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Donaldson C, de Abreu MG, Mascha EJ, Rowbottom J, Harvester E, Khanna A, Sura T, Sessler DI, Patarroyo FR, Gulluoglu A, Zajic P, Chauhan U, Essber H, Kurz A. Pressure injury treatment by intermittent electrical stimulation (PROTECT-2): protocol for a multicenter randomized clinical trial. Trials 2024; 25:313. [PMID: 38730383 PMCID: PMC11083768 DOI: 10.1186/s13063-024-08085-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 04/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Pressure ulcers account for a substantial fraction of hospital-acquired pathology, with consequent morbidity and economic cost. Treatments are largely focused on preventing further injury, whereas interventions that facilitate healing remain limited. Intermittent electrical stimulation (IES) increases local blood flow and redistributes pressure from muscle-bone interfaces, thus potentially reducing ulcer progression and facilitating healing. METHODS The Pressure Injury Treatment by Intermittent Electrical Stimulation (PROTECT-2) trial will be a parallel-arm multicenter randomized trial to test the hypothesis that IES combined with routine care reduces sacral and ischial pressure injury over time compared to routine care alone. We plan to enroll 548 patients across various centers. Hospitalized patients with stage 1 or stage 2 sacral or ischial pressure injuries will be randomized to IES and routine care or routine care alone. Wound stage will be followed until death, discharge, or the development of an exclusion criteria for up to 3 months. The primary endpoint will be pressure injury score measured over time. DISCUSSION Sacral and ischial pressure injuries present a burden to hospitalized patients with both clinical and economic consequences. The PROTECT-2 trial will evaluate whether IES is an effective intervention and thus reduces progression of stage 1 and stage 2 sacral and ischial pressure injuries. TRIAL REGISTRATION ClinicalTrials.gov NCT05085288 Registered October 20, 2021.
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Affiliation(s)
- Chase Donaldson
- Department of Intensive Care and Resuscitation, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Marcelo Gama de Abreu
- Department of Intensive Care and Resuscitation, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Edward J Mascha
- Department of Quantitative Health Sciences and Outcomes Research, Lerner Research Institute; Outcomes Research Consortium, Department of Anesthesiology, Hospital Based Care Institute, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - James Rowbottom
- Department of Intensive Care and Resuscitation, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Eric Harvester
- Department of Intensive Care and Resuscitation, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ashish Khanna
- Department of Anesthesiology, Section On Critical Care Medicine, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Tanmay Sura
- Department of Anesthesiology, 100 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Hospital Based Care Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Fabio Rodriguez Patarroyo
- Outcomes Research Consortium, Department of Anesthesiology, Hospital Based Care Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Alper Gulluoglu
- Outcomes Research Consortium, Department of Anesthesiology, Hospital Based Care Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Paul Zajic
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerpl, 5, Graz, 8036, Austria
| | - Utkarsh Chauhan
- University of Alberta Medical School, 1-002 Katz Group Centre for Pharmacy and Health Research, Edmonton, AB, T6G 2E1, Canada
| | - Hani Essber
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerpl, 5, Graz, 8036, Austria
| | - Andrea Kurz
- Departments of General Anesthesiology and Outcomes Research Consortium, Department of Anesthesiology, Hospital Based Care Institute, Cleveland Clinic , 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Baron MV, Silva PE, Koepp J, Urbanetto JDS, Santamaria AFM, Dos Santos MP, de Mello Pinto MV, Brandenburg C, Reinheimer IC, Carvalho S, Wagner MB, Miliou T, Poli-de-Figueiredo CE, Pinheiro da Costa BE. Efficacy and safety of neuromuscular electrical stimulation in the prevention of pressure injuries in critically ill patients: a randomized controlled trial. Ann Intensive Care 2022; 12:53. [PMID: 35695996 PMCID: PMC9188909 DOI: 10.1186/s13613-022-01029-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/05/2022] [Indexed: 11/30/2022] Open
Abstract
Background Pressure injuries (PIs), especially in the sacral region are frequent, costly, and increase morbidity and mortality of patients in an intensive care unit (ICU). These injuries can occur as a result of prolonged pressure and/or shear forces. Neuromuscular electrical stimulation (NMES) can increase muscle mass and improve local circulation, potentially reducing the incidence of PI. Methods We performed a randomized controlled trial to assess the efficacy and safety of NMES in preventing PI in critically ill patients. We included patients with a period of less than 48 h in the ICU, aged ≥ 18 years. Participants were randomly selected (1:1 ratio) to receive NMES and usual care (NMES group) or only usual care (control group—CG) until discharge, death, or onset of a PI. To assess the effectiveness of NMES, we calculated the relative risk (RR) and number needed to treat (NNT). We assessed the muscle thickness of the gluteus maximus by ultrasonography. To assess safety, we analyzed the effects of NMES on vital signs and checked for the presence of skin burns in the stimulated areas. Clinical outcomes were assessed by time on mechanical ventilation, ICU mortality rate, and length of stay in the ICU. Results We enrolled 149 participants, 76 in the NMES group. PIs were present in 26 (35.6%) patients in the CG and 4 (5.3%) in the NMES group (p ˂ 0.001). The NMES group had an RR = 0.15 (95% CI 0.05–0.40) to develop a PI, NNT = 3.3 (95% CI 2.3–5.9). Moreover, the NMES group presented a shorter length of stay in the ICU: Δ = − 1.8 ± 1.2 days, p = 0.04. There was no significant difference in gluteus maximus thickness between groups (CG: Δ = − 0.37 ± 1.2 cm vs. NMES group: Δ = 0 ± 0.98 cm, p = 0.33). NMES did not promote deleterious changes in vital signs and we did not detect skin burns. Conclusions NMES is an effective and safe therapy for the prevention of PI in critically ill patients and may reduce length of stay in the ICU. Trial registration RBR-8nt9m4. Registered prospectively on July 20th, 2018, https://ensaiosclinicos.gov.br/rg/RBR-8nt9m4
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Affiliation(s)
- Miriam Viviane Baron
- Pontifical Catholic University of Rio Grande do Sul, Rio Grande do Sul, Porto Alegre, Brazil. .,Instituto Interdisciplinar de Educação, Ciência e Saúde, Fortaleza, Ceará, Brazil.
| | - Paulo Eugênio Silva
- Secretaria de Estado de Saúde do Distrito Federal, Hospital de Base do Distrito Federal, Distrito Federal, Brasília, Brazil
| | - Janine Koepp
- University of Santa Cruz do Sul, Santa Cruz do Sul, Rio Grande do Sul, Brazil
| | | | | | | | | | - Cristine Brandenburg
- Faculdade de Educação, Ciências e Letras do Sertão Central, Quixadá, Ceará, Brazil.,Instituto Interdisciplinar de Educação, Ciência e Saúde, Fortaleza, Ceará, Brazil
| | | | - Sonia Carvalho
- Rigshospital, Inge Lehmannsvej, Copenhagen East, Denmark
| | - Mário Bernardes Wagner
- Pontifical Catholic University of Rio Grande do Sul, Rio Grande do Sul, Porto Alegre, Brazil
| | - Thomas Miliou
- State University of Campinas, Campinas, São Paulo, Brazil
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Trauma of Peripheral Innervation Impairs Content of Epidermal Langerhans Cells. Diagnostics (Basel) 2022; 12:diagnostics12030567. [PMID: 35328120 PMCID: PMC8947052 DOI: 10.3390/diagnostics12030567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/26/2022] [Accepted: 02/17/2022] [Indexed: 12/10/2022] Open
Abstract
Langerhans cells represent the first immune cells that sense the entry of external molecules and microorganisms at the epithelial level in the skin. In this pilot case-study, we evaluated Langerhans cells density and progression of epidermal atrophy in permanent spinal cord injury (SCI) patients suffering with either lower motor neuron lesions (LMNSCI) or upper motor neuron lesions (UMNSCI), both submitted to surface electrical stimulation. Skin biopsies harvested from both legs were analyzed before and after 2 years of home-based Functional Electrical Stimulation for denervated degenerating muscles (DDM) delivered at home (h-bFES) by large anatomically shaped surface electrodes placed on the skin of the anterior thigh in the cases of LMNSCI patients or by neuromuscular electrical stimulation (NMES) for innervated muscles in the cases of UMNSCI persons. Using quantitative histology, we analyzed epidermal thickness and flattening and content of Langerhans cells. Linear regression analyses show that epidermal atrophy worsens with increasing years of LMNSCI and that 2 years of skin electrostimulation reverses skin changes, producing a significant recovery of epidermis thickness, but not changes in Langerhans cells density. In UMNSCI, we did not observe any statistically significant changes of the epidermis and of its content of Langerhans cells, but while the epidermal thickness is similar to that of first year-LMNSCI, the content of Langerhans cells is almost twice, suggesting that the LMNSCI induces an early decrease of immunoprotection that lasts at least 10 years. All together, these are original clinically relevant results suggesting a possible immuno-repression in epidermis of the permanently denervated patients.
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The effects of Boswellia (Frankincense) gel and hydrocolloid dressing on healing of second- and third-degree pressure ulcers among hospitalized patients. J Herb Med 2021. [DOI: 10.1016/j.hermed.2021.100461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Incidence of Pressure Injury in Individuals With Spinal Cord Injury: A Systematic Review and Meta-analysis. J Wound Ostomy Continence Nurs 2021; 47:215-223. [PMID: 32384524 DOI: 10.1097/won.0000000000000633] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE The purpose of this systematic review and quantitative analysis of pooled data was to assess the global incidence of pressure injury (PI), across time frames and countries, in individuals with spinal cord injury (SCI). DESIGN Systematic review and meta-analysis. SEARCH STRATEGY PubMed, Web of Science, and EMBASE databases were systematically searched for studies published from database inception to January 2019, with only English language studies that reported the incidence of PIs in individuals with SCI were included. Study quality was assessed by a 14-item standardized checklist. We calculated the incidence of PIs as the number of new PIs in individuals with SCI and the total number of individuals with SCI during the study period. Findings are presented as incidence rate with 95% confidence intervals (CIs). RESULTS The search yielded 1652 studies; after studies were reviewed for inclusion criteria, 29 studies representing N = 82,722 patients were retained for data extraction. The global incidence of PIs was 0.23 (95% CI, 0.20-0.26). Data for regional distribution by country showed a pooled incidence of 0.43 (95% CI, 0.28-0.57) in individuals with SCI in South American countries, 0.36 (95% CI, 0.16-0.56) in African countries, 0.25 (95% CI, 0.14-0.37) in European countries, 0.23 (95% CI, 0.19-0.27) in North American countries, and 0.16 (95% CI, 0.06-0.25) in Asian countries. The incidence was 0.22 (95% CI, 0.19-0.26) in developing countries versus 0.27 (95% CI, 0.17-0.37) in developed countries. From 2000 to 2009, the incidence of PIs in individuals with SCI was 0.28 (95% CI, 0.09-0.47). The incidence rate of PIs before 2000 and after 2009 was 0.23. The hospital- and community-acquired PI incidence was 0.22 (95% CI, 0.19-0.26) and 0.26 (95% CI, 0.20-0.32), respectively. CONCLUSIONS Study findings indicate that more than 1 in 5 individuals with SCI will develop a PI. Individuals with SCI are at high risk of developing PI, especially in community settings or low- and middle-income developing countries. The findings highlight the importance of further investigation of risk factors and prevention and management strategies for PIs in individuals with SCI.
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ZHANG Z, LI B, WANG Z, WU L, SONG L, YAO Y. Efficacy of Bimodal High-Voltage Monopulsed Current in the Treatment of Pressure Ulcer: A Systematic Review. IRANIAN JOURNAL OF PUBLIC HEALTH 2019; 48:1952-1959. [PMID: 31970093 PMCID: PMC6961193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 02/21/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND We aimed to systematically evaluate the efficacy of high-voltage pulsed current (HVPC) in the treatment of pressure ulcer. METHODS We searched the databases of PubMed, Cochrane Library, Elsevier and EMBASE to identify randomized controlled studies on the application of HVPC in pressure ulcer treatment, up to January 2019. Two authors independently screened the literature according to the inclusion and exclusion criteria, extracted the data and evaluated the quality. RevMan 5.3 software was used for statistical analysis. Four randomized controlled trials involving a total of 176 patients were included in the study. RESULTS Meta-analysis showed that the percentage of wound area reduction in the HVPC treatment group was higher than that in the control group (95%CI 24.59, 47.76, P<0.001). Descriptive analysis showed that there was no significant difference in wound healing between the HVPC treatment group and the control group. One study reported that there was contact dermatitis, and the rest of the studies reported no adverse events. CONCLUSION Compared with the conventional therapy, the combination with HVPC therapy can reduce the area of pressure ulcers more effectively. However, due to the small number of the studies included in this evaluation, the conclusions need to be verified by more high-quality studies.
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Affiliation(s)
- Zhiwei ZHANG
- Department of Nursing, The Second Affiliated Hospital of Qiqihar Medical University, Qiqihar, Heilongjiang Province, China
| | - Bojun LI
- The Second Clinical Medical College, Nanchang University, Nanchang, Jiangxi Province, China
| | - Zhichao WANG
- Department of Academic Theory Research, Qiqihar Medical University, Qiqihar, Heilongjiang Province, China
| | - Lina WU
- School of Medical Technology, Qiqihar Medical University, Qiqihar, Heilongjiang Province, China
| | - Lili SONG
- Department of Anesthesiology, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar, Heilongjiang Province, China
| | - Yexiang YAO
- Department of Social Medicine and Health Management, School of Public Health, Qiqihar Medical University, Qiqihar, Heilongjiang Province, China
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