Does Pressure Cause Pressure Ulcers? An Inquiry Into the Etiology of Pressure Ulcers

Nomogram model for predicting pressure injury in COPD patients using SII: a Chinese clinical study

Objectives

This study aims to investigate the association between the Systemic Immune-Inflammation Index (SII) and the development of pressure injuries (PI) in patients with chronic obstructive pulmonary disease (COPD). Additionally, a nomogram model based on the SII will be constructed to predict the probability of pressure injury (PI) occurrence in patients with COPD.

Methods

A retrospective analysis was performed on the clinical data of 844 patients with COPD who were admitted to the Affiliated Hospital of Guangdong Medical University between June 2018 and December 2019. Logistic regression analysis was employed to identify risk factors associated with the development of PI, and the Wald chi-square test was used to select variables for constructing a predictive nomogram. The performance of the nomogram was assessed, followed by internal validation. Additionally, clinical data from 452 patients with COPD admitted to the Second Affiliated Hospital of Guangdong Medical University between January 2024 and December 2024 were prospectively collected for external validation.

Results

A total of 844 patients with COPD were included in this study, with 590 cases in the training group and 254 cases in the internal validation group. The predictors included in the nomogram model were age, respiratory rate [Breathe (R)], duration of COPD history, Serum albumin (ALB), SII, paralysis, edema, and activities of daily living (ADL). The nomogram demonstrated strong predictive performance and calibration. The area under the curve and 95% confidence intervals were 0.77 (0.72-0.82) for the training group, 0.77 (0.70-0.85) for the internal validation group, and 0.73 (0.66-0.81) for the external validation group.

Conclusion

This study identified the SII, age, respiratory rate, duration of COPD history, ALB, paralysis, and ADL as independent risk factors for the development of PI in patients with COPD. A nomogram model was successfully developed based on SII and validated through both internal and external testing. The findings suggest that SII is a reliable predictor of PI development in patients with COPD, and the model demonstrates strong predictive performance.

Markers for Pressure Injury Risk in Individuals with Chronic Spinal Cord Injury: A Pilot Study

ABSTRACT

OBJECTIVE

To identify markers associated with pressure injury (PrI) history in individuals with spinal cord injury (SCI) using two approaches: skin blood flow (SBF) response toward localized heating, and serum marker for insulin resistance.

METHODS

For this cross-sectional, observational study of adults with chronic traumatic SCI at T12 and above, researchers recruited two groups of participants: with history of PrI (group 1), and without history of PrI (group 2). The study protocol included obtaining fasting blood samples and measurement of SBF at bilateral heels with localized heating of 42 °C for 30 minutes from all participants. Primary SBF outcomes were initial peak and plateau SBF normalized to baseline SBF. The primary outcome for insulin resistance was Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), calculated from fasting plasma glucose and insulin. Secondary outcomes included demographic and SCI information. Researchers used the Fisher exact test and Wilcoxon-Mann-Whitney test to compare the intergroup difference of categorical and continuous variables, respectively.

RESULTS

Sixteen adults completed this study (group 1, n = 7; group 2, n = 9). In comparison with group 2, group 1 had significantly higher HOMA-IR (3.90 ± 0.71 vs 1.45 ± 0.71), suggesting higher insulin resistance, and longer duration of injury (22.54 ± 7.24 vs 7.98 ± 6.58 years). There were no between-group differences in SBF or other secondary outcomes.

CONCLUSIONS

HOMA-IR is a novel serum index associated with PrI history in persons with chronic SCI. Future longitudinal study is warranted to examine the role of insulin resistance in increasing PrI risk for the SCI population.

Development and validation of a risk prediction model for community-acquired pressure injury in a cancer population: A case-control study

BACKGROUND

Patients with cancer are susceptible to pressure injuries, which accelerate deterioration and death. In patients with post-acute cancer, the risk of pressure injury is ignored in home or community settings.

OBJECTIVE

To develop and validate a community-acquired pressure injury risk prediction model for cancer patients.

METHODS

All research data were extracted from the hospital's electronic medical record system. The identification of optimal predictors is based on least absolute shrinkage and selection operator regression analysis combined with clinical judgment. The performance of the model was evaluated by drawing a receiver operating characteristic curve and calculating the area under the curve (AUC), calibration analysis and decision curve analysis. The model was used for internal and external validation, and was presented as a nomogram.

RESULTS

In total, 6257 participants were recruited for this study. Age, malnutrition, chronic respiratory failure, body mass index, and activities of daily living scores were identified as the final predictors. The AUC of the model in the training and validation set was 0.87 (95 % confidence interval [CI], 0.85-0.89), 0.88 (95 % CI, 0.85-0.91), respectively. The model demonstrated acceptable calibration and clinical benefits.

CONCLUSIONS

Comorbidities in patients with cancer are closely related to the etiology of pressure injury, and can be used to predict the risk of pressure injury.

IMPLICATIONS FOR PRACTICE

This study provides a tool to predict the risk of pressure injury for cancer patients. This suggests that improving the respiratory function and nutritional status of cancer patients may reduce the risk of community-acquired pressure injury.

Enhancing Pressure Injury Surveillance Using Natural Language Processing

OBJECTIVE

This study assessed the feasibility of nursing handoff notes to identify underreported hospital-acquired pressure injury (HAPI) events.

METHODS

We have established a natural language processing-assisted manual review process and workflow for data extraction from a corpus of nursing notes across all medical inpatient and intensive care units in a tertiary care pediatric center. This system is trained by 2 domain experts. Our workflow started with keywords around HAPI and treatments, then regular expressions, distributive semantics, and finally a document classifier. We generated 3 models: a tri-gram classifier, binary logistic regression model using the regular expressions as predictors, and a random forest model using both models together. Our final output presented to the event screener was generated using a random forest model validated using derivation and validation sets.

RESULTS

Our initial corpus involved 70,981 notes during a 1-year period from 5484 unique admissions for 4220 patients. Our interrater human reviewer agreement on identifying HAPI was high ( κ = 0.67; 95% confidence interval [CI], 0.58-0.75). Our random forest model had 95% sensitivity (95% CI, 90.6%-99.3%), 71.2% specificity (95% CI, 65.1%-77.2%), and 78.7% accuracy (95% CI, 74.1%-83.2%). A total of 264 notes from 148 unique admissions (2.7% of all admissions) were identified describing likely HAPI. Sixty-one described new injuries, and 64 describe known yet possibly evolving injuries. Relative to the total patient population during our study period, HAPI incidence was 11.9 per 1000 discharges, and incidence rate was 1.2 per 1000 bed-days.

CONCLUSIONS

Natural language processing-based surveillance is proven to be feasible and high yield using nursing handoff notes.

The Pressurized Skin: A Review on the Pathological Effect of Mechanical Pressure on the Skin from the Cellular Perspective

Since human skin is the primary interface responding to external mechanical stimuli, extrinsic forces can disrupt its balanced microenvironment and lead to cutaneous lesions. We performed this review to delve into the pathological effects of mechanical pressure on skin from the cellular perspective. Fibroblasts of different subsets act as heterogeneous responders to mechanical load and express diverse functionalities. Keratinocytes relay mechanical signals through mechanosensitive receptors and the ensuing neurochemical cascades to work collaboratively with other cells and molecules in response to pressure. Mast cells release cytokines and neuropeptides, promoting inflammation and facilitating interaction with sensory neurons, while melanocytes can be regulated by pressure through cellular and molecular crosstalk. Adipocytes and stem cells sense pressure to fine-tune their regulations of mechanical homeostasis and cell differentiation. Applying mechanical pressure to the skin can induce various changes in its microenvironment that potentially lead to pathological alterations, such as ischemia, chronic inflammation, proliferation, regeneration, degeneration, necrosis, and impaired differentiation. The heterogeneity of each cellular lineage and subset from different individuals with various underlying skin conditions must be taken into consideration when discussing the pathological effects of pressure on the skin. Thus, elucidating the mechanotransduction and mechanoresponsive pathways from the cellular viewpoint is crucial in diagnosing and managing relevant dermatological disorders.

Thermal preconditioning can reduce the incidence of intraoperatively acquired pressure injuries

Intraoperatively acquired pressure injuries (IAPIs) occur frequently among patients who undergo surgical procedures that last longer than 3 h. Several studies indicated that heat shock proteins (HSPs) play an important role in the protection of stress-induced damages in skin tissues. Hence, the aim of this study was to investigate the potential preventive effect of thermal preconditioning (TPC) on IAPIs in surgical patients and rats and to identify the differentially expressed HSP genes in response to the above treatment. TPC was performed on one group of hairless rats before the model of pressure injuries was established. Subsequently, the size of skin lesions was measured and the expression levels of mRNA and protein of HSPs of the pressured skin were detected by real-time polymerase chain reaction (RT-PCR), western blot, and immunohistochemical staining. For human studies, 118 surgical patients were randomly divided into the TPC group (n = 59) and the control group (n = 59), respectively. The temperature and pressure of sacral skin, as well as the incidence of pressure injury (PI) were detected and compared. In animal studies, TPC significantly reduced both the size and incidence of PI in rats on the second, third and fourth days post treatment. In addition, the expression levels of both mRNA and protein of HSP27 were increased in the TPC group, compared with the control group. Immunohistochemical staining showed that HSP27 was distributed in various types of dermal cells and increased in basal cells. In human studies, a significant reduction (75%) of IAPIs was observed among the patients in the TPC group. TPC can reduce the incidence of PI in rats and humans, and the upregulation of HSP27 may play an important role in this biological progress. Further studies are warranted to explore the molecular mechanism of the preventive effect in PI mediated by HSP27.

Abnormal thrombosis and neutrophil activation increase hospital-acquired sacral pressure injuries and morbidity in COVID-19 patients

Hospitalized patients have an increased risk of developing hospital-acquired sacral pressure injury (HASPI). However, it is unknown whether SARS-CoV-2 infection affects HASPI development. To explore the role of SARS-CoV-2 infection in HASPI development, we conducted a single institution, multi-hospital, retrospective study of all patients hospitalized for ≥5 days from March 1, 2020 to December 31, 2020. Patient demographics, hospitalization information, ulcer characteristics, and 30-day-related morbidity were collected for all patients with HASPIs, and intact skin was collected from HASPI borders in a patient subset. We determined the incidence, disease course, and short-term morbidity of HASPIs in COVID-19(+) patients, and characterized the skin histopathology and tissue gene signatures associated with HASPIs in COVID-19 disease. COVID-19(+) patients had a 63% increased HASPI incidence rate, HASPIs of more severe ulcer stage (OR 2.0, p<0.001), and HASPIs more likely to require debridement (OR 3.1, p=0.04) compared to COVID-19(-) patients. Furthermore, COVID-19(+) patients with HASPIs had 2.2x increased odds of a more severe hospitalization course compared to COVID-19(+) patients without HASPIs. HASPI skin histology from COVID-19(+) patients predominantly showed thrombotic vasculopathy, with the number of thrombosed vessels being significantly greater than HASPIs from COVID-19(-) patients. Transcriptional signatures of a COVID-19(+) sample subset were enriched for innate immune responses, thrombosis, and neutrophil activation genes. Overall, our results suggest that immunologic dysregulation secondary to SARS-CoV-2 infection, including neutrophil dysfunction and abnormal thrombosis, may play a pathogenic role in development of HASPIs in patients with severe COVID-19.

NKG2D Ligand Expression Induced by Oxidative Stress Mitigates Cutaneous Ischemia-Reperfusion Injury

Pressure ulcers represent a crucial clinical problem, especially in hospitalized patients. Ischemia-reperfusion (I-R) is an important cause of these lesions. Natural killer (NK), invariant NK T (iNKT), and dendritic epidermal T-cells, which express the natural killer group 2, member D (NKG2D) receptor, have been reported to have physiological roles in skin tissue repair and wound healing. However, a role for NKG2D-NKG2D ligand interactions in I-R-induced skin injury has not been determined. Using a murine pressure ulcer model, we demonstrated that I-R-induced ulcers in NKG2D-deficient mice were larger than those in wild-type or T-cell receptor δ knockout mice. Histopathological evaluation revealed that accumulation of macrophages and neutrophils at the peripheral deep dermis and subcutaneous tissue of the ulcers was enhanced in NKG2D-deficient mice. Rae-1 mRNA, which encodes an NKG2D ligand, was induced, and RAE-1 protein was detected immunohistochemically in fibroblasts and inflammatory cells in the dermis after reperfusion. RAE-1 expression was also increased in primary mouse fibroblasts treated with sodium arsenite. These results suggested that NKG2D ligand expression was induced by oxidative stress after I-R injury and support a putative role for this ligand in wound repair. Furthermore, the influx of NKG2D-positive cells at I-R sites may mitigate pressure ulcers via NKG2D-NKG2D ligand interactions.

Development and Validation of a Risk Nomogram Model for Predicting Community-Acquired Pressure Injury Among the Older Adults in China: A Case-Control Study

Purpose

A predictive model of community-acquired pressure injury (CAPI) was established and validated to allow the early identification of the risk of pressure injuries by family caregivers and community workers.

Patients and Methods

The participants were hospitalized patients 65 years and older from two branches of a tertiary hospital in China, one for model training set and the other for validation set. This study was a case-control study based on hospital electronic medical records. According to the presence of pressure injury at admission, patients were divided into a case group and a control group. In the model training set, LASSO regression was used to select the best predictors, and then logistic regression was used to construct a nomogram. The performance of the model was evaluated by drawing the receiver operating characteristic curve (ROC) and calculating the area under the curve (AUC), calibration analysis, and decision curve analysis. The model used a 10-fold crossover for internal and external validation.

Results

The study included a total of 20,235 subjects, including 11,567 in the training set and 8668 in the validation set. The prevalence of CAPI in the training and validation sets was 2.5% and 1.8%, respectively. A nomogram was constructed including eight variables: age ≥ 80, malnutrition status, cerebrovascular accidents, hypoproteinemia, respiratory failure, malignant tumor, paraplegia/hemiplegia, and dementia. The AUC of the prediction model in the original model, internal validation, and external validation were 0.868 (95% CI: 0.847, 0.890), mean 0.867, and 0.840 (95% CI: 0.807,03.873), respectively. The nomogram showed acceptable calibration and clinical benefit.

Conclusion

We constructed a nomogram to predict CAPI from the perspective of comorbidity that is suitable for use by non-specialists. This nomogram will help family caregivers and community workers with the early identification of PI risks.

Machine Learning Approaches for Hospital Acquired Pressure Injuries: A Retrospective Study of Electronic Medical Records

Background

Many machine learning heuristics integrate well with Electronic Medical Record (EMR) systems yet often fail to surpass traditional statistical models for biomedical applications.

Objective

We sought to compare predictive performances of 12 machine learning and traditional statistical techniques to predict the occurrence of Hospital Acquired Pressure Injuries (HAPI).

Methods

EMR information was collected from 57,227 hospitalizations acquired from Dartmouth Hitchcock Medical Center (April 2011 to December 2016). Twelve classification algorithms, chosen based upon classic regression and recent machine learning techniques, were trained to predict HAPI incidence and performance was assessed using the Area Under the Receiver Operating Characteristic Curve (AUC).

Results

Logistic regression achieved a performance (AUC = 0.91 ± 0.034) comparable to the other machine learning approaches. We report discordance between machine learning derived predictors compared to the traditional statistical model. We visually assessed important patient-specific factors through Shapley Additive Explanations.

Conclusions

Machine learning models will continue to inform clinical decision-making processes but should be compared to traditional modeling approaches to ensure proper utilization. Disagreements between important predictors found by traditional and machine learning modeling approaches can potentially confuse clinicians and need to be reconciled. These developments represent important steps forward in developing real-time predictive models that can be integrated into EMR systems to reduce unnecessary harm.

Association Between Charlson Comorbidity Index and Community-Acquired Pressure Injury in Older Acute Inpatients in a Chinese Tertiary Hospital

PURPOSE

To explore the correlation between community-acquired pressure injury (CAPI) and comorbidities in elderly patients with emergency admission.

PATIENTS AND METHODS

Patients aged 65 years or above were enrolled from multiple departments, such as Internal Medicine, Surgery, Geriatrics, and Intensive Care Unit of Wuhan Third Hospital, which is affiliated to Wuhan University, from January to December 2020. Comorbidity data were extracted using the 10th edition of the International Classification of Diseases (ICD-10) from the hospital electronic medical record system, and the Charlson Comorbidity Index (CCI) was calculated using these data. Participants were divided into two groups according to whether pressure injury was present at admission. The baseline characteristics of the two groups were compared using Student's t-tests, Mann-Whitney U-tests, and chi-square tests. Univariate and multivariate logistic regression models were constructed to explore the relationship between CAPI and the CCI. Smooth curve fitting was used to show the relationship between the CCI and CAPI. By drawing the receiver operating characteristic curve, the CCI was used to predict CAPI.

RESULTS

A total of 5759 participants with an average age of 75.1 ± 7.6 were included in this population-based study. The prevalence of CAPI was 4.3%. In logistic regression analysis, there was a positive relationship between the CCI and CAPI after adjustment for sex, age, hypoproteinemia, and anemia (OR = 1.37, 95% CI = 1.29-1.45, p < 0.001, trend test p < 0.001). The area under the receiver operating characteristic curve was 0.75, and the maximum value of the Youden index was 0.35, with a critical value of 5.5.

CONCLUSION

The development of CAPI was positively correlated with the CCI. The risk of developing pressure injury increases with the number and severity of comorbidities. This study shows that the CCI has certain reference value in predicting CAPI.

Understanding Skin Failure: A Scoping Review

OBJECTIVE

To map the use of the term "skin failure" in the literature over time and enhance understanding of this term as it is used in clinical practice.

DATA SOURCES

The databases searched for published literature included PubMed, Embase, the Cumulative Index for Nursing and Allied Health Literature, and Google Scholar. The search for unpublished literature encompassed two databases, Open Gray and ProQuest Dissertation and Theses.

STUDY SELECTION

Search terms included "skin failure," "acute skin failure," "chronic skin failure," and "end stage skin." All qualitative and quantitative research designs, editorial, opinion pieces, and case studies were included, as well as relevant gray literature.

DATA EXTRACTION

Data collected included author, title, year of publication, journal name, whether the term "skin failure" was mentioned in the publication and/or in conjunction with other skin injury, study design, study setting, study population, sample size, main focus of the publication, what causes skin failure, skin failure definition, primary study aim, and primary outcome.

DATA SYNTHESIS

Two main themes of skin failure were identified through this scoping review: the etiology of skin failure and the interchangeable use of definitions.

CONCLUSIONS

Use of the term "skin failure" has increased significantly over the past 30 years. However, there remains a significant lack of empirical evidence related to skin failure across all healthcare settings. The lack of quality research has resulted in multiple lines of thinking on the cause of skin failure, as well as divergent definitions of the concept. These results illustrate substantial gaps in the current literature and an urgent need to develop a globally agreed-upon definition of skin failure, as well as a better understanding of skin failure etiology.

Brief intermittent pressure off-loading on skin microclimate in healthy adults - A descriptive-correlational pilot study

AIM

This study examined microclimate changes to the skin as a result of pressure over a 1 h period. The results were compared to skin parameter results following brief consecutive off-loading of pressure-prone areas.

DESIGN

A descriptive-correlational pilot study was undertaken.

METHOD

A convenience sample of 41 healthy adults aged 18-60 years was recruited. Participants engaged in four 1 h data collection sessions. The sessions were conducted in both semi-recumbent and supine positions. Measures of erythema, melanin, stratum corneum hydration, and skin temperature were taken at pressure-prone areas at baseline and after 1 h in an uninterrupted method (continuous pressure-loading) and every 10 min in an interrupted method (brief off-loading). The Corneometer and Mexameter (Courage + Khazaka Electronics GMbH, 2013) and Exergen DermaTemp DT-1001 RS Infrared Thermographic Scanner (Exergen Corporation, 2008) provided a digital appraisal of skin parameters. Intraclass correlation coefficients (ICC) were calculated to indicate test-retest reliability and absolute agreement of results between the two methods.

RESULTS

Strong agreement between the interrupted and uninterrupted method was observed with ICCs ranging from 0.72 to 0.99 (supine) and 0.62-0.99 (semi-recumbent). Endpoint measures tended to be higher compared to baseline measures for all skin parameters. Differences in skin parameters results by anatomical location were evident particularly for erythema and stratum corneum hydration; the elbows and heels yielded lower scores compared to the sacrum. Erythema had the most variation across methods. The supine and semi-recumbent positions had negligible effect on measured skin parameters.

CONCLUSIONS

Minimal variation between skin parameter results indicates that brief off-loading in the interrupted method did not significantly change the outcomes; minor shifts in positioning do not alter changes to the skin from pressure. Skin parameters varied by anatomical location and changed over a 1 h period of pressure-loading.

RELEVANCE TO CLINICAL PRACTICE

Biophysical techniques may be able to assist accurate assessment of skin microclimate and skin colour. As brief off-loading (interruptions) to enable skin parameter measurement does not alter skin readings, researchers can proceed with some confidence regarding the use of this protocol in future studies assessing skin parameters. This study data provides a library of cutaneous changes at pressure-prone areas of healthy adults and is expected to inform innovative approaches to pressure injury risk assessment.

The Incidence of Pressure Ulcers and its Associations in Different Wards of the Hospital: A Systematic Review and Meta-Analysis

Pressure ulcer is a health problem worldwide that is common among inpatients and elderly people with physical-motor limitations. To deliver nursing care and prevent the development of pressure ulcers, it is essential to identify the factors that affect it. This global systematic review and meta-analysis was conducted with the aim of evaluating the incidence of pressure ulcers in observational studies. In this study, databases including Web of Science, Embase, PubMed, Scopus, and Google Scholar were searched to collect data. Articles published from 1997 to 2017 about the factors influencing the incidence of pressure ulcers were retrieved and their results were analyzed using meta-analysis according to the Random-Effects Model. The heterogeneity of studies was investigated using the I2 statistic. Data were analyzed using the R and Stata software (version 14). In this study, 35 studies were included in the final analysis. The results showed that the pooled estimate of the incidence rate of pressure ulcer was 12% (95% CI: 10-14). The incidence rates of the pressure ulcers of the first, second, third, and fourth stages were 45% (95% CI: 34-56), 45% (95% CI: 34-56), 4% (95% CI: 3-5), and 4% (95% CI: 2-6), respectively. The highest incidence of pressure ulcers was observed among inpatients in orthopedic surgery ward (18.5%) (95% CI: 11.5-25). According to the final results, better conditions should be provided to decrease the incidence of pressure ulcers in different wards, especially orthopedics, and in patients with diabetes.

The relationship between pressure offloading and ischial tissue health in individuals with spinal cord injury: An exploratory study

Objectives: To compare thickness and texture measures of tissue overlying the ischial region in able-bodied (AB) individuals vs. individuals with spinal cord injury (SCI) and to determine if there is a relationship between pressure offloading of the ischial tuberosities (IT) and tissue health in individuals with SCI. Design: Exploratory cross-sectional study. Setting: University setting and rehabilitation hospital. Outcome Measures: Thickness and texture measurements from ultrasound images of tissues overlying the IT were obtained from AB individuals (n = 10) and individuals with complete or incomplete traumatic and non-traumatic SCI American Spinal Injury Association Impairment Scale (AIS) classification A-D (n = 15). Pressure offloading was measured in individuals with SCI and correlated with tissue health measurements. Results: The area overlying the IT occupied by the muscle was significantly greater in the SCI when compared with AB cohort. The area occupied by the muscle in individuals with SCI appeared to lose the striated appearance and was more echogenic than nearby skin and subcutaneous tissue (ST). There was no correlation between offloading times and thickness, echogenicity and contrast measurements of skin, ST and muscle in individuals with SCI. Conclusion: Changes in soft tissues overlying the ischial tuberosity occur following SCI corresponding to the loss of striated appearance of muscle and increased thickness of the area occupied by the muscle. Further studies using a larger sample size are recommended to establish if thickness and tissue texture differ between individuals with SCI who sustain pressure injuries vs. those who do not.

Local Growth Hormone Therapy for Pressure Ulcer Healing on a Human Skin Mouse Model

The growth hormone is involved in skin homeostasis and wound healing. We hypothesize whether it is possible to improve pressure ulcer (PU) healing by locally applying the recombinant human growth hormone (rhGH) in a human skin mouse model. Non-obese diabetic/severe combined immunodeficient mice (n = 10) were engrafted with a full-thickness human skin graft. After 60 days with stable grafts, human skin underwent three cycles of ischemia-reperfusion with a compression device to create a PU. Mice were classified into two groups: rhGH treatment group (n = 5) and control group (n = 5). In the rhGH group for local intradermal injections, each had 0.15 mg (0.5IU) applied to the PU edges, once per week for four weeks. Evaluation of the wound healing was conducted with photographic and visual assessments, and histological analysis was performed after complete wound healing. The results showed a healing rate twice as fast in the rhGH group compared to the control group (1.25 ± 0.33 mm2/day versus 0.61 ± 0.27 mm2/day; p-value < 0.05), with a faster healing rate during the first 30 days. The rhGH group showed thicker skin (1953 ± 457 µm versus 1060 ± 208 µm; p-value < 0.05) in the repaired area, with a significant decrease in collagen type I/III ratio at wound closure (62 days, range 60-70). Local administration of the rhGH accelerates PU healing in our model. The rhGH may have a clinical use in pressure ulcer treatment.

Hypotension at emergency department admission and hospital-acquired pressure ulcers in older patients: prospective study

OBJECTIVE

To investigate the relationship between admission hypotension and hospital acquired pressure ulcers (PU) among older patients in an emergency department.

METHODS

The study was a prospective cohort conducted between March and May 2017 in the emergency department of a tertiary care hospital in Eastern China. Data on PUs and possible PU risk factors were collected using a pre-designed form. Multivariate logistic regression was used to calculate the adjusted odds ratio (OR).

RESULTS

A total of 157 older patients were included in the study. PU incidence was 8.3%, with 95% confidence interval (CI) of 4.5 to 13.7%. The majority (76.9%) of PUs developed in the first three days of admission. On admission, 28 patients were found to be hypotensive, and 129 non-hypotensive. In the hypotensive group, PU incidence was 21.4% (6/28), and 5.4% (7/129) in the non-hypotensive group, respectively. The crude OR was 4.753 (95%CI: 1.183 to 18.086). After adjustment by patients' age, admission to emergency intensive care unit and if requiring assistance to move, the adjusted OR of hypotension on admission for PU risk was 1.755 (95%CI: 1.356 to 3.224).

CONCLUSION

Our study showed that admission hypotension was an independent risk factor of PU among elderly patients in emergency department. However, this conclusion should be confirmed by further studies with large sample size.

Education of healthcare professionals for preventing pressure ulcers

BACKGROUND

Pressure ulcers, also known as bed sores or pressure sores, are localised areas of tissue damage arising due to excess pressure and shearing forces. Education of healthcare staff has been recognised as an integral component of pressure ulcer prevention. These educational programmes are directed towards influencing behaviour change on the part of the healthcare professional, to encourage preventative practices with the aim of reducing the incidence of pressure ulcer development.

OBJECTIVES

To assess the effects of educational interventions for healthcare professionals on pressure ulcer prevention.

SEARCH METHODS

In June 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs, that evaluated the effect of any educational intervention delivered to healthcare staff in any setting to prevent pressure ulceration.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for eligibility. We obtained full versions of potentially relevant studies and two authors independently screened these against the inclusion criteria.

MAIN RESULTS

We identified five studies that met the inclusion criteria for this review: four RCTs and one cluster-RCT. The study characteristics differed in terms of healthcare settings, the nature of the interventions studied and outcome measures reported. The cluster-RCT, and two of the RCTs, explored the effectiveness of education delivered to healthcare staff within residential or nursing home settings, or nursing home and hospital wards, compared to no intervention, or usual practices. Educational intervention in one of these studies was embedded within a broader, quality improvement bundle. The other two individually randomised controlled trials explored the effectiveness of educational intervention, delivered in two formats, to nursing staff cohorts.Due to the heterogeneity of the studies identified, pooling was not appropriate and we have presented a narrative overview. We explored a number of comparisons (1) education versus no education (2) components of educational intervention in a number of combinations and (3) education delivered in different formats. There were three primary outcomes: change in healthcare professionals' knowledge, change in healthcare professionals' clinical behaviour and incidence of new pressure ulcers.We are uncertain whether there is a difference in health professionals' knowledge depending on whether they receive education or no education on pressure ulcer prevention (hospital group: mean difference (MD) 0.30, 95% confidence interval (CI) -1.00 to 1.60; 10 participants; nursing home group: MD 0.30, 95% CI -0.77 to 1.37; 10 participants). This was based on very low-certainty evidence from one study, which we downgraded for serious study limitations, indirectness and imprecision.We are uncertain whether there is a difference in pressure ulcer incidence with the following comparisons: training, monitoring and observation, versus monitoring and observation (risk ratio (RR) 0.63, 95% CI 0.37 to 1.05; 345 participants); training, monitoring and observation, versus observation alone (RR 1.21, 95% CI 0.60 to 2.43; 325 participants) or, monitoring and observation versus observation alone (RR 1.93, 95% CI 0.96 to 3.88; 232 participants). This was based on very low-certainty evidence from one study, which we downgraded for very serious study limitations and imprecision. We are uncertain whether multilevel intervention versus attention control makes any difference to pressure ulcer incidence. The report presented insufficient data to enable further interrogation of this outcome.We are uncertain whether education delivered in different formats such as didactic education versus video-based education (MD 4.60, 95% CI 3.08 to 6.12; 102 participants) or e-learning versus classroom education (RR 0.92, 95% CI 0.80 to 1.07; 18 participants), makes any difference to health professionals' knowledge of pressure ulcer prevention. This was based on very low-certainty evidence from two studies, which we downgraded for serious study limitations and study imprecision.None of the included studies explored our other primary outcome: change in health professionals' clinical behaviour. Only one study explored the secondary outcomes of interest, namely, pressure ulcer severity and patient and carer reported outcomes (self-assessed quality of life and functional dependency level respectively). However, this study provided insufficient information to enable our independent assessment of these outcomes within the review.

AUTHORS' CONCLUSIONS

We are uncertain whether educating healthcare professionals about pressure ulcer prevention makes any difference to pressure ulcer incidence, or to nurses' knowledge of pressure ulcer prevention. This is because the included studies provided very low-certainty evidence. Therefore, further information is required to clarify the impact of education of healthcare professionals on the prevention of pressure ulcers.

Risk of developing pressure sore in amyotrophic lateral sclerosis patients - a nationwide cohort study

BACKGROUND

Prior investigations with few cases have disclosed lack of pressure sore (PrS) formation was characteristic in amyotrophic lateral sclerosis (ALS) patients. However, studies with larger samples are lacking to ascertain this concept.

OBJECTIVE

To investigate whether patients with ALS have higher risk of PrS.

METHODS

Utilizing a Taiwan National Insurance claims data set with 23 million participants, we extracted 514 patients with ALS and 2056 controls from 1 January 2000 to 31 December 2008. Both groups were followed up until PrS occurrence during study period (2000-2011). The PrS risk was calculated with Cox proportional regression model.

RESULTS

The patients with ALS had a greater PrS risk (adjusted hazard ratio [aHR] = 8.82, 95% confidence interval [CI] = 4.90-15.9, P < 0.001) than the controls did. PrS risk was much higher in ALS women (aHR = 26.6, 95% CI = 9.05-78.2, P < 0.001) than in ALS men (aHR = 4.38, 95% CI = 1.99-9.68, P < 0.001). Besides, in people aged 20-54, ALS was linked with a much greater PrS risk (aHR = 27.7, 95% CI = 5.79-132, P < 0.001) than in those aged ≥55 (aHR = 6.10, 95% CI = 3.10-12.0, P < 0.001).

CONCLUSIONS

Amyotrophic lateral sclerosis is discovered to be correlated with an enhanced PrS risk. For PrS prevention, it is needed to pay more attention to the management of the patients with ALS, particularly in women and those with relatively younger age. Further investigations are needed to confirm the findings in this study.

Nonpharmacologic Interventions to Heal Pressure Ulcers in Older Patients: An Overview of Systematic Reviews (The SENATOR-ONTOP Series)

BACKGROUND

Pressure ulcers (PUs) are more frequent in older patients, and the healing process is usually challenging. Nonpharmacologic interventions may play a role in the treatment of older people with PUs, but most systematic reviews (SRs) have not addressed this specific population using convincing outcome measures.

OBJECTIVE

To summarize and critically appraise the evidence from SRs of the primary studies on nonpharmacologic interventions to treat PUs in older patients.

DESIGN

SR and meta-analysis of comparative studies.

METHODS

PubMed, Cochrane Database of Systematic Reviews, EMBASE, and CINHAL (from inception to October 2013) were searched. A new search for updates in the Cochrane Database was launched in July 2014. SRs that included at least 1 comparative study evaluating any nonpharmacologic intervention to treat PUs in older patients, in any health care setting, were included. Any primary study with experimental design was then identified and included. From each primary study, quality assessment was undertaken as specified by the Cochrane Collaboration and the Grading of Recommendations Assessment, Development and Evaluation working group. Interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis, using complete ulcer healing as the outcome measure.

RESULTS

One hundred ten SRs with 45 primary studies satisfied the inclusion criteria. The most frequent interventions explored in these trials were support surfaces (13 studies), nutrition (8), and electrotherapy (6). High or moderate quality of evidence was found in none of the interventions, mainly because of the very serious risk of bias of most studies and imprecision in the treatment effect. Evidence grade is very low or insufficient to support the use of any support surface, nutrition intervention, multicomponent interventions, repositioning or other adjunctive therapy (ultrasound, negative pressure, laser, electromagnetic, light, shock wave, hydrotherapy, radiofrequency, or vibration therapy) to increase the rates of PU healing in older patients. Electrotherapy showed some beneficial effect in the treatment of PUs, although the quality of evidence is low.

CONCLUSIONS

In older patients with PUs, evidence to use any nonpharmacologic therapy to increase the rates of wound healing is inconclusive, except for low quality evidence that supports the use of electrotherapy. This situation is especially alarming for interventions that are usually standard clinical practice (repositioning, support surfaces). Although there is some evidence in younger populations and other types of ulcers, studies in older populations with PUs using sound methodology are needed.

International multidisciplinary consensus conference on multimodality monitoring: ICU processes of care

There is an increased focus on evaluating processes of care, particularly in the high acuity and cost environment of intensive care. Evaluation of neurocritical-specific care and evidence-based protocol implementation are needed to effectively determine optimal processes of care and effect on patient outcomes. General quality measures to evaluate intensive care unit (ICU) processes of care have been proposed; however, applicability of these measures in neurocritical care populations has not been established. A comprehensive literature search was conducted for English language articles from 1990 to August 2013. A total of 1,061 articles were reviewed, with 145 meeting criteria for inclusion in this review. Care in specialized neurocritical care units or by neurocritical teams can have a positive impact on mortality, length of stay, and in some cases, functional outcome. Similarly, implementation of evidence-based protocol-directed care can enhance outcome in the neurocritical care population. There is significant evidence to support suggested quality indicators for the general ICU population, but limited research regarding specific use in neurocritical care. Quality indices for neurocritical care have been proposed; however, additional research is needed to further validate measures.

A novel model of human skin pressure ulcers in mice

INTRODUCTION

Pressure ulcers are a prevalent health problem in today's society. The shortage of suitable animal models limits our understanding and our ability to develop new therapies. This study aims to report on the development of a novel and reproducible human skin pressure ulcer model in mice.

MATERIAL AND METHODS

Male non-obese, diabetic, severe combined immunodeficiency mice (n = 22) were engrafted with human skin. A full-thickness skin graft was placed onto 4×3 cm wounds created on the dorsal skin of the mice. Two groups with permanent grafts were studied after 60 days. The control group (n = 6) was focused on the process of engraftment. Evaluations were conducted with photographic assessment, histological analysis and fluorescence in situ hybridization (FISH) techniques. The pressure ulcer group (n = 12) was created using a compression device. A pressure of 150 mmHg for 8 h, with a total of three cycles of compression-release was exerted. Evaluations were conducted with photographic assessment and histological analysis.

RESULTS

Skin grafts in the control group took successfully, as shown by visual assessment, FISH techniques and histological analysis. Pressure ulcers in the second group showed full-thickness skin loss with damage and necrosis of all the epidermal and dermal layers (ulcer stage III) in all cases. Complete repair occurred after 40 days.

CONCLUSIONS

An inexpensive, reproducible human skin pressure ulcer model has been developed. This novel model will facilitate the development of new clinically relevant therapeutic strategies that can be tested directly on human skin.

Mobile health platform for pressure ulcer monitoring with electronic health record integration

Pressure ulcers frequently occur in patients with limited mobility, for example, people with advanced age and patients wearing casts or prostheses. Mobile information communication technologies can help implement ulcer care protocols and the monitoring of patients with high risk, thus preventing or improving these conditions. This article presents a mobile pressure ulcer monitoring platform (mULCER), which helps control a patient's ulcer status during all stages of treatment. Beside its stand-alone version, it can be integrated with electronic health record systems as mULCER synchronizes ulcer data with any electronic health record system using HL7 standards. It serves as a tool to integrate nursing care among hospital departments and institutions. mULCER was experimented with in different mobile devices such as LG Optimus One P500, Samsung Galaxy Tab, HTC Magic, Samsung Galaxy S, and Samsung Galaxy i5700, taking into account the user's experience of different screen sizes and processing characteristics.

Ocorrência de úlcera por pressão em pacientes submetidos a cirurgias eletivas

OBJETIVO: Identificar a ocorrência de úlcera por pressão em pacientes submetidos a cirurgias eletivas de porte II, III e IV. MÉTODOS: Estudo de abordagem quantitativa, com delineamento de pesquisa não experimental, tipo descritivo e prospectivo. A amostra foi composta por 148 pacientes adultos, de ambos os gêneros, submetidos à cirurgia eletiva, conforme os critérios de seleção determinados previamente. RESULTADOS: Da amostra avaliada, 108 pacientes receberam alta hospitalar, três faleceram e 37 desenvolveram úlceras por pressão. Esses pacientes apresentaram 44 lesões, sendo a maioria diagnosticada de estágio II (56,8%), seguida por lesões de estágio I (40,9%) e estágio III (2,3%). As áreas corporais mais acometidas foram a região sacro/glútea (68,2%), calcâneos (18,1%), região dorsal (9%) e o pavilhão auricular (4,6%). CONCLUSÃO: A ocorrência de úlcera por pressão foi de 25% indicando a necessidade de implementação de intervenções efetivas para a prevenção desse evento adverso no perioperatório.

Risk factors associated with pressure ulcer development in critically ill traumatic spinal cord injury patients

Critically ill spinal cord injury (SCI) patients are at high risk for pressure ulcers. Research is needed to identify risk factors for pressure ulcers. The aim of this study was to investigate risk factors and outcomes of pressure ulcers in critically ill SCI patients. This is a retrospective cohort study. Data were gathered from medical records of adult patients with SCI admitted to surgical intensive care units. Ninety-four SCI patients participated in this study. Clinical variables associated with pressure ulcers were as follows: fecal management systems, incontinence, acidosis, support surfaces, steroids, and additional equipment. Hypotension was the strongest predictor of pressure ulcers. Nursing interventions may address risk factors and improve patient outcomes.

Pressure ulcer staging revisited: superficial skin changes & Deep Pressure Ulcer Framework©

Deficiencies in the current pressure ulcer classification system create the impetus for the current discourse on the clinical, legal, and economic implications of staging and considering shifting the paradigm in pressure ulcer description and assessment.

Effect of lysine hyaluronate on the healing of decubitus ulcers in rehabilitation patients

INTRODUCTION

Chronically hospitalized patients are often burdened with skin ulcerations, which may be persistent and even irreversible. Treatment with hyaluronic acid is widely used in the early phases of the ulcers to relieve symptoms and accelerate the healing process. The present study hypothesized that lysine hyaluronate (Lys-HA) (Lysial(®), Fatai-Nyl Srl; Jasper LLC, Lugano, Switzerland), a new formulation of hyaluronic acid, would improve the healing of decubitus ulcers more than the commonly used sodium hyaluronate (SH). A double-blind randomized controlled trial was designed to assess the superiority of Lys-HA versus SH on decubitus ulcer size reduction over a 15-day period, and on the time necessary to reach 50% lesion size regression.

METHODS

After a clinical evaluation, 50 hospitalized patients with decubitus ulcers were divided into three groups according to ulcer stage (stage 1: erythema and edema; stage 2: all-thickness skin destruction; stage 3: destruction of subcutaneous tissue) and randomized to receive Lys-HA or SH. Digital photographs were taken before the start of treatment, then every 3 days, and at the end of the study. Pre- and posttreatment differences in each group were tested using Student t tests and analysis of covariance with basis values as covariates.

RESULTS

Ulcer reduction was greater in all the Lys-HA groups than SH groups. In stage 1 patients, 90% and 70% lesion size reductions were observed in the groups allocated to Lys-HA and SH, respectively (P<0.05). In stage 2 patients, 70% and 40% lesion size reductions were observed in the Lys-HA and SH groups, respectively (P<0.02). In stage 3 patients, 71% and 29% lesion size reductions were observed in the Lys-HA and SH groups, respectively (P<0.01). The regression time of 50% of lesion size was shorter in all the Lys-HA groups than SH groups (P<0.05).

CONCLUSION

The use of Lys-HA in the healing process of decubitus ulcers provides an improved efficacy with respect to SH in hospitalized patients, suggesting its use from the early phases of ulceration.

Medical care in the nursing home

With the advent of the graying of the baby boomers, there is an urgent need to enhance care in the nursing home. This article focuses on the areas where high-quality care can improve outcomes.