < 0.05) before rehabilitation. Regardless of age, sex or risk status, the patients showed at a least small to medium improvement during rehabilitation for anxiety, depression, and most functioning and symptom scales. Some between-group differences were observed, none of which being of a relevant effect size as determined with the Cohen’s d. In conclusion, QOL is improved by rehabilitation in all patients groups, independently from age, sex, or the risk status.

Machine Learning-Based Pressure Ulcer Prediction in Modular Critical Care Data

Increasingly available open medical and health datasets encourage data-driven research with a promise of improving patient care through knowledge discovery and algorithm development. Among efficient approaches to such high-dimensional problems are a number of machine learning methods, which are applied in this paper to pressure ulcer prediction in modular critical care data. An inherent property of many health-related datasets is a high number of irregularly sampled time-variant and scarcely populated features, often exceeding the number of observations. Although machine learning methods are known to work well under such circumstances, many choices regarding model and data processing exist. In particular, this paper address both theoretical and practical aspects related to the application of six classification models to pressure ulcers, while utilizing one of the largest available Medical Information Mart for Intensive Care (MIMIC-IV) databases. Random forest, with an accuracy of 96%, is the best-performing approach among the considered machine learning algorithms.

The skin microbiome of infected pressure ulcers: A review and implications for health professionals

BACKGROUND

Pressure ulcers (PUs) are injuries resulting from ischaemia caused by prolonged compression or shear forces on the skin, adjacent tissues and bones. Advanced stages of PUs are associated with infectious complications and constitute a major clinical challenge, with high social and economic impacts in health care.

GOALS

This study aims to identify and describe the relationship between PU risk factors, stages and anatomical locations, and the relevance of microbial cohabitation and biofilm growth.

METHODS

The narrative review method to advocating a critical and objective analysis of the current knowledge on the topic was performed. Indexed databases and direct consultation to specialized and high-impact journals on the subject were used to extract relevant information, guided by co-authors. The Medical Subject Headings of pressure ulcer (or injury), biofilms, infection and other analogues terms were used.

RESULTS

Development of PUs and consequent infection depends on several direct and indirect risk factors, including cutaneous/PU microbiome, microclimate and behavioural factors. Infected PUs are polymicrobial and characterized by biofilm-associated infection, phenotypic hypervariability of species and inherent resistance to antimicrobials. The different stages and anatomical locations also play an important role in their colonization. The prevention and monitoring of PUs remain crucial for avoiding the emergence of systemic infections and reducing health care-associated costs, improve the quality of life of patients and reduce the mortality-associated infected PUs.

A Review of Intelligent Sensor-Based Systems for Pressure Ulcer Prevention

Pressure ulcers are a critical issue not only for patients, decreasing their quality of life, but also for healthcare professionals, contributing to burnout from continuous monitoring, with a consequent increase in healthcare costs. Due to the relevance of this problem, many hardware and software approaches have been proposed to ameliorate some aspects of pressure ulcer prevention and monitoring. In this article, we focus on reviewing solutions that use sensor-based data, possibly in combination with other intrinsic or extrinsic information, processed by some form of intelligent algorithm, to provide healthcare professionals with knowledge that improves the decision-making process when dealing with a patient at risk of developing pressure ulcers. We used a systematic approach to select 21 studies that were thoroughly reviewed and summarized, considering which sensors and algorithms were used, the most relevant data features, the recommendations provided, and the results obtained after deployment. This review allowed us not only to describe the state of the art regarding the previous items, but also to identify the three main stages where intelligent algorithms can bring meaningful improvement to pressure ulcer prevention and mitigation. Finally, as a result of this review and following discussion, we drew guidelines for a general architecture of an intelligent pressure ulcer prevention system.

An Exploratory Analysis of the Role of Adipose Characteristics in Fulltime Wheelchair Users' Pressure Injury History

Aim: The goals of this study were 1) to identify the relationship between adipose (subcutaneous and intramuscular) characteristics and pressure injury (PrI) history in wheelchair users and 2) to identify subject characteristics, including biomechanical risk, that are related to adipose characteristics. Materials and Methods: The buttocks of 43 full-time wheelchair users with and without a history of pelvic PrIs were scanned in a seated posture in a FONAR UPRIGHT® MRI. Intramuscular adipose (the relative difference in intensity between adipose and gluteus maximus) and the subcutaneous adipose characteristics (the relative difference in intensity between subcutaneous adipose under and surrounding the ischium) were compared to PrI history and subject characteristics. Results: Participants with a history of PrIs had different subcutaneous fat (subQF) characteristics than participants without a history of PrIs. Specifically, they had significantly darker adipose under the ischium than surrounding the ischium (subQF effect size = 0.21) than participants without a history of PrIs (subQF effect size = 0.58). On the other hand, only when individuals with complete fat infiltration (n = 7) were excluded did individuals with PrI history have more fat infiltration than those without a PrI history. The presence of spasms (μ intramuscular adipose, 95% CI with spasms 0.642 [0.430, 0.855], without spasms 0.168 [-0.116, 0.452], p = 0.01) and fewer years using a wheelchair were associated with leaner muscle (Pearson Corr = -0.442, p = 0.003). Conclusion: The results of the study suggest the hypothesis that changes in adipose tissue under the ischial tuberosity (presenting as darker SubQF) are associated with increased biomechanical risk for pressure injury. Further investigation of this hypothesis, and the role of intramuscular fat infiltration in PrI development, may help our understanding of PrI etiology. It may also lead to clinically useful diagnostic techniques that can identify changes in adipose and biomechanical risk to inform early preventative interventions.

Bedsores Management: Efficiency Simulation of a New Mattress Design

Bedsores, also known as pressure ulcers, are wounds caused by the applied external force (pressure) on body segments, thereby preventing blood supply from delivering the required elements to the skin tissue. Missing elements hinder the skin’s ability to maintain its health. It poses a significant threat to patients that have limited mobility. A new patented mattress design and alternative suggested designs aimed to reduce pressure are investigated in this paper for their performance in decreasing pressure. A simulation using Ansys finite element analysis (FEA) is carried out for comparison. Three-dimensional models are designed and tested in the simulation for a mattress and human anthropometric segments (Torso and Hip). All designs are carried out in solidworks. Results show that the original design can redistribute the pressure and decrease it up to 17% less than the normal mattress. The original design shows better ability to decrease the absolute amount of pressure on the body. However, increasing the surface area of the movable parts results in less pressure applied to the body parts. Thus, this work suggests changing the surface area of the cubes from 25 to 100 cm².

Incidence and prevalence of pressure ulcers in hospitals: 10-year cohort study

OBJECTIVE

Pressure ulcers (PUs) are a serious problem in patients with multiple comorbidities and are associated with a longer duration of hospital stay and higher medical costs. The aetiology and rate of PU occurrence in South Korea remains unclear. Therefore, we aimed to determine the incidence, prevalence, mortality and common comorbidities of hospitalised patients with PUs in the South Korean healthcare system.

METHOD

A 10-year cohort study using the healthcare insurance reimbursement claims from the South Korean National Health Insurance System database. Patients diagnosed with a PU on admission to hospital [ICD-10: L89 + procedure code] between January 2002 and December 2016 were included and their comorbidities evaluated. Patients <20 years of age and recurrent PU cases were excluded.

RESULTS

Incidence, prevalence, survival rate and risk factors related to survival rate of patients with PUs were determined. The study population in 2006 was 36,195,121 (all patients admitted to hospital that year), which changed yearly because of the inclusion of additional patients who met the study inclusion criteria, and removal of patients who had died during the year. Standardised PU incidence rate decreased from 17.1 in 2006 to 14.9 in 2015 per 10,000 people. Standardised PU prevalence also showed a slightly decreasing trend from 20.2 in 2006 to 18.9 in 2015 per 10,000 people.

CONCLUSION

This findings of this 10-year study showed that incidence and prevalence of PUs markedly increased with age after the seventh decade. Incidence of PUs increased in patients with pneumonia, cerebral infarction, sepsis, femoral neck fracture and malignant neoplasm of the bronchus. Patients with femoral neck fracture and cerebral infarction showed a higher rate of survival than those with other high-risk comorbidities.

Understanding Preventable Deaths in the Geriatric Trauma Population: Analysis of 3,452,339 Patients From the Center of Medicare and Medicaid Services Database

BACKGROUND

Patient safety indicators (PSIs) are avoidable complications that can impact outcomes. Geriatric patients have a higher mortality than younger patients with similar injuries, and understanding the etiology may help reduce mortality. We aim to estimate preventable geriatric trauma mortality in the United States and identify PSIs associated with increased preventable mortality.

METHODS

A retrospective cohort study of patients aged ≥65 years, in the CMS database, 2017-second quarter of 2020. Risk-adjusted multivariable regression was performed to calculate observed-to-expected (O/E) mortality ratios for failure-to-prevent and failure-to-rescue PSIs with significance defined as P < .05.

RESULTS

3,452,339 geriatric patients were analyzed. Patients aged 75-84 years had 33% higher odds of preventable mortality (adjusted odds ratio [aOR] = 1.33 and 95% confidence interval [CI] = 1.31, 1.36), whereas patients aged ≥85 years had 91% higher odds of preventable mortality (aOR = 1.91 and 95% CI = 1.87, 1.94) compared to patients aged 65-74 years. Failure-to-prevent O/E were >1 for all PSIs evaluated with central line-related blood stream infection having a high O/E (747.93). Failure-to-rescue O/E were >1 for 10/11 (91%) PSIs with physiologic and metabolic derangements having the highest O/E (5.98). United States' states with higher quantities of geriatric trauma patients experienced reduced preventable mortality.

CONCLUSION

Odds of preventable mortality increases with age. Perioperative venous thrombotic events, hemorrhage or hematoma, and postoperative physiologic/metabolic derangements produce significant preventable mortalities. United States' states differ in their failure-to-prevent and failure-to-rescue PSIs. Utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy especially anticoagulation, ensuring operative and procedure-based competencies, and greater incorporation of inpatient geriatricians may serve to reduce preventable mortality in elderly trauma patients.

Literature Review of Machine-Learning Algorithms for Pressure Ulcer Prevention: Challenges and Opportunities

Pressure ulcers are associated with significant morbidity, resulting in a decreased quality of life for the patient, and contributing to healthcare professional burnout, as well as an increase of health service costs. Their prompt diagnosis and treatment are important, and several studies have proposed solutions to help healthcare professionals in this process. This work analyzes studies that use machine-learning algorithms for risk assessment and management of preventive treatments for pressure ulcers. More specifically, it focuses on the use of machine-learning algorithms that combine information from intrinsic and extrinsic pressure-ulcer predisposing factors to produce recommendations/alerts to healthcare professionals. The review includes articles published from January 2010 to June 2021. From 60 records screened, seven articles were analyzed in full-text form. The results show that most of the proposed algorithms do not use information related to both intrinsic and extrinsic predisposing factors and that many of the approaches separately address one of the following three components: data acquisition; data analysis, and production of complementary support to well-informed clinical decision-making. Additionally, only a few studies describe in detail the outputs of the algorithm, such as alerts and recommendations, without assessing their impacts on healthcare professionals’ activities.

Effects of implementing Pressure Ulcer Prevention Practice Guidelines (PUPPG) in the prevention of pressure ulcers among hospitalised elderly patients: a systematic review protocol

INTRODUCTION

Pressure ulcers are serious and potentially life-threatening problems across all age groups and across all medical specialties and care settings. The hospitalised elderly population is the most common group to develop pressure ulcers. This study aims to systematically review studies implementing pressure ulcer prevention strategies recommended in the Pressure Ulcer Prevention Practice Guidelines for the prevention of pressure ulcers among hospitalised elderly patients globally.

METHODS AND ANALYSIS

A systematic review of all studies that have assessed the use of pressure ulcer prevention strategies in hospital settings among hospitalised elderly patients shall be conducted. A comprehensive search of all published articles in Medline Ovid, Cumulative Index to Nursing and Allied Health Literature, PubMed, Embase, Cochrane library, Scopus and Web of Science will be done using terms such as pressure ulcers, prevention strategies, elderly patients and hospital. Studies will be screened for eligibility through title, abstract and full text by two independent reviewers. Study quality and risk of bias will be assessed using the Joanna Briggs Institute for Meta-Analysis of Statistics Assessment and Review Instrument. If sufficient data are available, a meta-analysis will be conducted to synthesise the effect size reported as OR with 95% CIs using both fixed and random effect models. I² statistics and visual inspection of the forest plots will be used to assess heterogeneity and identify the potential sources of heterogeneity. Publication bias will be assessed by visual inspections of funnel plots and Egger's test.

ETHICS AND DISSEMINATION

No formal ethical approval or consent is required as no primary data will be collected. We aim to publish the research findings in a peer-reviewed scientific journal to promote knowledge transfer, as well as in conferences, seminars, congresses or symposia in a traditional manner.

PROSPERO REGISTRATION NUMBER

CRD42019129088.

The relationship between pressure injury complication and mortality risk of older patients in follow-up: A systematic review and meta-analysis

Pressure injuries (PIs) have now become a common complication of the elderly patients. Some studies have observed that pressure injuries may increase mortality, but this area of evidence has not been evaluated and summarised. The aim of this study was to compare the mortality of patients with pressure injuries and those without pressure injuries. A meta-analysis of observational studies was performed. PubMed, Cochrane Library, Embase, and Web of Science were searched up to April 2019. Studies about mortality among the elderly patients with and without pressure injuries were included. Methodological quality was assessed by the Newcastle-Ottawa Scale (NOS). The fixed effect or random effect model was determined by the test of heterogeneity. The subgroup analysis was performed based on the pressure injuries stages, the region, and the type of study design. The meta-regression analysis was performed to investigate the relationship between the mortality and patients' enrolled year, average age, the incidence of pressure injuries, and gender ratio. The sensitivity analysis was used to explore the impact of an individual study by excluding one at a time. The hazard ratio (HR) and 95% confidence intervals (CIs) in terms of the comparison of two groups were extracted for meta-analysis. A survival curve between two groups by individual patient-level was drew. Eight studies with 5523 elderly patients were included in the analysis. Follow-up periods for the included studies ranged from about 0.5 to 3 years. The elderly patients who complicated with pressure injuries had a higher risk of death. The pooled HR was 1.78 (95% CI 1.46-2.16). A funnel plot showed no publication bias. Further subgroup analysis showed that HR values for the patient stage 3 to 4 pressure injuries (HR:2.41; 95% CI:1.08-5.37) were higher than stage 1-4 and 2-4 pressure injuries (HR: 1.66; 95% CI: 1.35-2.05; HR: 1.74; 95% CI: 1.16-2.60). The meta-regression analysis found that patients' enrolled year, average age, the incidence of pressure injuries, and gender ratio were not the sources of heterogeneity. Sensitivity analyses showed that the outcomes of the study did not change after removing the Onder's article. The survival curve at the individual patient-level also indicated that patients complicated with pressure injuries significantly increased the risk of death (HR: 1.958; 95% CI: 1.79-2.14) in elderly patients. Our meta-analysis indicated that patients complicated with pressure injuries are estimated to have a two times higher risk on mortality compared with patients without pressure injuries during the 3 years follow-up period. Particular attention should be given to the elderly patients who are at higher risk for mortality.

High-Voltage Electrical Stimulation Versus Ultrasound in the Treatment of Pressure Ulcers

OBJECTIVE

The aim of this study was to assess and compare the efficacy of high-voltage electrical stimulation (HVES) with ultrasound (US) in treating Stage II through Stage IV pressure ulcers (PrUs)* of hospitalized patients.

DESIGN

This study was designed as a prospective, controlled trial in which patients were randomly assigned to 2 groups.

PARTICIPANTS AND SETTINGS

A total of 27 patients (22 male, 5 female) hospitalized for neurologic rehabilitation in the Clinic of Physical Medicine and Rehabilitation with Stage II through Stage IV PrUs were included in this study. The patients were randomly assigned to either HVES or US treatment group, and all patients underwent standard wound care. Over 4 to 12 weeks, HVES was applied for 60 minutes 3 times per week, and US was applied 3 times per week.

MAIN OUTCOME MEASURES

Properties of the PrUs were noted during pre- and posttreatment.

RESULTS

The PrUs of patients in the HVES and US groups healed at a mean rate of 43% and 63%, respectively. There was no statistically significant intergroup difference in healing found after treatment. Regression analysis was performed for the factors that could influence the wound surface areas, and significant effects were detected among the level of ambulation, pretreatment stage, and smoking.

CONCLUSIONS

Both HVES and US are promising methods for wound healing, and both electrotherapy modalities have been demonstrated to support the healing of PrUs.

Theoretical Perspectives of Hospitalized Older Patients and Their Health-Related Problems and Quality of Care: Systematic Literature Review

Introduction:

The proportion of aged people is growing worldwide. Older persons are affected by a number of physical, psychological and social factors that influence their health and quality of life. These factors are usually multiple and are often masked by sensory and cognitive impairments.

Purpose:

The purpose of this study was to examine the available literature emphasizing older persons’ care, care-related problems, and older persons’ quality of healthcare. Also, the paper aimed at exploring the future direction of research needs.

Results:

Good quality older patients’ care involves safety, professional interventions, recognition and management of physical and emotional wellbeing. Care of older patients requires addressing the aging process itself, the expected decrease in functionality, and diminished cognitive ability. Little statistical data were found to address the quality of hospitalized elderly patients in particular as well as study on healthcare facilities and nursing homes. Literature does not provide much guidance to the effectiveness of care strategies.

Conclusion:

The results assert that elderly health care is a priority. However, health care systems are not specific about elderly patients’ needs, leading to low quality of elderly care. There is a need to use an integrated model of care to improve the quality of life and quality of care provided to hospitalized older patients.

Adverse outcomes after major surgery in patients with pressure ulcer: a nationwide population-based retrospective cohort study

Background

Postoperative adverse outcomes in patients with pressure ulcer are not completely understood. This study evaluated the association between preoperative pressure ulcer and adverse events after major surgeries.

Methods

Using reimbursement claims from Taiwan’s National Health Insurance Research Database, we conducted a nationwide retrospective cohort study of 17391 patients with preoperative pressure ulcer receiving major surgery in 2008-2010. With a propensity score matching procedure, 17391 surgical patients without pressure ulcer were selected for comparison. Eight major surgical postoperative complications and 30-day postoperative mortality were evaluated among patients with pressure ulcer of varying severity.

Results

Patients with preoperative pressure ulcer had significantly higher risk than controls for postoperative adverse outcomes, including septicemia, pneumonia, stroke, urinary tract infection, and acute renal failure. Surgical patients with pressure ulcer had approximately 1.83-fold risk (95% confidence interval 1.54-2.18) of 30-day postoperative mortality compared with control group. The most significant postoperative mortality was found in those with serious pressure ulcer, such as pressure ulcer with local infection, cellulitis, wound or treatment by change dressing, hospitalized care, debridement or antibiotics. Prolonged hospital or intensive care unit stay and increased medical expenditures were also associated with preoperative pressure ulcer.

Conclusion

This nationwide propensity score-matched retrospective cohort study showed increased postoperative complications and mortality in patients with preoperative pressure ulcer. Our findings suggest the urgency of preventing and managing preoperative pressure ulcer by a multidisciplinary medical team for this specific population.

Biofilm-based infections in long-term care facilities

The recent trend in the early admittance to long-term care facilities (LTCFs) of severely injured patients transferred from general hospitals has given a new dynamic to the incidence of healthcare-associated infections, including biofilm-based infections related to the implant of urinary and intravascular catheters, and the onset of pressure ulcers. Catheter-associated urinary tract infections lead in most of the surveys on LTCFs, approximately 80% of urinary tract infections in these settings being due to the short- or long-term insertion of a urinary catheter. Furthermore, the implantation of intravascular catheters is often responsible for catheter-related bloodstream infections caused by the development of an intraluminal biofilm. Pressure ulcers, frequently occurring in bedridden patients admitted to LTCFs, are also susceptible to infection by biofilm-growing aerobic and anaerobic bacteria, the biofilm formation on the wound being the main reason for its delayed healing.

Infection in long term care facility in the kingdom of Bahrain

Infections in long term care facilities (LTCF) are common and are considered a major cause of mortality and morbidity. Endemic infections and outbreaks are observed in LTCF. Of particular concern is the growth of multi-drug resistant organisms. A study was conducted in the Kingdom of Bahrain concerning infections among the residents in a LTCF. The aim was to define the rate, type and outcomes of institutional infections. The different treatment modalities and antimicrobials used were evaluated. Our facility cares for the elderly and a heterogeneous group of patients from different populations (e.g., mentally retarded, bedbound due to various disabilities and other forms of consciousness impairment such as post stroke disability, cerebral palsy and anoxic brain damage). The initial span of six months was changed to seven months to increase the sample size and improve the data analysis. This was a prospective study conducted in Muharaq Geriatric Hospital in the Kingdom of Bahrain. The study was conducted over seven months from January 2013 to July 2013 on 104 patients. During that period, patients with new positive cultures from different sites were included. The clinical features, microbiological features and outcomes of the bacteremic episodes were included. The information was collected by a questionnaire created by the research team. From a total of 104 patients staying in the LTFC, 19 had positive cultures from different sites at different times. The study showed that infections are common, especially urinary tract infections.

Public sector residential aged care: identifying novel associations between quality indicators and other demographic and health-related factors

Objective To explore associations among quality indicators (QI; e.g. pressure ulcers, falls and/or fractures, physical restraint, use of multiple medications, unplanned weight loss) of the Victorian Public Sector Residential Aged Care Services (VPSRACS) with other demographic and health-related factors. Methods Data for 380 residents over a 3-month period were extracted retrospectively from client databases at four VPSRAC facilities. Results Four significant logistic regression models were developed. The strongest models related to falls and polypharmacy. Significant associations for these models included the following: (1) residents with a higher body mass index were 6% less likely (95% confidence interval (CI) 1%–11%) to fall, whereas high levels of cognitive impairment increased the risk of falling by 8% (95% CI 2%–14%); (2) being ambulant with a gait aid more than doubled the risk of falling compared with non-ambulant residents (95% CI 19%–546%); and (3) higher cognitive impairment was associated with a 6% (95% CI 1%–11%) reduction in the likelihood of polypharmacy. Conclusions Identification of significant relationships between the VPSRACS QI and other demographic and health-related factors is a preliminary step towards a more in-depth understanding of the factors that influence the QI and predict adverse events. What is known about the topic? Currently, the VPSRACS report on five QI. Previous research has shown associations between several of these indicators, but not all. What does this paper add? This paper examines associations between the five VPSRAC QI as well as other key demographic and health-related factors. Novel findings from regression analyses included an increased risk of falls associated with recommended body mass index and using gait aids, but no association between pressure ulcers and the Norton score. Regression models for other QI were limited by the small occurrences of the QI. However, significant associations were identified indicating that residents using a gait aid had a lower level of unplanned weight loss and residents with polypharmacy had higher unplanned weight loss. What are the implications for practitioners? This paper reinforces the value of collecting VPSRAC QI data to enable facilities to consider how these variables could impact on care quality and to proactively plan to reduce the risk of adverse events. Although QI data can be used to benchmark with other settings, this paper shows how QI data can be used to inform practice within a facility and help identify patient-related factors that may warrant further investigation.

Systemic factors and mortality in elderly patients with pressure ulcers

The aim of this article was to identify specific systemic factors associated with existence of pressure ulcers (PUs) and the effect on survival from the time of admission. Patients admitted to the Skilled Nursing Department of the Herzog Hospital, Jerusalem, between 1 July 2008 and 31 December 2011. Of the 174 admitted patients (mean age: 77·4 ± 13·2 years), 107 (61·5%) had pre-existing PUs and 67 (38·5%) did not have PUs. Major systemic factors were assessed for each patient at the time of admission: sociodemographic characteristics, comorbidities, use of urinary catheter, tube feeding and tracheostomy; nutritional state; Global Deterioration Scale, Glasgow Coma Scale and Norton Scale. Complications such as the number of provided antibiotic courses, and length and outcomes of hospitalisation were identified at the end of the study. In the univariate analysis, patients in the PU group had significantly prevalent characteristics including advanced age, low cognitive and consciousness function, low Norton scale, Parkinson's disease and anaemia due to chronic diseases, low nutritional parameters and higher number of antibiotics provided. Conditions that were associated with PUs in multiple regression analyses included advanced dementia (OR = 3·0, 95% CI: 1·4-6·3; P = 0·002), urinary catheter usage (OR = 2·25, 95% CI: 1·06-4·7; P = 0·03), low body mass index, BMI (OR = 0·92, 95% CI: 0·86-0·99; P = 0·02) and anaemia level (OR = 0·7, 95% CI: 0·58-0·9; P = 0·004). The median survival time of patients with PUs was significantly lower than the non PUs group (94 versus 414 days, respectively) (P = 0·005, log rank test). Length of stay was also significantly lower in the PU group (166 versus 270 days, P = 0·02). The existence of PUs may indicate a final common pathway of various systemic factors (geriatric conditions, diseases and frailty dysfunction).

Objective evaluation by reflectance spectrophotometry can be of clinical value for the verification of blanching/non blanching erythema in the sacral area

Early detection of non blanching erythema (pressure ulcer category I) is necessary to prevent any further skin damage. An objective method to discriminate between blanching/non blanching erythema is presently not available. The purpose of this investigation was to explore if a non invasive objective method could differentiate between blanching/non blanching erythema in the sacral area of patients undergoing hip fracture surgery. Seventy-eight patients were included. The sacral area of all patients was assessed using (i) conventional finger-press test and (ii) digital reading of the erythema index assessed with reflectance spectrophotometry. The patients were examined at admission and during 5 days postsurgery. Reflectance spectrophotometry measurements proved able to discriminate between blanching/non blanching erythema. The reliability, quantified by the intra-class correlation coefficient, was excellent between repeated measurements over the measurement period, varying between 0·82 and 0·96, and a significant change was recorded in the areas from day 1 to day 5 (P < 0·0001). The value from the reference point did not show any significant changes over the same period (P = 0·32). An objective method proven to identify early pressure damage to tissue can be a valuable tool in clinical practice.

Three cases of sacral pressure ulcers presenting primary dermatoporosis on the forearms

The relatively new term dermatoporosis refers to chronic deficiencies in the skin's functions in the elderly population due to aging. This syndrome is marked by chronic cutaneous fragility clinically represented by skin atrophy, senile purpura, stellate pseudoscars, skin laceration, and dissecting hematoma of the skin. In this paper, we report three cases of sacral pressure ulcers presenting primary dermatoporosis on the forearms. Case 1 was a 74-year-old male who presented with a stage IV sacral pressure ulcer. The signs of dermatoporosis appeared on the forearms. Histopathology of the lesions revealed epidermal thinning with loss of rete ridges. Azan and Elastica van Gieson staining demonstrated the degeneration of the dermal collagen fibers and elastic fibers, respectively. In spite of 6 months of treatment, the ulcer failed to heal sufficiently. Case 2 was a 74-year-old male and Case 3 was a 97-year-old female. Both cases presented with a stage II sacral pressure ulcer and dermatoporosis on the forearms. Histopathological examinations and the clinical course of the wound could not be ascertained in Cases 2 and 3. None of the patients had previously used corticosteroids. The presence of a primary dermatoporosis on the forearms in these cases may be associated with the increased risk of pressure ulcer development.

Oxidative stress and DNA damage signalling in skeletal muscle in pressure-induced deep tissue injury

The molecular mechanisms that contribute to the pathogenesis of pressure-induced deep tissue injury are largely unknown. This study tested the hypothesis that oxidative stress and DNA damage signalling mechanism in skeletal muscle are involved in deep tissue injury. Adult Sprague Dawley rats were subject to an experimental protocol to induce deep tissue injury. Two compression cycles with a static pressure of 100 mmHg was applied to an area of 1.5 cm(2) over the mid-tibialis region of right limb of the rats. The left uncompressed limb served as intra-animal control. Muscle tissues underneath compression region were collected for examination. Our analyses indicated that pathohistological characteristics including rounding contour of myofibres and extensive nuclei accumulation were apparently shown in compressed muscles. The elevation of 8OHdG immunopositively stained nuclei indicated the presence of oxidative DNA damage. Increase in oxidative stress was revealed by showing significant elevation of 4HNE and decreases in mRNA abundance of SOD1, catalase and GPx, and protein content of SOD2 in compressed muscles relative to control muscles. Increase in nitrosative stress was demonstrated by significant elevation of nitrotyrosine and NOS2 mRNA content. The activation of tumor suppressor p53 signalling was indicated by the remarkable increases in protein contents of total p53 and serine-15 phosphorylated p53. The transcript expression of the DNA-repairing enzyme, Rad23A, was significantly suppressed in compressed muscles. Our time-course study indicated that increased oxidative/nitrosative stress and proapoptotic signalling were maintained in muscles receiving increasing amount of compression cycles and post-compression time. Furthermore, resveratrol was found to attenuate the histological damage, oxidative/nitrosative stress and proapoptotic signalling in response to prolonged moderate compression. In conclusion, our findings are consistent with the hypothesis that oxidative stress and DNA damage signalling in skeletal muscle are involved in the underlying mechanisms responsible for the pathogenesis of pressure-induced deep tissue injury.

Diagnosis and management of skin and soft-tissue infections (SSTI): a literature review and consensus statement on behalf of the Italian Society of Infectious Diseases and International Society of Chemotherapy

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges and resulting in significant morbidity and mortality among patients as well as increased healthcare costs. eight members of the SSTI working group of the Italian Society of infectious Diseases prepared a draft of the statements, grading the quality of each piece of evidence after a careful review of the current literature using MEDLINE database and their own clinical experience. Statements were graded for their strength and quality using a system based on the one adopted by the Infectious Diseases Society of America (IDSA). The manuscript was successively reviewed by seven members of the SSTI working group of the international Society of Chemotherapy, and ultimately re-formulated by all e xperts. the microbiological and clinical aspects together with diagnostic features were considered for uncomplicated and complicated SSTIs. Antimicrobial therapy was considered as well -both empirical and targeted to methicillin-resistant Staphylococcus aureus (MRSA) and/or other main pathogens.

Proteasome inhibition alleviates prolonged moderate compression-induced muscle pathology

BACKGROUND

The molecular mechanism initiating deep pressure ulcer remains to be elucidated. The present study tested the hypothesis that the ubiquitin proteasome system is involved in the signalling mechanism in pressure-induced deep tissue injury.

METHODS

Adult Sprague Dawley rats were subjected to an experimental compression model to induce deep tissue injury. The tibialis region of the right hind limb was subjected to 100 mmHg of static pressure for six hours on each of two consecutive days. The compression pressure was continuously monitored by a three-axial force transducer within the compression indentor. The left hind limb served as the intra-animal control. Muscle tissues underneath the compressed region were collected and used for analyses.

RESULTS

Our results demonstrated that the activity of 20S proteasome and the protein abundance of ubiquitin and MAFbx/atrogin-1 were elevated in conjunction with pathohistological changes in the compressed muscle, as compared to control muscle. The administration of the proteasome inhibitor MG132 was found to be effective in ameliorating the development of pathological histology in compressed muscle. Furthermore, 20S proteasome activity and protein content of ubiquitin and MAFbx/atrogin-1 showed no apparent increase in the MG132-treated muscle following compression.

CONCLUSION

Our data suggest that the ubiquitin proteasome system may play a role in the pathogenesis of pressure-induced deep tissue injury.

Effects of Intramuscular Fat Infiltration, Scarring, and Spasticity on the Risk for Sitting-Acquired Deep Tissue Injury in Spinal Cord Injury Patients

Sitting-acquired deep tissue injury (DTI) is a severe form of pressure ulcer (PU) often affecting patients with spinal cord injury (SCI) who also tend to suffer from intramuscular fat infiltration, soft tissue scarring (due to previous PU), and/or muscle spasticity in their buttocks. We previously used finite element (FE) modeling to evaluate whether abnormal bodyweight is a risk factor for sitting-acquired DTI. Here we hypothesize that fat infiltration, scarring, or spasms increase internal loads in the gluteus muscles in the vicinity of the ischial tuberosities during sitting, which consequently put SCI patients with these conditions at a higher risk for DTI. Our objective was to determine changes in gluteal strains and stresses and tissue volumes exposed to elevated strains/stresses associated with these factors. Thirty-five FE models of coronal slices through the seated buttocks, simulating these conditions at different severities, were developed. We calculated peak strains and stresses in glutei and percentage volumes of muscle tissue exposed to above-critical strains/stresses (compression strain≥50%, compression/von Mises stress≥2 kPa, and strain energy density≥0.5 kPa). Progressive intramuscular fat infiltration increased all the aforementioned outcome measures. Increase in size of scar patterns that were contained in both muscle and fat tissues similarly elevated the outcome measures. Spasms increased muscle stresses and volumetric exposures to stress, but tissue volumes at risk were ∼1–2% and increases due to spasticity were slight. We conclude that the above potential risk factors can be listed according to the following order of importance: (i) fat infiltration, (ii) scars contained in both muscle and fat tissues, and (iii) spasms. This information should be considered when prioritizing prevention means and resources for patients with SCI.

Pressure ulcers in orthopaedics

Pressure ulcers can be a devastating complication in the care of orthopaedic patients. Their presence leads to increased morbidity, mortality, and cost of care. Therapy and rehabilitation cannot progress on a normal postoperative course in the patient with a pressure ulcer. Risk factors for the development of pressure ulcers include spinal cord injury, advanced age, and cognitive impairment. Several grading scales have been developed for the assessment of pressure ulcer. Frequent patient turning, close monitoring, and frequent skin checks are important factors in the prevention of pressure ulcer.

Effects of skin wrinkles, age and wetness on mechanical loads in the stratum corneum as related to skin lesions

Finite element models of skin were developed to determine the effects of wetness, age, and wrinkles on mechanical strains and stresses in the stratum corneum (SC) as related to skin lesions. We modeled two geometries, young (0.12-mm-deep wrinkles) and aged (0.18-mm-deep wrinkles), and for each geometry, three loading conditions were applied (compression in a dry environment, compression and shear in dryness, and compression with shear in wetness). Effects of skin wrinkling were studied independently or while coupled with age-related mechanical property changes. For each simulation, we calculated the peak maximal shear strain and stress in the SC, peak shear stress on the skin surface, and volumetric exposure of the SC to potentially injurious shear stresses (<70 kPa). Compression and shear with wetness produced the highest skin surface loads. Volumetric exposure of aged skin to potentially injurious shear stresses was six times greater than in the young skin for these conditions. Deeper wrinkles caused elevated loads in the SC consistently for all outcome measures and independently of the age factor. Thinning and/or stiffening the SC increased both the surface and internal SC stresses. Our findings indicate that theoretically, wetness, skin aging, and/or skin wrinkling are all risk factors for skin lesions such as superficial pressure ulcers.

Wound healing in older adults

Chronic wounds affect a substantial number of individuals throughout the world, and impose a significant psychological, physical and economic burden. As the population ages, the incidence of chronic wounds is also expected to rise. Clinicians struggle to find the optimal approaches to prevention and treatment of these nonhealing or slow-healing wounds. This review discusses current best practices and evidence-based recommendations for preventing and managing chronic wounds in general, as well as pressure ulcers, diabetic foot ulcers and venous leg ulcers specifically. This review highlights the significant gaps and inconsistencies in the current evidence base for chronic wound care, which have hindered making substantial progress in improving wound healing rates. It concludes with recommendations for improving the research and clinical knowledge base related to optimal wound-care practices.

Development of three-dimensional tissue-engineered models of bacterial infected human skin wounds

While infected skin wounds are on the increase because of ageing populations, rising incidence of diabetes, and antibiotic resistance, we lack relevant in vivo or in vitro models to study many aspects of bacterial interaction with skin. The aim of this study was to develop three-dimensional models of normal human skin to study bacterial infection. The common dermatological pathogens Staphylococcus aureus and Pseudomonas aeruginosa were used to infect tissue-engineered skin, and the course of infection in the skin was examined over several days. Two forms of model were developed-one in which bacteria were introduced directly to 10 mm wounds in the epidermis, and another in which wounds were created by burning a 4 mm hole in the center of the tissue before inoculation. The bacteria flourished within the engineered skin, and colonized the upper epidermal layers before invasion into the dermis. Infection with P. aeruginosa caused a loss of epidermis and de-keratinization of the skin constructs, as well as partial loss of basement membrane. These novel complex human skin infection models could be used to investigate microbial invasion of normal skin epithelium, basement membrane, and connective tissue, and as a model to study approaches to reduce bacterial burden in skin wounds.

A chronic pressure ulcer model in the nude mouse

The pathophysiology of pressure ulcers is not yet fully understood. Widely used experimental models lead to pressure ulcers in the skin and the subcutaneous tissue only. The aim of the present study was to develop a clinically relevant deep pressure ulcer model in nude mice involving all relevant tissue layers. Balb/c nude mice were anesthetized and a steel disk was implanted under the great gluteus muscle. Full recovery was allowed for 10 days. Pressure was then periodically applied (2 hours compression, 1 hour recovery) using a Neodymium magnet in conjunction with the disk in the unanesthetized mouse. Cycles were repeated for 1, 4, 6, 8, or 10 times. Controls underwent the same procedure without placement of the magnet. The pressure ulcer grade was found to be cycle dependent,with the highest degree after 10 cycles. Histological evaluations revealed signs of necrosis in the skin and subcutaneous fat after four, and in the muscle after eight and 10 cycles of compression. Polymorphnuclear granulocyte infiltration in certain layers was found to be dependent on the number of cycles. We conclude that this clinically relevant nude mouse model can be used to investigate the mechanism of pressure ulcer development and to study new therapeutic approaches.

Exposure to internal muscle tissue loads under the ischial tuberosities during sitting is elevated at abnormally high or low body mass indices

Deep tissue injury (DTI) is a severe pressure ulcer characteristic of chairfast or bedfast individuals, such as those with impaired mobility or neurological disorders. A DTI differs from superficial pressure ulcers in that the onset of DTI occurs under intact skin, in skeletal muscle tissue overlying bony prominences, and progression of the wound continues subcutaneously until skin breakdown. Due to the nature of this silently progressing wound, it is highly important to screen potentially susceptible individuals for their risk of developing a DTI. Abnormally low and high values of the body mass index (BMI) have been proposed to be associated with pressure ulcers, but a clear mechanism is lacking. We hypothesize that during sitting, exposure to internal muscle tissue loads under the ischial tuberosities (IT) is elevated at abnormally high or low body mass indices. Our aims in this study were: (a) to develop biomechanical models of the IT region in the buttocks that represent an individual who is gaining or losing weight drastically. (b) To determine changes in internal tissue load measures: principal compression strain, strain energy density (SED), principal compression stress and von Mises stress versus the BMI. (c) To determine percentage volumes of muscle tissue exposed to critical levels of the above load measures, which were defined based on our previous animal and tissue engineered model experiments: strain>or=50%, stress>or=2 kPa, SED>or=0.5 kPa. A set of 21 finite element models, which represented the same individual, but with different BMI values within the normal range, above it and below it, was solved for the outcome measures listed above. The models had the same IT shape, size, distance between the IT, and (non-linear) mechanical properties for all soft tissues, but different thicknesses of gluteus muscles and fat tissue layers, corresponding to the BMI level. The resulted data indicated a trend of progressive increase in internal tissue loading, particularly in volumetric exposure to critical loading for BMI values outside the 17<or=BMI<or=22 kg/m(2) range, supporting our hypothesis for this study. We concluded that exposure to internal muscle tissue loads under the IT during sitting is optimally reduced at the low-normal BMI range, which is important not only in the context of DTI research, but also for understanding general sitting biomechanics.

Biologic therapeutics and molecular profiling to optimize wound healing

Non-healing wounds represent a significant cause of morbidity and mortality for a large portion of the adult population. Wounds that fail to heal are entrapped in a self-sustaining cycle of chronic inflammation leading to the destruction of the extracellular matrix. Among cancer patients, malnutrition, radiation, physical dehabilitation, chemotherapy, and the malignancy itself increase the likelihood of chronic wound formation, and these co-morbidity factors inhibit the normal wound healing process. Current wound treatments are aimed at some, but not all, of the underlying causes responsible for delayed healing of wounds. These impediments block the normal processes that allow normal progression through the specific stages of wound healing. This review summarizes the current information regarding the management and treatment of complex wounds that fail to heal normally and offers some insights into novel future therapies [Menke N, Ward KR, Diegelmann R. Non-healing wounds. Emerg Med Rep 2007; 28(4).,Menke NB, Ward KR, Witten TM, Bonchev DG, Diegelmann RF. Impaired wound healing. Clin Dermatol 2007;25:19-25].

Patient care and management of frontotemporal lobar degeneration

Frontotemporal lobar degeneration (FTLD) is a neurodegenerative disease that affects frontal and temporal regions of the brain. Two proteins indicated in the pathology are tau and the recently discovered TDP-43. Major manifestations include progressive aphasia and a disorder of social comportment. The diagnosis of a patient includes a detailed cognitive exam, clinical testing, and neuroimaging techniques. The current goal of therapy for FTLD is symptomatic management with medications borrowed from other conditions. Nonpharmacologic management such as behavioral interventions and environmental engineering are also efficacious in optimizing quality of life.

Infection in the elderly

Many functional, demographic, and immunologic changes associated with aging are responsible for increasing the incidence and severity of infectious diseases in the elderly. Management is complicated by age-related organ system changes. Because many of the elderly are on multiple medications for underlying illnesses, antimicrobial therapy needs to be chosen keeping drug interactions and adverse events in mind. Common infections seen in the elderly are infections of skin and soft tissue, urinary tract, respiratory tract, and gastrointestinal tract. Organized and well-funded programs to address infectious disease issues in the elderly are the only way to improve care.