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Kottner J, Amin R, Tomova-Simitchieva T, Hillmann K, Blume-Peytavi U. Effects of a mattress cover with special airflow technology on the structure and function of the sacral and heel skin during loading: A two-arm exploratory crossover trial. Int Wound J 2024; 21:e14957. [PMID: 38994923 DOI: 10.1111/iwj.14957] [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: 04/29/2024] [Revised: 06/14/2024] [Accepted: 06/14/2024] [Indexed: 07/13/2024] Open
Abstract
Prolonged mechanical loading of the skin and underlying soft tissue cause pressure ulceration. The use of special support surfaces are key interventions in pressure ulcer prevention. They modify the degree and duration of soft tissue deformation and have an impact on the skin microclimate. The objective of this randomized cross-over trial was to compare skin responses and comfort after lying for 2.5 h supine on a support surface with and without a coverlet that was intended to assist with heat and moisture removal at the patient/surface interface. In addition, physiological saline solution was administered to simulate an incontinence episode on the mattress next to the participants' skin surface. In total, 12 volunteers (mean age 69 years) with diabetes mellitus participated. After loading, skin surface temperature, stratum corneum hydration and skin surface pH increased, whereas erythema and structural stiffness decreased at the sacral area. At the heel skin area, temperature, erythema, and stratum corneum hydration increased. These results indicate occlusion and soft tissue deformation which was aggravated by the saline solution. The differences in skin response showed only minor differences between the support surface with or without the coverlet.
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Affiliation(s)
- Jan Kottner
- Institute for Clinical Nursing Science, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ruhul Amin
- Department of Dermatology, Venereology and Allergology, Clinical Research Center for Hair and Skin Science, Charité - Universitätsmedizin Berlin, Berlin, Germany
- BCSIR Laboratories Dhaka, Bangladesh Council of Scientific and Industrial Research, Dhaka, Bangladesh
| | - Tsenka Tomova-Simitchieva
- Department of Dermatology, Venereology and Allergology, Clinical Research Center for Hair and Skin Science, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kathrin Hillmann
- Department of Dermatology, Venereology and Allergology, Clinical Research Center for Hair and Skin Science, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Blume-Peytavi
- Department of Dermatology, Venereology and Allergology, Clinical Research Center for Hair and Skin Science, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Kottner J, Coleman S. The theory and practice of pressure ulcer/injury risk assessment: a critical discussion. J Wound Care 2023; 32:560-569. [PMID: 37682783 DOI: 10.12968/jowc.2023.32.9.560] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Pressure ulcer/injury (PU) risk assessment is widely considered an essential component in clinical practice. It is a complex and broad concept that includes different approaches, such as clinical judgement, using standardised risk assessment instruments, skin assessments, or using devices to measure skin or tissue properties. A distinction between PU risk assessment and early detection is important. PU risk measures the individual's susceptibility to developing a PU under a specific exposure (primary prevention), and early detection includes the assessment of early (sub)clinical signs and symptoms to prevent progression and to support healing (secondary prevention). PU risk is measured using prognostic/risk factors or prognostic models. Every risk estimate is a probability statement containing varying degrees of uncertainty. It therefore follows that every clinical decision based on risk estimates also contains uncertainty. PU risk assessment and prevention is a complex intervention, where delivery contains several interacting components. There is a huge body of evidence indicating that risk assessment and its outcomes, the selection of preventive interventions and PU incidence are not well connected. Methods for prognostic model development and testing in PU risk research must be improved and follow state-of-the-art methodological standards. Despite these challenges, we do have substantial knowledge about PU risk factors that helps us to make better clinical decisions. An important next step in the development of PU risk prediction might be the combination of clinical and other predictors for more individualised care. Any prognostic test or procedure must lead to better prevention at an acceptable cost.
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Affiliation(s)
- Jan Kottner
- Charité-Universitätsmedizin Berlin, Institute of Clinical Nursing Science, Berlin, Germany
| | - Susanne Coleman
- Leeds Institute of Clinical Trials Research, University of Leeds, UK
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Jayabal H, Abiakam NS, Filingeri D, Bader DL, Worsley PR. Inflammatory biomarkers in sebum for identifying skin damage in patients with a Stage I pressure ulcer in the pelvic region: A single centre observational, longitudinal cohort study with elderly patients. Int Wound J 2023; 20:2594-2607. [PMID: 36872612 PMCID: PMC10410330 DOI: 10.1111/iwj.14131] [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: 11/14/2022] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 03/07/2023] Open
Abstract
Pressure Ulcers (PU) are a major burden for affected patients and healthcare providers. Current detection methods involve visual assessments of the skin by healthcare professionals. This has been shown to be subjective and unreliable, with challenges associated with identifying erythema in darker colour skin. Although there exists a number of promising non-invasive biophysical techniques such as ultrasound, capacitance measurements, and thermography, the present study focuses on directly measuring the changes in the inflammatory status of the skin and underlying tissues. Therefore, in this study, we aim to analyse inflammatory cytokines collected through non-invasive sampling techniques to detect early signs of skin damage. Thirty hospitalised patients presenting with Stage I PU were recruited to evaluate the inflammatory response of skin at the site of damage and an adjacent healthy control site. Sebutapes were collected over three sessions to investigate the temporal changes in the inflammatory response. The panel of cytokines investigated included high-abundance cytokines, namely, IL-1α and IL-1RA, and low abundance cytokines; IL-6, IL-8, TNF-α, INF-γ, IL-33, IL-1β and G-CSF. Spatial and temporal differences between sites were assessed and thresholds were used to determine the sensitivity and specificity of each biomarker. The results suggest significant (P < .05) spatial changes in the inflammatory response, with upregulation of IL-1α, IL-8, and G-CSF as well as down-regulation of IL-1RA over the Stage I PU compared with the adjacent control site. There were no significant temporal differences between the three sessions. Selected cytokines, namely, IL-1α, IL-1RA, IL-8, G-CSF, and the ratio IL-1α/IL-1RA offered clear delineation in the classification of healthy and Stage-I PU skin sites, with receiver operating characteristic curves demonstrating high sensitivity and specificity. There were limited influences of intrinsic and extrinsic factors on the biomarker response. Inflammatory markers provided a high level of discrimination between the sites presenting with Stage I PU and an adjacent healthy skin site, in a cohort of elderly inpatients. Indeed, the ratio of IL-1α to IL-1RA provided the highest sensitivity and specificity, indicative that inflammatory homeostasis is affected at the PU site. There was a marginal influence of intrinsic and extrinsic factors, demonstrating the localised effects of the inflammation. Further studies are required to investigate the potential of inflammatory cytokines incorporated within Point of Care technologies, to support routine clinical use.
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Affiliation(s)
| | | | | | - Dan L. Bader
- School of Health SciencesUniversity of SouthamptonSouthamptonUK
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Orlov A, Gefen A. Differences in prophylactic performance across wound dressing types used to protect from device-related pressure ulcers caused by a continuous positive airway pressure mask. Int Wound J 2023; 20:942-960. [PMID: 36106557 PMCID: PMC10031247 DOI: 10.1111/iwj.13942] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/14/2022] [Accepted: 08/15/2022] [Indexed: 12/01/2022] Open
Abstract
Prolonged use of continuous positive airway pressure masks, as often required for non-invasive ventilation, involves a risk for facial tissue breakdown due to the sustained deformations caused by tightening of the stiff mask surfaces to the head and the moist environment. The risk of developing mask-related facial injuries can be reduced through suitable cushioning materials placed at the skin-mask interfaces to spread the localised contact forces and disperse the surface and internal tissue stresses. Using an integrated experimental-computational approach, we compared the biomechanical protective performance of three popular foam-based wound dressings to that of a market-lead hydrocolloid dressing when applied to protect the facial skin under a mask. We measured the compressive stiffness properties of the four commercial dressing types in dry and moist conditions, and then fed those to an anatomically realistic finite element model of an adult male head, with an applied simulated mask. Through this process, we calculated the protective efficacy index of each dressing type, indicating the relative contribution of the specified dressing to alleviating facial soft tissue loads with respect to the no-dressing case. The foam-based dressings generally performed substantially better than the hydrocolloid, but foam dressings were also demonstrated to vary by their protective performance.
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Affiliation(s)
- Aleksei Orlov
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Amit Gefen
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
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Bridges E, Whitney J, Metter D, Burr R. Prevention of pressure injuries during military aeromedical evacuation or prolonged field care: A randomized trial. Nurs Outlook 2022; 70:S115-S126. [PMID: 36585058 DOI: 10.1016/j.outlook.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND During military aeromedical evacuation (AE) and prolonged field care (PFC), casualties are at increased pressure injury (PI) risk. Operational PI mitigation strategies research is limited. PURPOSE Using multiple factors, this study examined Mepilex/LiquiCell effects on PI risk under simulated AE/PFC. METHODS Healthy adults were stratified by body fat (%) and randomized to six groups on three surfaces. Set A: Warrior Evacuation Litter Pad (WELP) with/without Mepilex; Set B: Vacuum Spine Board (VSB) with/without Mepilex; Set C: Talon litter with/without LiquiCell. Two hours supine (loaded) was needed. OUTCOMES Sacral skin transcutaneous tissue oxygen (TcPO2), temperature, moisture, interface pressure, interleukin-1α/Total Protein. FINDINGS 54 participants. Sets A/B: No Mepilex effects; temperature increased 2.5°C. Set C: No LiquiCell effects. Significant ΔTcPO2 (unloaded-loaded), with 100% impaired perfusion; temperature increased 1.2°C. DISCUSSION Multiple risk factors for PI mitigating strategies must consider. Talon with increased pressure/impaired perfusion but smaller temperature/moisture changes; WELP/VSB with increased temperature/moisture but lower pressure/adequate perfusion.
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Affiliation(s)
- Elizabeth Bridges
- Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle Washington, USA; United States Air Force Nurse Corps (ret).
| | - JoAnne Whitney
- Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle Washington, USA
| | - Debra Metter
- Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle Washington, USA
| | - Robert Burr
- Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle Washington, USA
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Gefen A. Alternatives and preferences for materials in use for pressure ulcer prevention: An experiment-reinforced literature review. Int Wound J 2022; 19:1797-1809. [PMID: 35274443 DOI: 10.1111/iwj.13784] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 02/21/2022] [Accepted: 02/24/2022] [Indexed: 12/15/2022] Open
Abstract
Alleviation of localised, sustained tissue loads and microclimate management are the most critical performance criteria for materials in use for pressure ulcer prevention, such as in prophylactic dressings, padding or cushioning. These material performance criteria can be evaluated by calculating the extents of matching between the material stiffness (elastic modulus) and the thermal conductivity of the protective dressing, padding or cushioning with the corresponding properties of native skin, separately or in combination. Based on these bioengineering performance criteria, hydrocolloids, which are commonly used for prophylaxis of medical device-related pressure ulcers, exhibit poor stiffness matching with skin. In addition, there is remarkable variability in the modulus and thermal conductivity matching levels of different material types used for pressure ulcer prevention, however, it appears that among the materials tested, hydrogels provide the optimal matching with skin, followed by gels and silicone foams. The stiffness matching for hydrocolloids appears to be inferior even to that of gauze. This article provides quantitative performance criteria and metrics for these evaluations, and grades commonly used material types to biomechanically guide clinicians and industry with regards to the selection of dressings for pressure ulcer prevention, both due to bodyweight forces and as a result of applied medical devices.
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Affiliation(s)
- Amit Gefen
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
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Völzer B, Kottner J. Associations between skin structural and functional changes after loading in healthy aged females at sacral and heel skin: A secondary data analysis. J Tissue Viability 2022; 31:239-244. [DOI: 10.1016/j.jtv.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/10/2022] [Accepted: 01/29/2022] [Indexed: 10/19/2022]
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Lichterfeld-Kottner A, Vogt A, Tomova-Simitchieva T, Blume-Peytavi U, Kottner J. Effects of loading and prophylactic dressings on the sacral and heel skin: An exploratory cross-over trial. Int Wound J 2021; 18:909-922. [PMID: 33939289 PMCID: PMC8613394 DOI: 10.1111/iwj.13596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/18/2021] [Accepted: 03/23/2021] [Indexed: 01/21/2023] Open
Abstract
Pressure ulcers/injuries are caused by sustained loading and deformation of skin and underlying soft tissues. Prophylactic dressings are recommended as an adjunct to other preventive measures such as repositioning and offloading. The aim of this study was to investigate the effects of prophylactic soft silicone multi‐layered foam dressings on the skin structure and function of the two most common pressure areas, sacrum and heel, with and without loading. An exploratory randomised cross‐over trial using intra‐individual comparisons was conducted. Eight healthy volunteers (mean age 27.5 years) were assigned to three groups and either spent 2.5 hours on a standard hospital mattress lying in supine position with and without dressings or spent 2.5 hours with dressings applied but without loading. Skin temperature, stratum corneum, and epidermal hydration increased in all groups irrespective of wearing a dressing and/or loading. Mean roughness decreased at the heels. Reactive hyperaemia and the release of interleukin 1 alpha were associated with loading only. Results suggest that the occlusive effects of dressings are similar or only slightly greater than those observed with non‐loading or loading without dressings. Thus, a dressing does not cause additional irritation or skin changes during loading but it may reduce the inflammatory response.
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Affiliation(s)
- Andrea Lichterfeld-Kottner
- Department of Geriatrics and Medical Gerontology, Geriatrics Research Group, Nursing Research Group, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Annika Vogt
- Department of Dermatology and Allergology, Clinical Research Center for Hair and Skin Science, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tsenka Tomova-Simitchieva
- Department of Dermatology and Allergology, Clinical Research Center for Hair and Skin Science, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Blume-Peytavi
- Department of Dermatology and Allergology, Clinical Research Center for Hair and Skin Science, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Kottner
- Charite Center for Health and Human Sciences, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Kottner J, Blume-Peytavi U. Reliability and agreement of instrumental skin barrier measurements in clinical pressure ulcer prevention research. Int Wound J 2021; 18:716-727. [PMID: 33626239 PMCID: PMC8450794 DOI: 10.1111/iwj.13574] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 12/11/2022] Open
Abstract
In skin and wound research the instrumental measurement of skin function is established. Despite the widespread use, empirical evidence about measurement errors is widely lacking. The aim of this study was to measure reliability and agreement of skin temperature, transepidermal water loss, epidermal hydration, and erythema at the heel and sacral skin. Four experienced researchers performed skin measurements in 15 subjects. Lowest reliability was observed for transepidermal water loss at the sacral skin (ICC (1) 0.46 (95% CI 0.00‐0.78)) and highest for skin temperature at the heel skin (ICC (1) 0.99 (95% CI 0.99‐1.00)). Lowest Standard Errors of Measurement were calculated for skin temperature measurements at the heels (0.11°C) and highest for erythema measurements at the sacral skin (26.7 arbitrary units). There was a clear association between variability of estimates and reliability coefficients. Single measurements of skin temperature, stratum corneum, and epidermal hydration at the sacral and heel skin areas can be used in clinical research and practice. Means of at least two measurements should be used for estimating transepidermal water loss and erythema. Evidence is needed to inform researchers about relative and absolute measurement errors of commonly applied instruments and measurements in skin and wound research.
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Affiliation(s)
- Jan Kottner
- Charité Center for Health and Human Sciences, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Ulrike Blume-Peytavi
- Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany
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