Spinal Cord Injury survey to determine pressure ulcer vulnerability in the outpatient population

Pressure ulcers and acute risk factors in individuals with traumatic spinal fractures with or without spinal cord injuries: A prospective analysis of the National Spinal Column/Cord Injury Registry of Iran (NSCIR-IR) data

PURPOSE

To identify risk factors for developing pressure ulcers (PUs) in the acute care period of traumatic spinal fracture patients with or without spinal cord injuries (SCIs) METHODS: Data were collected prospectively in participating the National Spinal column/Cord Injury Registry of Iran (NSCIR-IR) centers from individuals with traumatic spinal fractures with or without SCIs, inclusive of the hospital stay from admission to discharge. Trained nursing staff examined the patients for the presence of PUs every 8 h during their hospital stay. The presence and grade of PUs were assessed according to the European Pressure Ulcer Advisory Panel classification. In addition to PU, following data were also extracted from the NSCIR-IR datasets during the period of 2015-2021: age, sex, Glasgow coma scale score at admission, having SCIs, marital status, surgery for a spinal fracture, American Spinal Injury Association impairment scale (AIS), urinary incontinence, level of education, admitted center, length of stay in the intensive care unit (ICU), hypertension, respiratory diseases, consumption of cigarettes, diabetes mellitus and length of stay in the hospital. Logistic regression models were used to estimate the unadjusted and adjusted odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

Altogether 2785 participants with traumatic spinal fractures were included. Among them, 87 (3.1%) developed PU during their hospital stay and 392 (14.1%) had SCIs. In the SCI population, 63 (16.1%) developed PU during hospital stay. Univariate logistic regression for the whole sample showed that marital status, having SCIs, urinary incontinence, level of education, treating center, number of days in the ICU, age, and Glasgow coma scale score were significant predictors for PUs. However, further analysis by multiple logistic regression only revealed the significant risk factors to be the treating center, marital status, having SCIs, and the number of days in the ICU. For the subgroup of individuals with SCIs, marital status, AIS, urinary incontinence, level of education, the treating center, the number of days in the ICU and the number of days in the hospital were significant predictors for PUs by univariate analysis. After adjustment in the multivariate model, the treating center, marital status (singles vs. marrieds, OR 3.06, 95% CI 1.55-6.03, p = 0.001), and number of days in the ICU (OR 1.06, 95% CI 1.04-1.09, p < 0.001) maintained significance.

CONCLUSIONS

These data confirm that individuals with traumatic spinal fractures and SCIs, especially single young patients who suffer from urinary incontinence, grades A-D by AIS, prolonged ICU stay, and more extended hospitalization are at increased risk for PUs; as a result strategies to minimize PU development need further refinement.

Association of overweight and obesity with the prevalence and incidence of pressure ulcers: A systematic review and meta-analysis

BACKGROUND & AIM

Pressure ulcers challenge the health status, complicate medical conditions, and affect quality of life. The aim of this systematic review and meta-analysis was to investigate the role of obesity and body weight status, as potentially modifiable risk factors, in the incidence and prevalence of pressure ulcers.

METHODS

A systematic search of observational studies was performed to assess documents published between January 1990 and December 2019 in PubMed and Scopus. Finally, 17 articles with total sample size of 2228724 in the prevalence and 218178 in the incidence study were included in the meta-analysis.

RESULTS

The pooled data analysis showed no significant effect of obesity on odds of pressure ulcers' prevalence (OR 0.91, 95% CI 0.65 to 1.27, P = 0.579, I² = 84.8%) or incidence (OR 0.97, 95% CI 0.56 to 1.66, P = 0.905, I² = 89.8%) compared with non-obese individuals. Overweight was associated with significantly lower odds of prevalence of pressure ulcers compared to non-overweight individuals (OR 0.54, 95% CI 0.33 to 0.88, P = 0.014, I² = 90.2%). The subgroup analyses showed significantly higher odds of prevalence (OR 2.38, 95% CI 1.72 to 3.29, P < 0.001, I² = 63.4%) and incidence (OR 2.28, 95% CI 1.77 to 2.94, P < 0.001, I² = 27.9%) of pressure ulcers in the underweight compared to normal weight groups. Pooled data analyses showed significantly lower odds of prevalence (OR 0.6, 95% CI 0.37 to 0.96, P = 0.034, I² = 82%) and incidence (OR 0.72, 95% CI 0.53 to 0.98, P = 0.039, I² = 67.1%) of pressure ulcers in the overweight than normal weight individuals. The findings showed no significant differences in the odds of prevalence or incidence of pressure ulcers in the obese and morbidly obese compared to normal weight individuals.

CONCLUSION

This systematic review and meta-analysis showed no significant effect of obesity or morbid obesity on the odds of pressure ulcers. Additionally, overweight was associated with lower odds of pressure ulcers while underweight significantly increased the odds of pressure injuries.

Pressure Ulcer Risk Factors in Persons with Mobility-Related Disabilities

OBJECTIVE

To assess pressure ulcer (PU) risk in persons with mobility impairments using a large data set to identify demographic, laboratory, hemodynamic, and pharmacologic risk factors.

METHODS

The cohort of interest was persons with disabilities who have mobility impairments and are diagnostically at risk of PUs. To define this cohort, diagnoses that qualify patients for skin protection wheelchair cushions were used. Data were obtained from the Cerner Health Facts data warehouse. Two cohorts were defined: persons with and without a history of PUs. Analysis included descriptive statistics and multivariate logistic regression modeling. Variables retained in the model were identified using LASSO, gradient boosting, and Bayesian model averaging.

MAIN RESULTS

The resulting cohorts included more than 87,000 persons with a history of PUs and more than 1.1 million persons who did not have a PU. The data revealed seven disability groups with the greatest prevalence of PUs: those with Alzheimer disease, cerebral palsy, hemiplegia, multiple sclerosis, paraplegia/quadriplegia, Parkinson disease, and spina bifida. Ulcers in the pelvic region accounted for 82% of PUs. Persons with disabilities who were male or black had a greater prevalence of PUs. Physiologic risk factors included the presence of kidney or renal disease, decreased serum albumin, and increased serum C-reactive protein.

CONCLUSIONS

The results indicate that, although persons with disabilities can exhibit a wide functional range, they remain at risk of PUs and should be evaluated for proper preventive measures, including support surfaces and wheelchair cushions.

Surgical reconstruction of pressure ulcers in spinal cord injury individuals: A single- or two-stage approach?

INTRODUCTION

There are two surgical approaches to reconstruct a pressure ulcer (PU): one-stage reconstruction or two-stage reconstruction. One stage reconstruction consists of surgical debridement and flap reconstruction during one operation. Two-stage surgery consist of a surgical debridement and a final reconstruction in two different sessions, with approximately six weeks between both sessions.

OBJECTIVE

The aim of this study was to compare the results of single stage surgery and two-stage surgery on the PU recurrence rate and other important post operative complications.

METHOD

A retrospective, comparative study in Spinal Cord Injured (SCI) individuals with a single- or two stage surgical reconstruction between 2005 and 2016 was designed. A total of 81 records were included for analysis.

RESULTS

The primary outcome, the difference in occurrence of a recurrent PU in the reconstructed area (33.3% versus 31.6%), is not statistically significant between one-and two-stages reconstruction. Also, the mean duration to develop a recurrent PU between both surgical reconstructions is not statistically significant. Other surgical complications in the reconstructed area like wound hematoma, hemorrhage, seroma or (partial) flap failure did not differ significantly between both groups, apart and in total. We calculated the additional costs in case of a two-stage approach compared with a single-stage reconstruction at EUR 16,362.

CONCLUSIONS

There are no statistical significant differences in PU recurrence rate or other post operative complications between SCI patients who have undergone one- or two stage PU reconstructive surgery. The most obvious choice for a one-stage approach in case of PU reconstructive surgery has great positive implications for the patient, family, health care providers and the health care system.

The global burden of pressure ulcers among patients with spinal cord injury: a systematic review and meta-analysis

BACKGROUND

Pressure ulcers (PU), one of the common challenging public health problems affecting patient with spinal cord injury. PUs occurs over bony areas of the body where pressure and tissue distortion is greatest. It has a significant impact to the patient and health care system. Moreover, it has psychological, physical, social burden and decrease the quality of life (QoL) of patients. Despite its serious complications, limited evidence is available on the global magnitude of pressure ulcers among patient with spinal cord injury. Hence, this review and meta-analysis aimed to estimate the global magnitude of pressure ulcers among patient with spinal cord injury.

METHODS

PubMed, Scopus, Google Scholar, African Journals Online, PsycINFO, and Web of Science were systematically searched to retrieve related articles. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline was followed. DerSimonian and Laird random-effects model was applied to obtain the pooled effect size. To investigate heterogeneity across the included studies, I2 test was employed. Publication bias was examined using funnel plot and Egger's regression test statistic. Sensitivity analysis was deployed to see the effect of a single study on the overall estimation. Analysis was done using STATA™ Version 14 software.

RESULTS

A total of 24 studies which comprises of 600,078 participants were included in this study. The global pooled magnitude of pressure ulcers among patients with spinal cord injury was 32.36% (95% CI (28.21, 36.51%)). Based on the subgroup analysis, the highest magnitude of pressure ulcer was observed in Africa 41.19% (95% CI: 31.70, 52.18).

CONCLUSION

This systematic review and meta-analysis revealed that about one in three patients with spinal cord injury had pressure ulcers. This implies that the overall global magnitude of pressure ulcer is relatively high. Therefore, policy maker and other concerned body should be design country context- specific preventive strategies to reduce the burden of pressure ulcers in patients with spinal cord injury.

Pressure ulcer knowledge, beliefs and practices in a group of South Africans with spinal cord injury

Study design

A quantitative, descriptive study using a cross-sectional survey.

Objectives

To describe the pressure ulcer knowledge, beliefs and practices amongst persons with SCI, who received rehabilitation at a Cape Town rehabilitation centre.

Setting

A rehabilitation centre for clients with physical disabilities in Cape Town, South Africa.

Methods

A quantitative, descriptive study, that employed consecutive sampling, was done. Participants included inpatients (n = 30), outpatients (n = 33) and peer supporters (n = 8). Data were collected during April and March 2015 with a questionnaire developed through collating existing questionnaires and adapting it for the study context. This rendered a knowledge score and data on beliefs and practices. The Fisher's exact test was used for comparative analysis (p < 0.05).

Results

The mean combined knowledge score was 42.7%. The majority of participants (88.7%) believed pressure ulcers to be serious and 45% thought they were likely to develop a PU. They believed daily skin checks (80.3%), weight shifting (86%) and limiting sitting time (80.3%) could prevent PU development. Study participants indicated that they did not regularly follow guideline recommended practices like regular pressure relief (51%) (36 participants) or daily skin inspection (38%) (27 participants) and 37% (26 participants) reported being current smokers.

Conclusion

Participants showed a lack of knowledge, which might have affected their pressure ulcer prevention practices negatively. The study findings can be used to assist with the development of a contextually relevant training programme on pressure care.

Beyond the Diagnosis: Lived Experiences of Persons with Spinal Cord Injury in a Selected Town in Ghana

Background

Although several studies have been conducted on the lived experiences of persons with spinal cord injury (SCI) in high income countries, there is no published data on such experiences in Ghana. The purpose of this study was to explore the lived experiences of persons with SCI in the Tamale Metropolis of the Northern Region of Ghana.

Material and Methods

A qualitative descriptive design involving thirteen participants was conducted at the Tamale Metropolis-Ghana. A purposive sampling technique was used to recruit participants, using the Neurosurgical Unit of the Tamale Teaching Hospital as an outlet for recruitment of the sample. Data was gathered mainly through face-to-face in-depth interviews. The data was analyzed concurrently with data collection, using thematic content analysis. Ethical approval was obtained for the study from the Noguchi Memorial Institute for Medical Research and the research unit of the Tamale Teaching Hospital.

Results

The three main themes that emerged from the data during analysis were “physical effects,” “psychological effects,” and “social issues.” Conclusion. The findings from the study suggest that SCI is a life threatening condition and that persons with SCI grapple with a myriad of physical symptoms that range from chronic pain and paralysis of lower and/or upper limbs, to bladder and bowel incontinence. These physical symptoms have significant psychological and social effects on the functioning of the affected persons.

Buttock tissue response to loading in men with spinal cord injury

OBJECTIVE/BACKGROUND

Despite the fact that most people with a spinal cord injury who use a wheelchair for mobility are considered at-risk for pressure ulcer (PrU) development, there still exists a spectrum of risk amongst this group. Efforts to differentiate risk level would benefit from clinical tools that can measure or predict the buttocks response to loading. Therefore, the goal of this study was to identify how tissue compliance and blood flow were impacted by clinically-measurable risk factors in young men with SCI.

METHODS

Blood flow at the ischial tuberosity was measured using laser Doppler flowmetry while the seated buttock was unloaded, and loaded at lower (40-60 mmHg) and high (>200 mmHg) loads. Tissue compliance of the buttock was measured using the Myotonometer while subject were lifted in a Guldmann Net.

RESULTS

Across 28 participants, blood flow was significantly reduced at high loads, while no consistent, significant changes were found at lower loads. At 40-60 mmHg, blood flow decreased in participants with a pressure ulcer history and lower BMI, but stayed the same or increased in most other participants. The buttock displaced an average of 9.3 mm (2.7 mm) at 4.2 N, which represented 82% (7%) of maximum displacement. BMI was related to the amount of buttock tissue displacement while smoking status explained some of the variation in the percent of max displacement.

CONCLUSION

Wide variability in tissue compliance and blood flow responses across a relatively homogeneous population indicate that differences in biomechanical risk may provide an explanation for the spectrum of PrU risk among persons with SCI.

Mechanisms of human amniotic epithelial cell transplantation in treating stage III pressure ulcer in a rat model

The aim of the present study was to determine the function of human amniotic epithelial cell transplantation (hAECT) in promoting the healing of rats with stage III pressure ulcer (PU) and to initially investigate its possible mechanisms. A total of 96 Sprague Dawley rats were allocated at random into the model, hAECT, conventional treatment or control groups (n=24 per group). In each group, 6 rats were observed to determine the wound-healing rate. The mRNA and protein expression levels of vascular endothelial growth factor (VEGF) and tumor necrosis factor (TNF)-α in the wound tissue and serum were detected using reverse transcription-quantitative polymerase chain reaction analysis and enzyme-linked immunosorbent assay. The transplantation of hAECs significantly increased the healing rate of the stage III PUs and was accompanied by the significant upregulation of VEGF mRNA and protein expression levels and the significant downregulation of TNF-α mRNA and protein expression. Immunofluorescence staining showed that, on day 7 of transplantation, hAECs remained alive inside the skin tissues. Therefore, hAECT through subcutaneous injection appears to significantly improve the wound-healing rate of stage III PUs in rats, and this effect may be associated with the upregulation of the proangiogenic factor VEGF and the downregulation of the inflammatory cytokine TNF-α.