The impact of human papilloma virus status on the prediction of head and neck cancer chemoradiotherapy outcomes using the pre-treatment apparent diffusion coefficient

Objective:

To determine the impact of Human Papilloma Virus (HPV) oropharyngeal cancer (OPC) status on the prediction of head and neck squamous cell cancer (HNSCC) chemoradiotherapy (CRT) outcomes with pre-treatment quantitative diffusion-weighted magnetic resonance imaging (DW-MRI).

Methods:

Following ethical approval, 65 participants (53 male, age 59.9 ± 7.86) underwent pre-treatment DW-MRI in this prospective cohort observational study. There were 46 HPV OPC and 19 other HNSCC cases with Stage III/IV HNSCC. Regions of interest (ROIs) (volume, largest area, core) at the primary tumour (n = 57) and largest pathological node (n = 59) were placed to analyse ADC_mean and ADC_min. Unpaired t-test or Mann–Whitney test evaluated the impact of HPV OPC status and clinical parameters on their prediction of post-CRT 2 year locoregional and disease-free survival (LRFS and DFS). Multivariate logistic regression compared significant variables with 2 year outcomes.

Results:

On univariate analysis of all participants, the primary tumour area ADC_mean was predictive of 2 year LRFS (p = 0.04). However, only the HPV OPC diagnosis (LFRS p = 0.03; DFS p = 0.02) predicted outcomes on multivariate analysis. None of the pre-treatment ADC values were predictive of 2 year DFS in the HPV OPC subgroup (p = 0.21–0.68). Amongst participants without 2 year disease-free survival, HPV-OPC was found to have much lower primary tumour ADC_mean values than other HNSCC.

Conclusion:

Knowledge of HPV OPC status is required in order to determine the impact of the pre-treatment ADC values on post-CRT outcomes in HNSCC.

Advances in knowledge:

Pre-treatment ADC_mean and ADC_min values acquired using different ROI methods are not predictive of 2 year survival outcomes in HPV OPC.

MRI in head and neck cancer following chemoradiotherapy: what is the optimal delay to demonstrate maximal response?

OBJECTIVES

To investigate the optimal timing for post-chemoradiotherapy (CRT) reference magnetic resonance imaging (MRI) in head and neck cancer, so as to demonstrate a maximal treatment response. To assess whether this differs in human papillomavirus-related oropharyngeal cancer (HPV-OPC) and whether the MRI timing impacts on the ability to predict treatment success.

METHODS

Following ethical approval and informed consent, 45 patients (40 male, mean age 59.7 ± 7.9 years, 33 HPV-OPC) with stage 3 and 4 HNSCC underwent pre-treatment, 6- and 12-week post-CRT MRIs in this prospective cohort study. Primary tumour (n = 39) size, T2w morphology and diffusion weight imaging (DWI) scores, together with nodal (n = 42) size and necrotic/cystic change, were recorded. Interval imaging changes were analysed for all patients and according to HPV-OPC status. MRI descriptors and their interval changes were also compared with 2-year progression-free survival (PFS).

RESULTS

All MRI descriptors significantly changed between pre-treatment and 6-week post-treatment MRI studies (p < .001). Primary tumour and nodal volume decreased between 6- and 12-week studies; however, interval changes in linear dimensions were only evident for HPV-OPC lymph nodes. Nodal necrosis scores also evolved after 6 weeks but other descriptors were stable. The 6-week nodal necrosis score and the 6- and 12-week nodal volume were predictive of 2-year PFS.

CONCLUSION

Apart from HPV-OPC patients with nodal disease, the 6-week post-CRT MRI demonstrates maximal reduction in the linear dimensions of head and neck cancer; however, a later reference study should be considered if volumetric analysis is applied.

KEY POINTS

• This study provides guidance on when early post-treatment imaging should be performed in head and neck cancer following chemoradiotherapy, in order to aid subsequent detection of recurrent tumour. • Lymph nodes in HPV-related oropharyngeal cancer patients clearly reduced in size from 6 to 12 weeks post-treatment. However, other lymph node disease and all primary tumours showed only a minor reduction in size beyond 6 weeks, and this required a detailed volumetric analysis for demonstration. • Timing of the reference MRI following chemoradiotherapy for head and neck cancer depends on whether the patient has HPV-related oropharyngeal cancer and whether there is nodal disease. MRI as early as 6 weeks post-treatment may be performed unless volumetric analysis is routinely performed.

Apparent diffusion coefficient agreement and reliability using different region of interest methods for the evaluation of head and neck cancer post chemo-radiotherapy

Objectives:

Post chemoradiotherapy (CRT) interval changes in apparent diffusion coefficient (ADC) have prognostic value in head and neck squamous cell cancer (HNSCC). The impact of using different region of interest (ROI) methods on interobserver agreement and their ability to reliably detect the changes in the ADC values was assessed.

Methods:

Following ethical approval, 25 patients (mean age 59.5 years, 21 male) with stage 3–4 HNSCC undergoing CRT were recruited for this prospective cohort study. Diffusion weighted MRI (DW-MRI) was performed pre-treatment and at 6 and 12 weeks following CRT. Two radiologists independently delineated ROIs using whole volume (ROI_v), largest area (ROI_a) or representative area (ROI_r) methods at primary tumour (n = 22) and largest nodal (n = 24) locations and recorded the ADC_mean. When no clear focus of increased DWI signal was evident at follow-up, a standardised ROI was placed (non-measurable or NM). Bland-Altman plots and interclass correlation coefficient (ICC) were assessed. Paired t-tests evaluated interval changes in pre- and post-treatment ADC_mean at each location, which were compared to the smallest detectable difference (SDD).

Results:

Excellent agreement was obtained for all ROI methods at pre-treatment (ICC 0.94–0.98) and 6-week post-treatment (ICC 0.94–0.98). At 12-week post-treatment, agreement was excellent (ICC 0.91–0.94) apart from ROI_r (ICC 0.86) and the NM nodal disease (ICC 0.87). There were significant interval increases in ADC_mean between pre-treatment and post-treatment studies, which were greater than the SDD for all ROIs.

Conclusions:

ADC_mean values can be reproducibly obtained in HNSCC using the different ROI techniques on pre- and post-CRT MRI, and this reliably detects the interval changes.

Morphological comparison of internal auditory canal diverticula in the presence and absence of otospongiosis on computed tomography and their impact on patterns of hearing loss

PURPOSE

The association of internal auditory canal (IAC) fundal diverticula with otospongiosis (OS) and their clinical significance remain unclear. We explored whether isolated IAC diverticula were morphologically different from those with additional CT features of OS, and whether IAC diverticula morphology influenced patterns of hearing loss.

METHODS

Consecutive temporal bone CT studies with (n = 978) and without (n = 306) features of OS were retrospectively assessed. Two independent observers evaluated the presence of IAC diverticula morphological features (depth, neck:depth ratio, definition of contour and angulation of shape), and these were correlated with the presence of fenestral and pericochlear OS. Audiometric profiles were analysed for the isolated IAC diverticula and those with fenestral OS alone. Continuous data was compared using Wilcoxon rank sum tests and categorical data with chi-squared and Fisher's exact tests.

RESULTS

Ninety-five isolated IAC diverticula were demonstrated in 54/978 patients (5.5%) without CT evidence of OS (31M, 23F, mean age 46), and 119 IAC diverticula were demonstrated in 71/306 patients (23%) with CT evidence of OS (23M, 48F, mean age 55). Reduced neck:depth ratio, ill definition and angulation were all significantly associated with the presence of pericochlear OS (p < 0.001), whilst only ill definition was associated with the presence of fenestral OS alone (p < 0.05). No morphological feature was associated with conductive hearing loss in isolated diverticula or with sensorineural hearing loss in diverticula with fenestral OS alone.

CONCLUSION

IAC diverticula associated with pericochlear OS demonstrate different morphological features from isolated IAC diverticula. There are no clear audiometric implications of these morphological features.

Head and neck manifestations of granulomatosis with polyangiitis

Granulomatosis with polyangiitis is a rare autoimmune condition which causes respiratory tract granulomas, small to medium vessel vasculitis and renal disease. Head and neck manifestations are some of the most common presentations of the condition, with a significant proportion of patients experiencing sinonasal disease alone. The recognition of suggestive imaging findings, in combination with clinical history and serology, aids the diagnosis and appropriate treatment. This pictorial review describes and illustrates the head and neck imaging features of granulomatosis with polyangiitis, highlighting the range of CT and MRI findings of upper aerodigestive tract, orbital and skull-base disease. Recognition of the radiological appearances is of importance, since clinical presentations may be non-specific and limited disease may have negative serology. Imaging features may overlap with other pathologies so important differential diagnoses will be considered, and these are particularly relevant in the context of treatment resistance.

Which is the optimally defined vestibular cross-section to diagnose unilateral Meniere's disease with delayed post-gadolinium 3D fluid-attenuated inversion recovery MRI?

OBJECTIVES

Delayed post-gadolinium 3D fluid-attenuated inversion recovery (FLAIR) MRI is used to support a diagnosis of Ménière's disease (MD) with the ratio of the endolymphatic space (ES) to the sum of the endolymphatic and perilymphatic spaces (SEPS) on a cross-section through the vestibule being a key diagnostic criterion. It was hypothesised that the exact definition of the vestibular cross-section would influence the ES: SEPS ratio, its ability to diagnose MD, and its reproducibility.

METHODS

Following institutional approval, 22 patients (five male, 17 female; mean age 52.1) with unilateral MD and delayed post-gadolinium 3D FLAIR MRI were retrospectively analysed. Two observers measured the ES and SEPS on predefined axial (superior and inferior) and sagittal vestibular cross-sections. Receiver operating characteristic (ROC) curves, Bland-Altman plots and intraclass correlation (ICC) were analysed for the ES:SEPS ratios.

RESULTS

The area under the curve (AUC) was decreased for the ES:SEPS ratios on the superior axial section through the vestibule (AUC 0.737) compared to the inferior axial (AUC 0.874) and sagittal sections (AUC 0.878). The resulting optimal thresholds (sensitivities/specificities) were 0.21 (0.66/0.75), 0.16 (0.77/0.9) and 0.285 (0.75/0.96). The reproducibility was excellent for all measures with ICCs of 0.97, 0.98 and 0.99.

CONCLUSION

Inferior axial or sagittal vestibular cross-sections are more accurate for the diagnosis of MD ears and have excellent reproducibility.

ADVANCES IN KNOWLEDGE

The choice of vestibular cross-section influences both the ability to distinguish MD from asymptomatic contralateral ears, and the optimum threshold ES:SEPS value.

Automated quantitative MRI volumetry reports support diagnostic interpretation in dementia: a multi-rater, clinical accuracy study

Objectives

We examined whether providing a quantitative report (QReport) of regional brain volumes improves radiologists’ accuracy and confidence in detecting volume loss, and in differentiating Alzheimer’s disease (AD) and frontotemporal dementia (FTD), compared with visual assessment alone.

Methods

Our forced-choice multi-rater clinical accuracy study used MRI from 16 AD patients, 14 FTD patients, and 15 healthy controls; age range 52–81. Our QReport was presented to raters with regional grey matter volumes plotted as percentiles against data from a normative population (n = 461). Nine raters with varying radiological experience (3 each: consultants, registrars, ‘non-clinical image analysts’) assessed each case twice (with and without the QReport). Raters were blinded to clinical and demographic information; they classified scans as ‘normal’ or ‘abnormal’ and if ‘abnormal’ as ‘AD’ or ‘FTD’.

Results

The QReport improved sensitivity for detecting volume loss and AD across all raters combined (p = 0.015* and p = 0.002*, respectively). Only the consultant group’s accuracy increased significantly when using the QReport (p = 0.02*). Overall, raters’ agreement (Cohen’s κ) with the ‘gold standard’ was not significantly affected by the QReport; only the consultant group improved significantly (κ_s 0.41➔0.55, p = 0.04*). Cronbach’s alpha for interrater agreement improved from 0.886 to 0.925, corresponding to an improvement from ‘good’ to ‘excellent’.

Conclusion

Our QReport referencing single-subject results to normative data alongside visual assessment improved sensitivity, accuracy, and interrater agreement for detecting volume loss. The QReport was most effective in the consultants, suggesting that experience is needed to fully benefit from the additional information provided by quantitative analyses.

Key Points

• The use of quantitative report alongside routine visual MRI assessment improves sensitivity and accuracy for detecting volume loss and AD vs visual assessment alone.

• Consultant neuroradiologists’ assessment accuracy and agreement (kappa scores) significantly improved with the use of quantitative atrophy reports.

• First multi-rater radiological clinical evaluation of visual quantitative MRI atrophy report for use as a diagnostic aid in dementia.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-020-07455-8.

Active middle ear implantation: imaging in the pre-operative planning and post-operative assessment of the Vibrant SoundbridgeTM

Active middle ear implants augment sound waves and directly stimulate the middle ear structures. The most frequently utilised active middle ear implant is the Vibrant Soundbridge ^TM (VSB).CT plays a vital role in appropriate patient selection and surgical planning of active middle ear implant surgery. The VSB ^TM offers a number of options for implant placement. The ideal location is influenced by the patient's middle ear and mastoid anatomy as well as the type and severity of the hearing loss. CT provides important information on the surgical access to the middle ear and helps determine the most appropriate implant site by assessing the adjacent middle ear anatomy and the continuity of the ossicular chain. Post-operative active middle ear implant imaging may be indicated in the setting of poor auditory outcomes and when revision surgery is being considered so as to assess for suboptimal implant placement or migration.This pictorial review will describe the VSB ^TM middle ear device and explain the role of imaging in both the pre-operative and post-operative settings.

Imaging anatomy of the retrotympanum: variants and their surgical implications

The retrotympanic anatomy is complex and variable but has received little attention in the radiological literature. With advances in CT technology and the application of cone beam CT to temporal bone imaging, there is now a detailed depiction of the retrotympanic bony structures.With the increasing use of endoscopes in middle ear surgery, it is important for the radiologist to appreciate the nomenclature of the retrotympanic compartments in order to aid communication with the surgeon. For instance, in the context of cholesteatoma, clear imaging descriptions of retrotympanic variability and pathological involvement are valuable in pre-operative planning.The endoscopic anatomy has recently been described and the variants classified. The retrotympanum is divided into medial and lateral compartments with multiple described potential sinuses separated by bony crests.This pictorial review will describe the complex anatomy and variants of the retrotympanum. We will describe optimum reformatting techniques to demonstrate the structures of the retrotympanum and illustrate the associated anatomical landmarks and variants with CT. The implications of anatomical variants with regards to otologic surgery will be discussed.

Detection of avascular necrosis on routine diffusion-weighted whole body MRI in patients with multiple myeloma

OBJECTIVE

Current therapies for multiple myeloma, which include corticosteroids, increase risk of avascular necrosis. The aim of this study was to assess incidental detection of femoral head avascular necrosis on routine whole body MRI including diffusion weighted MRI.

METHODS

All whole body MRI studies, performed on patients with known multiple myeloma between 1 January 2010 to 1 May 2017 were assessed for features of avascular necrosis.

RESULTS

650 whole body MR scans were analysed. 15 patients (6.6%) had typical MR features of avascular necrosis: 2/15 (13.3%) had femoral head collapse, 4/15 (26.7%) had bilateral avascular necrosis and 9/15 (60%) were asymptomatic.

CONCLUSION

This is the first report of avascular necrosis detected on routine whole body MRI in patients with multiple myeloma. Targeted review of femoral heads in multiple myeloma patients undergoing whole body MR is recommended, including in patients without symptoms.

ADVANCES IN KNOWLEDGE

Whole body MR which includes diffusion-weighted MRI is extremely sensitive for evaluation of bone marrow. Although whole body MRI is primarily used for evaluation of multiple myeloma disease burden, it also presents an unique opportunity to evaluate the femoral heads for signs of avascular necrosis which can predate symptoms.

Decision making in venous thromboembolism prophylaxis: Is LWMH being inappropriately withheld from patients admitted with chronic liver disease?

Although chronic liver disease (CLD) constitutes a significant proportion of acute medical admissions, it is not known how CLD influences venous thromboembolism (VTE) prophylaxis decision making and low molecular weight heparin (LMWH) prescription. Furthermore, recent evidence suggests that VTE risk has been underestimated in CLD and that prophylactic LMWH is safe and may improve outcome in this patient group. We therefore evaluated VTE prophylaxis in patients with CLD and aimed to determine the factors contributing to decisions to prescribe LMWH. Prescription of LMWH was significantly less likely in CLD patients than in general medical patients (29% vs 55%; p < 0.01). Patients with CLD who were prescribed LMWH were more likely to have been admitted for a 'non-liver' reason than those that did not receive LMWH (19% vs 52%; p < 0.01). These preliminary results show that many patients admitted with CLD, who may benefit from LMWH prophylaxis, do not receive this therapy, because of perceived contraindications for which there may be little evidence. Decision making appears to be affected by whether an admission is 'liver' or 'non-liver' related. Prophylactic LMWH was safe in this small cohort. Further studies are warranted to further inform LMWH prescription in CLD.

Increased use of pre-operative imaging and laparoscopy has no impact on clinical outcomes in patients undergoing appendicectomy

INTRODUCTION

The aim of this study was to review changes in the management of acute appendicitis in a ten-year period at a large university teaching hospital in London.

METHODS

This was a retrospective cohort study reviewing the medical records of patients who underwent an appendicectomy over a period of 12 months either in 1999 or 2009. Data collected included use of radiological investigations (ultrasonography, computed tomography [CT]), technique of appendicectomy (open [OA] or laparoscopic [LA]), operative time, histopathology and post-operative complications. Univariate and multivariate analysis was performed to assess the influence of variables on the incidence of negative appendicectomy, appendiceal perforation and post-operative complications.

RESULTS

All of the patients operated on in 1999 (n=109) had OA. Of the patients operated on in 2009 (n=164), 67 had OA, 91 had LA and 6 had LA converted to OA. None of the patients in 1999 had CT whereas in 2009 26% of patients had CT (sensitivity 94.7%, specificity 75.0%). This increased use of pre-operative imaging had no effect on negative appendicectomy (25.7% vs 12.8%, p=0.445), perforation (30.0% vs 21.3%, p=0.308) or complication rates (9.2% vs 10.4%). The complication rate was also similar regardless of whether patients had OA or LA (11.9% vs 9.9%). Multivariate analysis revealed that age was the only predictor of negative appendicectomy (p=0.029) or perforation (p=0.014).

CONCLUSIONS

This study shows that significant increase in the use of pre-operative imaging and laparoscopy in the management of patients with acute appendicitis failed to reduce negative appendicectomy, perforation and complications rates. The patient's age was the only predictor of negative appendicectomy and perforation.

Decreasing the prevalence of pressure ulcers using agency standards

Home care patients either have or are at high risk for pressure ulcers. This article describes the outcome of a study that examined the effects of pressure ulcer prevention and treatment standards on the prevalence rate of a home healthcare agency's client caseload. Implications for practice and further research also are discussed.

Pressure ulcer incidence in an acute care setting

The purpose of this prospective study was to determine the incidence of pressure ulcers and to examine factors related to pressure ulcer development in patients in an acute care setting. Adult medical and surgical patients who were free of pressure ulcers at admission were assessed within 36 hours of admission and then three times per week for 2 weeks or until discharge. Instruments included a demographic data form, a skin assessment form, and the Braden Scale for Predicting Pressure Sore Risk. Most subjects had 46 assessments completed. The sample consisted of 149 subjects, with a pressure ulcer incidence rate of 13.4% (n = 20). Subjects who acquired pressure ulcers had lower hemoglobin levels (t = 2.17, p = 0.03), spent more time in bed (t = 3.90, p = 0.0001), and spent less time in a chair (t = 3.2, p = 0.002) than those who did not acquire pressure ulcers. A stepwise logistic regression analysis was used to calculate risk of pressure ulcer development. In the final model, hemoglobin level and hours spent in bed continued to be predictors of pressure ulcer development (chi 2 = 9.306, df = 2, p = 0.0095). All 20 subjects who acquired pressure ulcers were further categorized into groups with stage I (n = 12) or stage II (n = 8) ulcers. Patients with stage I pressure ulcers were primarily receiving post-surgical care (67%), whereas patients who acquired stage II ulcers had medical conditions that affected tissue perfusion, such as respiratory diseases (50%) and diabetes mellitus (12%).

The effectiveness of skin care protocols for pressure ulcers

Pressure ulcers (PU) remain a serious healthcare problem in the United States. This study investigated the effectiveness of a prevention and early intervention program in reducing the prevalence of pressure ulcers (i.e., the number or the percentage of persons with pressure ulcers at a given time) in a rehabilitation hospital. The Braden Scale for Predicting Pressure Sore Risk was used to assess subjects' PU risk. Protocols were established for PU stages consistent with the National Pressure Ulcer Advisory Panel consensus statement on pressure ulcers. Staff were educated about PUs and the specific protocols for prevention and treatment. Concurrent quarterly prevalence audits on a total of 116 patients were conducted for 1 year. An audit also was done 16 months after protocols had been established. There was a 60% decrease in pressure ulcer prevalence from the 25% baseline to the 10% found at the audit following implementation of the protocols.

Skin care strategies in a skilled nursing home

1. Pressure ulcers continue to be a serious problem in nursing home settings. They are significant as a source of discomfort and disability among nursing home residents, as well as a source of financial concern for the institutional agencies responsible for resident care. 2. Prevention and intervention at the earliest stages of pressure ulcer development offer the most effective approaches to mediating the human and economic costs imposed by pressure ulcers. 3. Strategies that are effective in reducing both the development and severity of pressure ulcers can be successfully implemented in long-term care settings. Further studies are needed that will provide additional support for the strategies and protocols used in this study.

Evaluation of pressure ulcer prevalence rates for hospice patients post-implementation of pressure ulcer protocols

Hospice patients may be particularly at risk for pressure ulcer development due to several factors. Identifying populations at risk for pressure ulcer development, such as hospice patients, and providing prevention and risk protocols for these populations can substantially reduce the prevalence and incidence of pressure ulcers. However, are hospice patients prone for skin breakdown despite prevention and treatment efforts? This study examines the prevalence of pressure ulcers in hospice patients following the implementation of pressure ulcer prevention and treatment protocols. Levine's theory of conservation of structural integrity formed the theoretical framework for this descriptive study. A midwestern hospital-based hospice agency was the site for this study. All patients 18 years of age and older were included in the study. Pressure ulcer prevalence audits were done at four, eight, 12, and 18 months after protocols were outlined by the hospice staff. Results of the audits revealed prevalence rates of 14.8 percent, 8.5 percent, 13.6 percent, and 23.8 percent, at each of the aforementioned audits. 10 of 15 patients who were pressure ulcer positive were males; the sacral location was most common (seven of 19 ulcers occurred sacrally) with the ischial location being the next common (six of 19 ulcers were ischially located). No ulcers occurred above the waist or in patients below 51 years of age. Recommendations from this study urge that particular prevention attention be given to protocols which address "sitting," due to the predominance of ulcers located in the sacral and ischial regions. In addition, the author concludes that perhaps, pressure ulcers may occur in this population despite the best of efforts to prevent them.

Skin problems: epidemiology of pressure ulcers in a skilled care facility

The majority of nursing home residents have conditions that place them at risk for the development of pressure ulcers. Reported pressure ulcer prevalence rates range from 16% to 35%. Pressure ulcers are multifactorial in origin and necessitate ongoing vigilance by the entire health-care team. Associated risk factors include impairments of circulation, sensation, physical condition, nutrition, mobility, and activity. Stage I pressure ulcers frequently go unrecognized, yet their recognition is essential to prevent further damage. Comprehensive initial assessments of the skin and risk factors of pressure ulcer development at admission will allow for easier reassessment and comparison.

Pressure ulcer prevalence and incidence in a rehabilitation hospital

Pressure ulcers remain a serious health problem, especially in terms of personal suffering and economics. The study described here, conducted in a rehabilitation setting, investigated the prevalence (number of persons with pressure ulcers at a given time) and the incidence (number of persons developing pressure ulcers over a given time) of pressure ulcers. Skin assessments and risk assessments of the subjects were completed using the Braden Scale for Predicting Pressure Sore Risk. Demographic data were obtained. The prevalence rate was 25%, although there was no incidence during the time of this study. Factors associated with the prevalence of pressure ulcers are discussed.

The prevalence and incidence of pressure ulcers in the hospice setting: analysis of two methodologies

Hospice patients may be at greater risk of pressure ulcer development than most patients. This descriptive study explored the prevalence and incidence of pressure ulcers in the hospice setting, utilizing both a prospective and retrospective methodological approach. Levine's theory of the four principles of conservation formed the theoretical basis for the study, and the Braden Scale for Predicting Pressure Ulcer Risk was used for data collection. Prevalence of pressure ulcers was noted to be 13 percent in the study. Incidence of pressure ulcers was found to be zero percent using prospective methodology and 13 percent using retrospective methodology. Five of eight ulcers (62 percent) occurred within two weeks of patient death. Factors related to pressure ulcer development are presented, as well as a discussion of using research methodologies in the hospice setting. The article suggests the need for preventive protocols for skin care for patients who are at risk for pressure ulcer development.

Incidence and prediction of pressure ulcers in five patient care settings

Pressure ulcers (PU), one example of an alteration in skin integrity, remain a prominent healthcare concern in all patient care settings. Incidence refers to the number of "new cases occurring over a given time period" (NPUAP, 1989, p. 26). Adult patients (n = 190) in five patient care settings who were assessed to be free of PUs on admission were followed over a specified period of time to assess the incidence of pressure ulcer development for each setting. Subjects each had a skin assessment, along with a risk assessment utilizing the Braden Scale. A demographic data form was also completed on each subject. Pressure ulcers developed post-admission in 18 (9%) patients, 11 of whom were acute care patients and eight of whom were patients in skilled care. No patients developed pressure ulcers in the rehabilitation, home care, or hospice settings. Incidence for acute care was 15% and 28% in skilled care. Braden predictor scores were also recommended for each setting and factors associated with pressure ulcer development were discussed.

Tissue plasminogen activator: hospital experience

Tissue plasminogen activator (t-PA) is administered safely and efficiently in the treatment of acute myocardial infarction (MI). A study of 74 patients administered t-PA for acute MI associated with a low complication rate showed an acceptable patency rate, and a good outcome.