Assessment of a prognostic biochemical indicator of nutrition and inflammation for identification of pressure ulcer risk

BACKGROUND

Pressure ulcers represent a major cost to the healthcare systems of the world but preventative measures are expensive and could be better targeted. Current risk screening mechanisms are often subjective and could be improved.

AIMS

To evaluate whether a biochemical assessment tool (Prognostic Inflammatory and Nutritional Index; PINI) based on measurement of albumin, alpha1-acid glycoprotein, C-reactive protein, and prealbumin is of value in estimating the prognosis of patients with pressure ulcers of European Pressure Ulcer Advisory Panel grade 1 and above.

METHODS

Serum samples were collected from patients participating in a clinical trial of a pressure ulcer preventing mattress. These were analysed for the markers listed above and the PINI calculated. PINI was then evaluated against patient outcome.

RESULTS

A statistically significant difference between PINI values in patients whose pressure ulcers improved and those whose ulcers worsened was found in parametric testing, but significance was not achieved in non-parametric testing. A receiver operating characteristic plot showed the PINI was superior to chance in estimating prognosis.

CONCLUSIONS

The PINI appears to offer a potential route to improving pressure ulcer risk estimation and thus allocation of scarce equipment to improve prevention.

Dietary determinants of post-menopausal bone loss at the lumbar spine: a possible beneficial effect of iron

INTRODUCTION

Previous studies suggesting different effects of diet on post-menopausal bone loss may have given conflicting results because they sometimes failed to exclude confounding conditions or used imprecise methodology.

DESIGN

To identify dietary determinants of bone loss from the lumbar spine after menopause in women not taking hormone replacement who developed no evidence of spondylotic or sclerotic degenerative disease, forty-three women were followed with repeated (mean = 12) measurements of bone mineral density (BMD) at L2-4 for 11-14 years. Eleven developed evidence suggestive of degenerative disease and were excluded. Diet was assessed at the beginning of the study and 2.5 years later using 3-day and 7-day periods of weighed intakes. Nutrients estimated were: carbohydrate, fat, protein, fibre, calcium, magnesium, iron, phosphorus, copper, zinc and six vitamins. We tested the ability of diet to predict post-menopausal bone loss using stepwise regression.

RESULTS

Each woman's BMD change was described by a single coefficient after log transformation of the BMD data. The best model for BMD loss including dietary factors alone had two significant determinants: daily energy or protein (p=0.0003) intake was adverse, while dietary iron (p=0.002) was predictive of bone maintenance, an effect that persisted if iron was expressed as a ratio to energy intake. Adding body mass index to the model increased the goodness of fit (R (2)adj rose from 0.33 to 0.42) without affecting the statistical significance of the dietary determinants.

CONCLUSIONS

Diet may influence bone loss after menopause, with dietary iron (or an associated factor) possibly having a protective effect on bone at the spine.

Evidence-based practice and support surfaces: are we throwing the baby out with the bath water?

OBJECTIVE

This study aimed to explore aspects of the effectiveness of three pressure-redistributing support surfaces in routine clinical practice.

METHOD

A non-randomised prospective cohort study was used, with skin outcomes reported for 219 subjects at risk of pressure ulcer development.

RESULTS

Few instances of new pressure damage were observed; these related to specific clinical issues, such as incontinence and inadequate use of cushions when sitting. Of the 77 subjects (33.3%) with pressure ulcers on recruitment into the study, most (n=70) either improved or remained unchanged following allocation of the support surface.

CONCLUSION

Cohort studies do not indicate the efficacy of an intervention but may give an indication of effectiveness--that is, the clinical outcomes that may be observed in routine clinical practice.

Using image analysis to determine cause, severity, status and healing prognosis in wound management

It is vital to evaluate the visual appearance of a wound when considering potential management options. However, where human vision lacks precision, image analysis has been shown to offer a more reliable method of assessment.

Genotypic heterogeneity and clinical phenotype in triple A syndrome: a review of the NIH experience 2000-2005

Triple A syndrome (AAAS, OMIM#231550) is an autosomal recessive condition characterized by adrenal insufficiency, achalasia, alacrima, neurodegeneration and autonomic dysfunction. Mutations in the AAAS gene on chromosome 12q13 have been reported in several subjects with AAAS. Over the last 5 years, we have evaluated six subjects with the clinical diagnosis of AAAS. Three subjects had mutations in the AAAS gene-- including one novel mutation (IVS8+1 G>A)-- and a broad spectrum of clinical presentations. However, three subjects with classic AAAS did not have mutations in the AAAS gene on both alleles. This finding supports the notion of genetic heterogeneity for this disorder, although other genetic mechanisms cannot be excluded.

Patient repositioning revisited

Everyone agrees that regular patient repositioning helps to prevent pressure ulceration. This paper describes the benefits and disadvantages, as cited in the literature, of the various patient positions used in clinical practice.

A randomised controlled trial comparing Drawtex with standard dressings for exuding wounds

OBJECTIVE

This randomised controlled clinical trial compared a capillary dressing (Drawtex, now rebranded as Vibriant RCD [Vibriant Technology Services]) with routine practice for exuding wounds greater than 2.5 x 2.5 cm.

METHOD

The target population was 300 control and 300 test subjects across three sites in the UK, but recruitment difficulties resulted in only 125 patients being evaluable. Wound progress was recorded by nurses' perception of the progress of wound healing and by objective digital imaging. In the final analysis digital images were randomised (in time order) and a panel of nurses who were not otherwise involved in the research project graded the wound's progress.

RESULTS

After deconvolution of the data, the subjective (nurse perception) method of evaluation determined that the new dressing resulted in wound improvement in 12.7% more patients than did routine practice, but the blinded assessment method (based on the digital images) showed that routine practice was better by 6.6%.

CONCLUSION

Evaluation of wound progress is clearly difficult. Human nature makes us favour novelty if we believe it is going to be better. Making interpretation more objective removed that bias and did not demonstrate a significant advantage for the test dressing. The findings suggest that unblinded assessment by trial nurses is unacceptable on its own. Blinded assessments may miss finer nuances of wound progression, but are likely to be more accurate. The authors suggest that the true result lies somewhere in the middle, with the trial dressing likely to be as effective as, but not more effective than, a standard dressing.

Effect of lifestyle changes on whole-body protein turnover in obese adolescents

OBJECTIVE

To investigate the effect of lifestyle changes on whole-body protein turnover (WBPT) in obese adolescents.

DESIGN/METHODS

Randomized and controlled nonpharmacological intervention study of WBPT in obese adolescents using stable isotope dilution techniques.

SUBJECTS AND MEASUREMENTS

We studied a total of 21 adolescents (11 boys and 10 girls, matched for their pubertal status) of which 15 were obese (age=15.8+/-0.4 y old and BMI=38.6+/-3.3 kg/m(2)) and six were lean controls (age=16.0+/-0.4 y old and BMI=21.3+/-1.2 kg/m(2)). The obese subjects were subjected to a randomized controlled lifestyle intervention program that involved moderate physical activity and diet changes for 3 months. A group of lean age-matched subjects was also studied at baseline to compare the WBPT in obese and lean adolescents. The studies were performed during a primed, continuous infusion of L-[1-(13)C]leucine. Leucine appearance rate (Leu Ra) was used as an index of whole protein breakdown and the nonoxidative portion of leucine disposal (NOLD) as an index of whole-body protein synthesis.

RESULTS

The obese groups showed significantly higher body mass index (BMI), fat mass (FM), percent body fat (%BF), fat-free mass (FFM), resting energy expenditure (REE) and WBPT compared to the lean controls. The intervention program resulted in a redistribution of the parameters of body composition without apparent changes in BMI or body weight. There was a significant decrease in WBPT in the obese intervention group, but not in the obese control group. Insulin levels also decreased significantly in the obese group after intervention but not in the obese control group, whereas the glucose concentrations remained normal in all groups at baseline and also after intervention/or control.

CONCLUSIONS

Results from the current study suggest: (i). abonormalities of protein metabolism occur early in the clinical course of obesity and (ii). these abnormalities are modifiable by moderate lifestyle changes in obese adolescents. The mechanism for these changes in WBPT in obese adolescents as well as their impact on specific cardiovascular risk factors and turnover of specific proteins will require further investigation.

A comparison of healing rates on two pressure-relieving systems

The authors have previously reported the preliminary results of a randomized-controlled trial comparing the relative efficacy of two pressure-relieving systems: Huntleigh Nimbus 3 and Aura Cushion, and Pegasus Cairwave Therapy System and ProActive Seating Cushion (Russell et al, 2000). Although both the mattresses and cushions were effective treatments for pressure ulcers, the Huntleigh equipment was demonstrated to be statistically more effective for heel ulcers, but no differences were demonstrated for sacral ulcers. This article gives a more detailed analysis of the 141 patients assessed using computerized-image analysis of the digital images of sacral ulcers captured during the trial and specifically discusses the healing rates and other patient characteristics. Ninety-eight per cent of ulcers examined were deemed superficial (Torrance grade 2a, 2b, 3). Precision of image analysis assessed by within- and between-batch coefficients of variation was excellent: calibration CV 0.93-1.84%; area CV 4.61-5.72%. The healing rates on the two mattresses were not shown to be statistically different from each other.

Risk factors for antibiotic-resistant infection and treatment outcomes among hospitalized patients transferred from long-term care facilities: does antimicrobial choice make a difference?

A prospective observational study of 153 patients transferred from long-term care facilities and admitted to acute-care hospitals who had microbiologically confirmed infections was undertaken to determine the risk factors, outcomes, and resource use associated with isolation of antibiotic-resistant bacteria (ARB). Eighty patients (52%) were infected with ARB. In multivariable logistic analysis, the presence of a feeding tube (odds ratio, 3.0) or polymicrobial infection (odds ratio, 4.6) was associated with isolation of ARB. Forty-nine percent of patients infected with ARB received an initial antibiotic regimen to which their isolate was not susceptible. Fifty-one percent of all patients had a change in their antibiotic regimen during their hospital course. For these patients, length of stay, number of days of antibiotic therapy, and cost of hospitalization were significantly higher. However, neither infection with ARB nor appropriateness of initial treatment regimen was significantly related to outcome or resource use.

Randomized comparison trial of the RIK and the Nimbus 3 mattresses

A randomized comparison trial was carried out at Queen's Hospital, Burton-on-Trent, to compare patient outcomes on the RIK mattress (KCI) and the Nimbus 3 mattress (Huntleigh Healthcare). One hundred and fifty-eight patients, who were assessed to be at particular risk of development of pressure ulcers using the Waterlow score (85 on RIK mattress, 83 on Nimbus), completed the trial. There were no statistically significant differences in baseline parameters at recruitment or pressure ulcer progress. Lack of difference can be as useful as evidence of superiority. Other factors such as nursing interventions required accessible equipment, and costs are important when making equipment choices. For a significant proportion of patients, a static (RIK) mattress can be as effective as an active (Nimbus 3) mattress for management of pressure ulcers.

Epithelioid leiomyosarcoma of the uterus with oncocytic change

We report on a rare case of epithelioid leiomyosarcoma of the uterus with oncocytic change and aggressive clinical behavior. The tumor arose in the left lateral wall of the uterus and measured 22 cm in greatest dimension. Histologically, it consisted of solid sheets of round and polygonal cells displaying a homogeneously eosinophilic cytoplasm and pleomorphic nuclei with prominent nucleoli. Six mitotic figures were found per 10 high-power fields in the most mitotically active areas, and focal tumor cell necrosis was present elsewhere. Under electron microscopy, numerous normal-appearing mitochondria and occasional bundles of microfilaments with focal densities were noted in the tumor cell cytoplasm, and poorly-formed external basal lamina and occasional pinocytic vesicles were found on the cell membrane of some tumor cells.

Overview of research to investigate pressure-relieving surfaces

Pressure-relieving equipment plays a key role in the prevention and treatment of pressure ulcers. Every year an increasing amount of equipment is launched on to the market. The efficacy of this equipment is traditionally qualified with interface pressure and case studies, but rarely with randomized controlled trials. With the advent of The New NHS: Modern, Dependable (Department of Health (DoH), 1997) and Pressure Ulcer Risk Assessment and Prevention (National Institute for Clinical Excellence (NICE), 2001), a clinical governance system has started to be put into place and hopefully more evidence will be produced by the manufacturers and the NHS. With some 200 different types of mattresses on the market, emphasis needs to be placed on good quality randomized clinical trials to establish effectiveness of what can be costly equipment. This article gives an overview of how, historically, pressure-relieving mattresses were marketed on case studies and interface measurement. Recently, randomized controlled clinical trials are being used to demonstrate the efficacy of the mattress and reduction in the incidence of pressure ulcers. Seating is also an important aspect in continuing 24-hours pressure area prevention and treatment. Patient posture in a chair needs to be fully understood by the practitioner and key strategies are made in this article. Little research into seating has been undertaken and is urgently required.

Strikethrough: review of research on mattress cover performance

During the past few years there have been increasing concerns regarding the performance of pressure-reducing foam mattress covers. Initially, a small number of people observed these problems. However, recently, many more people have begun to identify similar problems with their covers. This article is the result of a collaboration between Medical Support Systems and members of the editorial board of the British Journal of Nursing Tissue Viability Supplement. Medical Support Systems commissioned research from Nottingham Trent University and Cardiff University. The research findings were then passed to members of the editorial board for consideration and the development of this article. The article will present the rationale for the research and the results will be highlighted. It is hoped that it will help inform us and assist those currently working towards a resolution of this problem. The full benefit of this new information will only be felt after an extended debate of not only the results, but also their wider implications.

VACUTEX capillary action dressing: a multicentre, randomized trial

This article describes a preliminary study comparing the effect of VACUTEX capillary action wound dressing vs standard protocol for the treatment of sloughy and necrotic wounds. The study was carried out over a period of 5 months. Randomization was computer generated and batches of trial numbers and dressing allocation were delivered to each of the three study sites, sealed in opaque envelopes to ensure blinding of allocation. A total of 35 patient participants were recruited (17 VACUTEX 14, standard protocol, three withdrew, one died). All participants gave their consent to enter the study. All participants were assessed and photographs were taken on days 1, 8, 15, 22 and 29. Nursing assessments of size, site, depth, severity, tissue type of wound and causation were collected, as were demographic factors including mental status, primary/associated medical history, weight, height, and ethnic origin.

Clinical assessment of a chemosensitivity assay as a treatment planning tool for dogs with cancer

This study evaluated the clinical utility of a commercially available chemosensitivity assay. In the first part of the study, tumor tissues from dogs with various malignancies were tested, and the dogs were treated with a mitoxantrone/cyclophosphamide combination protocol. Tumor response was evaluated and compared to the predicted response. Assay results were not a significant predictor of clinical response to chemotherapy or of survival time. In the second part of the study, assay results were used to direct therapy in dogs with refractory lymphoma. There was no significant correlation (p equals 0.323) between predicted response and case outcome.

The importance of patients' nutritional status in wound healing

Good nutritional status is essential for wound healing to take place. Ignoring nutritional status may compromise the patient's ability to heal and subsequently prolong the stages of wound healing. Glucose provides the body with its power source for wound healing and this give energy for angiogenesis and the deposition of new tissue. Therefore, it is vital that the body receives adequate amounts of glucose to provide additional energy for wound healing. Fatty acids are essential for cell structure and have an important role in the inflammatory process. Wound healing is dependent on good nutrition and the presence of suitable polyunsaturated fatty acids in the diet. Protein deficiency has been demonstrated to contribute to poor healing rates with reduced collagen formation and wound dehiscence. High exudate loss can result in a deficit of as much as 100g of protein in one day. This subsequently needs to be replaced with a high protein diet. Vitamins are also important in wound healing. Vitamin C deficiency contributes to fragile granulation tissue. There is a correlation between low serum albumin and body mass index (BMI) and the development of pressure ulcers. Also, low serum albumin and high Waterlow score have a positive association. The body automatically renews tissue while we are asleep but this does not mean that protein synthesis does not take place during our wakeful hours. Holistic assessment of nutrition and early detection of malnutrition are essential to promote effective wound healing.

Phase III randomized trial of amifostine as a radioprotector in head and neck cancer

PURPOSE

Radiotherapy for head and neck cancer causes acute and chronic xerostomia and acute mucositis. Amifositine and its active metabolite, WR-1065, accumulate with high concentrations in the salivary glands. This randomized trial evaluated whether amifostine could ameliorate these side effects without compromising the effectiveness of radiotherapy in these patients.

PATIENTS AND METHODS

Patients with previously untreated head and neck squamous cell carcinoma were eligible. Primary end points included the incidence of grade > or =2 acute xerostomia, grade > or =3 acute mucositis, and grade > or =2 late xerostomia and were based on the worst toxicity reported. Amifostine was administered (200 mg/m(2) intravenous) daily 15 to 30 minutes before irradiation. Radiotherapy was given once daily (1.8 to 2.0 Gy) to doses of 50 to 70 Gy. Whole saliva production was quantitated preradiotherapy and regularly during follow-up. Patients evaluated their symptoms through a questionnaire during and after treatment. Local-regional control was the primary antitumor efficacy end point.

RESULTS

Nausea, vomiting, hypotension, and allergic reactions were the most common side effects. Fifty-three percent of the patients receiving amifostine had at least one episode of nausea and/or vomiting, but it only occurred with 233 (5%) of 4,314 doses. Amifostine reduced grade > or =2 acute xerostomia from 78% to 51% (P<.0001) and chronic xerostomia grade > or = 2 from 57% to 34% (P=.002). Median saliva production was greater with amifostine (0.26 g v 0.10 g, P=.04). Amifostine did not reduce mucositis. With and without amifostine, 2-year local-regional control, disease-free survival, and overall survival were 58% versus 63%, 53% versus 57%, and 71% versus 66%, respectively.

CONCLUSION

Amifostine reduced acute and chronic xerostomia. Antitumor treatment efficacy was preserved.

The Arabidopsis COMATOSE locus regulates germination potential

Mutation of the COMATOSE locus in Arabidopsis results in a marked reduction in germination potential. Whilst the morphology of comatose (cts) embryos is not altered, physiological analysis reveals that mature cts seeds do not respond to gibberellin. Prolonged chilling of imbibed seeds only partially restores germination potential, and seeds do not after ripen. Genetic analysis shows that the cts phenotype is expressed in the embryo and phenotypic differences between wild-type and mutant plants were not observed during other stages of plant growth and development. Therefore cts represents a new class of mutant, with a specific lesion that results in severely impaired germination potential. Genetic interactions were analysed between cts and loci that regulate embryo maturation, and abscisic acid biosynthesis and perception. Results from these studies showed that the cts mutant phenotype required the wild-type action of these loci, and suggested that CTS exerts a repressive function on these loci. A model is presented postulating that CTS promotes increased germination potential, and represses embryo dormancy. These functions of CTS may result in the removal of embryo dormancy as a prerequisite to germination.

Fever and pneumonia in a steroid treated patient with systemic lupus erythematosus

Systemic lupus erythematosus is reported to affect the lungs in almost half of patients, but pleuritis is most commonly encountered. Acute pneumonitis is an uncommon but recognized manifestation of SLE. Infection and drug reactions are more frequently diagnosed. The case discussed below permits consideration of the dilemmas typical of the SLE patient who presents with an acute pulmonary process.