Multilayered silicone foam dressings potentially used for preventing recurrence of pressure injuries: A bench-to-clinical bedside study

AIM

This study aimed to evaluate the use of multilayered silicone foam dressings for preventing pressure injury recurrence by reducing friction, pressure, and shear force at skin sites where previous pressure injuries closed.

METHODS

A bench-to-clinical bedside investigation was conducted. In the bench, three multilayered silicone foam dressings were assessed. The simulated skin-shearing test consisted of a weight, a polyurethane-based skin model containing a three-axis tactile sensor, dressings, a table covered with bedsheets, and a mechanical tester. The mechanical tester simultaneously measured the interface friction force and internal shear force and pressure continuously during skin model movements. No-dressing was used as a negative control. In clinical bedside assessments, a multilayered silicone foam dressing with lower friction and shear force was applied to two bedridden patients. Photographs and ultrasound images were used to assess the recurrence of pressure injury.

RESULTS

The dressings significantly reduced friction, pressure, and shear force compared with these parameters in the negative control. No significant differences in the shear forces between the dressings were observed. One clinical case did not develop a new pressure injury reaching the dermis. However, the second case developed a new pressure injury within one month after the first pressure injury closed.

CONCLUSION

Our bench-to-clinical bedside study revealed that multilayered silicone foam dressings can potentially prevent pressure injury recurrence.

Japanese clinical practice guidelines for aspiration and pharyngeal residual assessment during eating and swallowing for nursing care

AIM

This clinical practice guideline aims to provide and recommend methods of assessing aspiration and pharyngeal residue during eating and swallowing and methods of selecting and implementing nursing care for adults to prevent the development of aspiration pneumonia through early and appropriate management of oropharyngeal dysphagia.

METHODS

In April 2018, the Japan Academy of Nursing Science established the Supervisory Committee in Nursing Care Development/Standardization Committee to develop clinical practice guidelines for aspiration and pharyngeal residual assessment during eating and swallowing for nursing care. This clinical practice guideline was developed according to the Minds Manual for Guideline Development 2017, with the aim of providing a specific pathway for nurses to determine the policy for selecting management for oropharyngeal dysphagia based on research evidence and multifaceted factors including the balance of benefits and harms and patients' values.

RESULTS

Based on the 10 clinical questions related to assessment by physical assessment, the Repetitive Saliva Swallowing Test, Modified Water Swallowing Test, Food Test, cervical auscultation, observation using an ultrasound diagnostic device, and an endoscope, 10 recommendations have been developed. Eight recommendations have been evaluated as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) 2C, and the other two have been evaluated as no GRADE.

CONCLUSION

The first reliable clinical practice guideline has been produced from an academic nursing organization that focuses on assessment for nursing care and incorporates the latest findings.

Increased temperature at the healed area detected by thermography predicts recurrent pressure ulcers

Preventing recurrent pressure ulcers is an important challenge in healthcare. One of the reasons for the high rate of recurrent pressure ulcers is the lack of assessment methods for their early detection. Therefore, this study aimed to determine the thermographic characteristics of the healed area and to consider the predictive validity of thermographic images for recurrent pressure ulcers within a 2-week period. This observational study was conducted at a long-term care facility in Japan between July 2017 and February 2019 among patients whose pressure ulcers had healed. Thermographic images of the healed area were recorded once a week until recurrence or until the end of the study. We enrolled 30 participants, among whom 8 developed recurrent pressure ulcers. The generalised estimation equation revealed that the thermographic finding of increased temperature at the healed area compared to that of the surrounding skin was significantly associated with recurrent pressure ulcers (odds ratio: 101.13, 95% confidence interval: 3.60-2840.77, p = .007); the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio for recurrent pressure ulcers within 2 weeks were 0.80, 0.94, 0.62, 0.97, 12.9 and 0.2, respectively. Our thermographic findings revealed that the temperature of the healed area was higher than that of the surrounding skin; this could be a useful predictor of pressure ulcer recurrence within 2 weeks, even in the absence of macroscopic changes.

Diagnostic accuracy of ultrasound examination in detecting aspiration and pharyngeal residue in patients with dysphagia: A systematic review and meta-analysis

AIM

To estimate diagnostic accuracy of ultrasonography for detecting aspiration and pharyngeal residue in patients with dysphagia.

METHODS

A systematic search was conducted in MEDLINE (via PubMed), CINAHL, EMBASE, Ichushi-Web, and Cochrane Library databases to identify articles that showed diagnostic accuracy of ultrasonography for detecting aspiration and residue published in English and Japanese until August 2019. Cross-sectional studies, case-control studies, and cohort studies were included. The diagnostic accuracy results were extracted and the pooled estimated sensitivity and specificity were calculated. The risk of bias of the studies was assessed using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies 2. The certainty of the evidence was assessed using the Grades of Recommendation Assessment, Development, and Evaluation methodology.

RESULTS

Five studies were included in this review. The pooled estimated sensitivity and specificity for detecting aspiration were 0.82 (95% CI: 0.72-0.89) and 0.87 (95% CI: 0.81-0.92), respectively. One study was included that evaluated ultrasound assessments of pharyngeal residue. The sensitivity and specificity were 0.62 (95% CI: 0.32-0.86) and 0.67 (95% CI: 0.22-0.96), respectively. The certainty of the evidence was low and very low for the diagnostic accuracy of aspiration and pharyngeal residue, respectively.

CONCLUSION

Ultrasound is a non-invasive method with good sensitivity and specificity in detecting aspiration as well as reference standards. While risk of bias and small number of studies limited the strength of this systematic review, our results suggested that ultrasound examination was useful as a bedside screening tool for detecting aspiration.

Effects of inhibition of lymphangiogenesis by the vascular endothelial growth factor receptor 3 (VEGFR-3) inhibitor, MAZ51 on full thickness wounds in mice

We herein used MAZ51 to inhibit lymphangiogenesis and aimed to clarify the effect of inhibition of lymphangiogenesis on wound healing. BALB/c male mice were divided into two groups: the control group which was injected the dimethyl sulfoxide (DMSO), the experiment group was injected MAZ51 in the DMSO. All wounds were observed for 15 days and the wound areas were measured. Tissue samples were harvested on day 3, 7, 9, 11, 13 and 15, and subjected to immunostaining of blood vessels and lymphatic vessels. There are no significant differences between two groups in the wound area, the number of blood vessels and lymphatic vessels. The number of blood vessels peaked on day 7 in both groups as with previous studies, while the number of lymphatic vessels peaked on 13 or 15 in both groups. This result revealed delayed lymphangiogenesis in comparison with previous studies. The wound healing process in the control and experiment groups were similar, but both groups seemed delayed lymphangiogenesis comparing with previous studies. Injections of MAZ51 or/and DMSO did not affect angiogenesis, while they may affect lymphangiogenesis.

Stability of Skin Microbiome at Sacral Regions of Healthy Young Adults, Ambulatory Older Adults, and Bedridden Older Patients After 2 Years

OBJECTIVE

The sacral skin of bedridden older patients often develops a dysbiotic condition. To clarify whether the condition changes or is sustained over time, we analyzed the skin microbiome and the skin physiological functions of the sacral skin in patients who completed our 2017 study.

METHODS

In 2019, we collected the microbiome on the sacral region and measured sacral skin hydration, pH, and transepidermal water loss from 7 healthy young adults, 10 ambulatory older adults, and 8 bedridden older patients, all of whom had been recruited for the 2017 study. For microbiome analysis, 16S ribosomal RNA-based metagenomic analysis was used.

RESULTS

No significant differences in the microbial compositions or any alpha diversity metrics were found in the bedridden older patients between the 2017 and 2019 studies; the higher gut-related bacteria were still observed on the sacral skin of the bedridden older patients even after 2 years. Only skin pH showed a significant decrease, approaching normal skin condition, in the bedridden older patients over 2 years.

CONCLUSION

This study indicated that gut-related bacteria stably resided in the sacral skin in bedridden patients, even if the patient had tried to restore skin physiological functions using daily skin care. We propose the importance of skin care that focuses more on bacterial decontamination for the sacral region of bedridden older patients, in order to decrease the chances of skin/wound infection and inflammation.

Skin Physiology and its Microbiome as Factors Associated with the Recurrence of Pressure Injuries

BACKGROUND

Preventing recurrent pressure injuries (RPIs) is one of the important challenges faced in healthcare, but the risk factors of RPIs have not been fully revealed. This study aims to explore factors associated with RPIs, by focusing on skin physiology and its microbiome as local factors crucial for the health of healed tissue after pressure injury healing.

METHODS

This prospective observational study was conducted in a long-term care facility in Japan with patients whose PIs had healed within 1 month. Skin physiology was evaluated by stratum corneum (SC) hydration, pH, and transepidermal water loss. Skin bacteria was collected by tape stripping, followed by 16S ribosomal RNA-based metagenomics analysis. These parameters were evaluated every two weeks over a period of six weeks.

RESULTS

A total of 30 patients were included in this study, and 8 patients (26.7%) had an RPI within 6 weeks. In this study, significantly lower SC hydration and a higher rate of Staphylococcus species on the healed site were found in the RPI group.

DISCUSSION

A high rate of RPIs (about one in four) points out the necessity of a further care strategy on the healed PIs. Lower skin hydration and/or the increase in Staphylococcus bacteria may have a potential to be used as a biomarker for the prediction of RPIs, or may be an intervention point for the prevention of RPIs by, for example, skin cleansing with moisturizing care.

Distinct Skin Microbiome and Skin Physiological Functions Between Bedridden Older Patients and Healthy People: A Single-Center Study in Japan

With the increase in the older populations, the number of bedridden older patients is becoming a matter of concern. Skin microbiome and skin physiological functions are known to change according to lifestyle and community; however, such changes in case of movement- and cleaning-restricted bedridden older patients have not yet been revealed. To address this issue, we analyzed skin microbiome and skin physiological functions, including pH, hydration, sebum level, and transepidermal water loss (TEWL), of bedridden older patients, compared with those of ambulatory older and young individuals. For this analysis, we enrolled 19 healthy young and 18 ambulatory older individuals from the community and 31 bedridden older patients from a single, long-term care hospital in Japan. The area of interest was set to the sacral (lower back) skin, where pressure injuries (PIs) and subsequent infection frequently occurs in bedridden older patients. We observed a higher number of gut-related bacteria, fewer commensals, higher skin pH, and lower TEWL on the sacral skin of bedridden older patients than on that of young or ambulatory older individuals. In addition, we observed that 4 of the 31 bedridden older patients developed PIs during the research period; a higher abundance of pathogenic skin bacteria were also observed inside the PI wounds. These findings imply distinct skin microbiome and skin physiological functions in bedridden older patients in comparison with healthy individuals and may suggest the need for more stringent cleaning of the skin of bedridden older patients in light of the closeness of skin and wound microbiome.

Development of recurrent pressure ulcers, risk factors in older patients: a prospective observational study

Objective:

Prevention of recurrent pressure ulcers (PU) is one of the most important challenges in wound care, furthermore, the risk factors for recurrent PUs are still not fully understood. This study aimed to explore the risk factors for recurrent PU development within two weeks, including biophysical skin properties, pro-inflammatory cytokine (tumour necrosis factor [TNF]-α) levels and bacterial species, in older patients.

Method:

This prospective study was conducted in a long-term care facility with patients whose PU had healed within two months. Biophysical skin properties were evaluated by stratum corneum hydration, pH, sebum content and transepidermal water loss. TNF-α level was measured using skin blotting. Skin bacteria were collected using tape stripping and determined by species-specific gene amplification. These parameters, along with Braden scale and interface pressure, were evaluated every two weeks for a total period of eight weeks. A penalised generalised estimating equation analysis was used to determine the risk factors for recurrent PUs.

Results:

In total, 20 patients were included in this study, with 57 observations. Of these, recurrent PU was seen in eight observations. Elevation of pH (p=0.049; odds ratio [OR] per 1 unit=3.91, 95% confidence interval [CI]:1.01–15.15), presence of Acinetobacter spp. (p=0.039; OR versus culture-negative=6.28, 95%CI:1.10–35.86) and higher interface pressure (p=0.008; OR per 1 mmHg=1.06, 95%CI:1.01–1.10) on the healed PU were significantly related to the development of recurrent PU.

Conclusion:

Higher pH, existence of Acinetobacter spp. and higher interface pressure on the site of the healed PU were associated with the development of recurrent PUs in older patients undergoing conservative treatments.

Pre-collecting lymphatic vessels form detours following obstruction of lymphatic flow and function as collecting lymphatic vessels

Background

Previously, we showed that lymphatic vessels (LVs) formed detours after lymphatic obstruction, contributing to preventing lymphedema. In this study, we developed detours using lymphatic ligation in mice and we identified the detours histologically.

Methods and results

Under anesthesia, both hindlimbs in mice were subcutaneously injected with Evans blue dye to detect LVs. We tied the right collecting LV on the abdomen that passes through the inguinal lymph node (LN) at two points. The right and left sides comprised the operation and sham operation sides, respectively. Lymphography was performed to investigate the lymph flow after lymphatic ligation until day 30, using a near-infrared fluorescence imaging system. Anti-podoplanin antibody and 5-ethynyl-2’-deoxyuridine (EdU) were used to detect LVs and lymphangiogenesis. Within 30 days, detours had developed in 62.5% of the mice. Detours observed between two ligation sites were enlarged and irregular in shape. Podoplanin⁺ LVs, which were located in the subcutaneous tissue of the upper panniculus carnosus muscle, connected to collecting LVs at the upper portion from the cranial ligation site and at the lower portion from the caudal ligation site. EdU⁺ cells were not observed in these detours. The sham operation side showed normal lymph flow and did not show enlarged pre-collecting LVs until day 30.

Conclusions

Detours after lymphatic ligation were formed not by lymphangiogenesis but through an enlargement of pre-collecting LVs that functioned as collecting LVs after lymphatic ligation. Further studies are required to explore the developmental mechanism of the lymphatic detour for treatment and effective care of lymphedema in humans.

Efficacy of Honeydew Honey and Blossom Honey on Full-thickness Wound Healing in Mice

INTRODUCTION

The wound healing properties of honey, including blossom honey, are well known; however, the effects of honeydew honey during the wound healing process have not yet been investigated and thus remain unclear.

OBJECTIVE

This study compares the effects of honeydew honey with those of blossom honey.

MATERIALS AND METHODS

A total of 140 mice were divided into 2 control groups, which received either a hydrocolloid dressing (HCD; n = 22) or gauze (n = 22), and 4 experimental groups: honeydew honey (n = 23), Acacia honey (n = 23), Manuka honey (n = 22), and Japanese Pharmacopoeia honey (n = 28). Two circular full-thickness wounds were made and measured for 14 days. Each wound in the experimental groups was treated with 0.1 mL of honey and covered with gauze. Dressings in the control and experimental groups were changed daily.

RESULTS

The wounds in all of the honey groups and the HCD group were moist by day 14, while those in the gauze group were dry. The ratio of wound area to initial wound area and the number of inflammatory cells decreased during the inflammatory phase in all honey groups. However, the honey groups exhibited reepithelialization rates of < 40%, numerous neutrophils, weak wound contraction, and impaired collagen deposition in wounds after day 11.

CONCLUSIONS

These results suggest honeydew honey and blossom honey both exert anti-inflammatory effects during the inflammatory phase. However, all of the honeys examined were less effective at promoting full-thickness wound healing than the controls. Further studies are warranted.

Changes in dermal structure and skin oxidative stress in overweight and obese Japanese males after weight loss: a longitudinal observation study

BACKGROUND/PURPOSE

Previous studies have reported decreased dermal echogenicity and increased skin oxidative stress in overweight males. However, it is unknown whether these skin parameters of overweight and obese people are similar to those of individuals exhibiting a normal body weight following weight loss. The purpose of this study was to (1) compare the changes in the dermal structure parameters and levels of skin oxidative stress before and after weight loss in overweight and obese people in Japan and (2) to clarify how these aspects changed when body weight would be reduced to normal body weight.

METHODS

Male volunteers with a body mass index of ≥25 kg/m² were recruited. The dermal structure was visualized and dermal echogenicity and thickness were measured using ultrasound scanners. The mRNA expression level of heme oxygenase-1 in the hair follicles was quantitatively analyzed as a marker of skin oxidative stress.

RESULTS

When overweight individuals in their 20s to 30s reduced their weight to normal, decreased dermal thickness in the abdominal region was observed in 50% of the subjects; however, no increase in dermal echogenicity was observed. A decrease in dermal thickness and an increase in dermal echogenicity in the thighs was observed in 83.3% of the subjects. No decrease in the level of dermal oxidative stress was observed.

CONCLUSION

The dermal structure in the thighs of overweight young individuals can be improved to the level of the structure in those of normal body weight individuals following weight loss.

Establishing a new appropriate intramuscular injection site in the deltoid muscle

It is becoming increasingly important for clinicians to identify a safer intramuscular (IM) injection site in the deltoid muscle because of possible complications following the vaccine administration of IM injections. We herein examined 4 original IM sites located on the perpendicular line through the mid-acromion to establish a safer IM injection site. Thirty healthy volunteers participated in this study and the distances from our 4 IM sites to some anatomical landmarks on their left arms were measured. Ultrasonography (US) was also performed to measure the thickness of the deltoid muscle and identify the posterior circumflex humeral artery (PCHA) along the course of the axillary nerve. Subcutaneous thickness was measured using 2 methods: measuring the skin thickness with caliper after pinching the skin, and with US. The results obtained revealed that the intersection between the anteroposterior axillary line (the line between the upper end of the anterior axillary line and the upper end of the posterior axillary line) and the perpendicular line from the mid-acromion was the most appropriate site for IM injections because it was distant from the axillary nerve, PCHA, and subdeltoid/subacromial brusa. At this site, depth of needle insertions was 5 mm greater than the subcutaneous thickness at a 90° angle, which was sufficient to penetrate subcutaneous tissue in both sexes. Subcutaneous thickness can be assessed with almost the same accuracy by US or measuring with calipers after pinching the skin. The results of the present study support the improved vaccine practice for safer IM injections.

Effectiveness of Changing the Application of Japanese Honey to a Hydrocolloid Dressing in Between the Inflammatory and Proliferative Phases on Cutaneous Wound Healing in Male Mice

INTRODUCTION

The aim of this study was to investigate the effects of changing the application of Japanese honey to a hydrocolloid dressing (HCD) in between the inflammatory and proliferative phases on cutaneous wound healing in 8-week-old, BALB/cCrSlc male mice.

MATERIALS AND METHODS

Mice were divided into 4 groups: acacia honey followed by a HCD, buckwheat flour honey followed by a HCD, Chinese milk vetch honey followed by a HCD, and a HCD alone (control group). All mice received 2 full-thickness wounds on both sides of the dorsum using a Disposable Biopsy Punch. The wounds of the control group were covered with a HCD, whereas wounds in the other groups were treated with 0.1 mL of the relevant type of honey until day 3 post-wound and then were covered with a HCD from days 4 to 14.

RESULTS

In the experimental groups, the wound area ratio was significantly smaller in the inflammatory phase but significantly larger in the proliferative phase. Reepithelialization, collagen deposition, and wound contraction were significantly delayed compared with those in the control group.

DISCUSSION

The re-expansion of the wounds in the proliferative phase could not be prevented, and reepithelialization, collagen deposition, and wound contraction were delayed compared with those upon the use of a HCD.

CONCLUSION

The study's authors concluded that these methods do not promote cutaneous wound healing better than the use of a HCD alone.

Evaluation of Effects of Topical Estradiol Benzoate Application on Cutaneous Wound Healing in Ovariectomized Female Mice

Estrogen promotes cutaneous wound healing in ovariectomized (OVX) female mice. However, the effects of topical estrogen application on wounds remain unclear. Therefore, the aim of this study was to compare the effects of topical estrogen application on wounds with standard treatment methods. Eight-week-old C57BL/6J female mice underwent OVX and received two full-thickness wounds four weeks later. Mice were divided into three groups: topical estradiol benzoate (EB) (0.75 μg/g/day) wound treatment, subcutaneous estradiol (E2) pellets (0.05 mg, 21 days), and topical E2 (0.01 g/day) skin application. Wound healing was observed until day 14. Wound area ratios were significantly smaller in the topical EB wound treatment group than in the subcutaneous E2 pellet group on days 1–14 (p < 0.05) and topical E2 skin application group on days 1–9 (p < 0.05). Neutrophil and macrophage numbers were significantly smaller in the topical EB wound treatment group than in the subcutaneous E2 pellet and topical E2 skin application groups on day 7 (p < 0.05). Moreover, the number of new blood vessels and ratio of myofibroblasts were significantly larger in the topical EB wound treatment group than in the subcutaneous E2 pellet and topical E2 application skin groups on day 7 (p < 0.05). These results demonstrate that the application of estrogen to wounds reduced inflammatory responses and promoted angiogenesis and wound contraction more than the two other standard treatment methods.

17β-Estradiol administration promotes delayed cutaneous wound healing in 40-week ovariectomised female mice

This study investigated the effect of 17β-estradiol on wound healing in 40-week ovariectomised female mice. Thirty-six-week-old female mice were divided into three groups: medication with 17β-estradiol after ovariectomy (OVX + 17β-estradiol), ovariectomy (OVX) and sham (SHAM). The mice received two full-thickness wounds, and the OVX + 17β-estradiol group was administered 17β-estradiol at 0·01 g/day until healing. In the OVX + 17β-estradiol group, the ratio of wound area was significantly smaller than those of the OVX and SHAM groups on days 1-3, 5, 6, 8-12 and 9-12, respectively, the numbers of neutrophils and macrophages were significantly smaller than those on days 3 and 7, the ratio of re-epithelialisation was significantly higher than those on days 3 and 11, the ratio of myofibroblasts was significantly higher than those on day 11 and smaller on day 14, and the ratio of collagen fibres was significantly larger than that of the OVX group on days 7-14. We found that 17β-estradiol administration promotes cutaneous wound healing in 40-week female mice by reducing wound area, shortening inflammatory response, and promoting re-epithelialisation, collagen deposition and wound contraction. Our results suggest that cutaneous wound healing that is delayed because of ageing is promoted by exogenous and continuous 17β-estradiol administration.

Effectiveness of indonesian honey on the acceleration of cutaneous wound healing: an experimental study in mice

The purpose of this study was to investigate the effectiveness of Indonesian honey in wound healing compared to Tegaderm hydrocolloid dressing and Manuka honey. Three groups of male mice were treated to produce 2 circular, full-thickness skin wounds on the dorsum. They were then randomly allocated to receive daily Indonesian honey, Manuka honey, or hydrocolloid (control). Macroscopic findings were observed from day 0 to 14 after wounding. Microscopic findings on days 3, 7, 11, and 14 after wounding were obtained. The ratios of wound areas for honey groups on day 3 were smaller than those of the control group. Wound areas of honey groups gradually decreased to almost the same wound area as the control group on day 14, while the control group wound area peaked on day 5 and rapidly decreased until day 14. On day 3, myofibroblasts and new blood capillaries in wound tissue of honey groups were observed, but were not seen in the control group. After day 7, microscopic findings were almost the same among the 3 groups. These results indicate that Indonesian honey is almost as effective for wound healing as Manuka honey and hydrocolloid dressing. .