Investigating Inflammatory Markers in Wound Healing: Understanding Implications and Identifying Artifacts

Understanding the complex interplay of pro-inflammatory and anti-inflammatory cytokines is crucial in the field of wound healing, as it holds the key to developing effective therapeutics. In the initial stages of wound healing, pro-inflammatory cytokines like IL-1β, IL-6, TNF-α, and various chemokines play vital roles in recruiting cells for debris clearance and the recruitment of growth factors. Careful regulation and timely resolution of this early inflammation are essential for optimal wound repair. As the healing process progresses, anti-inflammatory proteins such as IL-10 and IL-4 become instrumental in facilitating the transition to later stages where pro-inflammatory cytokines promote angiogenesis and wound remodeling. This Perspective underscores the complexity of inflammatory cytokines in wound healing research and emphasizes the need for comprehensive and unbiased methodologies in their evaluation. For robust and reliable results in wound-healing research, a more holistic approach is necessary-one that considers the roles, interactions, and timing of biological molecules, alongside careful sampling and evaluation strategies.

Exploring the relationship between government stringency and preventative social behaviours during the COVID-19 pandemic in the United Kingdom

We constructed a preventive social behaviours (PSB) Index using survey questions that were aligned with WHO recommendations, and used linear regression to assess the impact of reported COVID-19 deaths (RCD), people's confidence of government handling of the pandemic (CGH) and government stringency (GS) in the United Kingdom (UK) over time on the PSB index. We used repeated, nationally representative, cross-sectional surveys in the UK over the course of 41 weeks from 1st April 2020 to January 28th, 2021, including a total of 38,092 participants. The PSB index was positively correlated with the logarithm of RCD (R: 0.881, p < .001), CGH (R: 0.592, p < .001) and GS (R: 0.785, p < .001), but was not correlated with time (R: -0.118, p = .485). A multivariate linear regression analysis suggests that the log of RCD (coefficient: 0.125, p < .001), GS (coefficient: 0.010, p = .019), and CGH (coefficient: 0.0.009, p < .001) had a positive and significant impact on the PSB Index, while time did not affect it significantly. These findings suggest that people's behaviours could have been affected by multiple factors during the pandemic, with the number of COVID-19 deaths being the largest contributor towards an increase in protective behaviours in our model.

Minimizing bias in a diabetic foot ulcer clinical evaluation: analysis of the HIFLO Trial

INTRODUCTION

Publications aimed at improving the quality of evidence in wound care clinical research have stressed the importance of minimizing study bias. In particular, lack of a universal definition of healing in wound studies leads to detection bias, resulting in noncomparable healing rates.

OBJECTIVE

This report analyzes the steps taken to reduce the main sources of bias in a particular RCT (the HIFLO Trial) that evaluated healing in DFUs using microvascular tissue.

MATERIALS AND METHODS

To address "definition of healing"-induced detection bias, 3 blinded adjudicators independently assessed each DFU using a rigorous 4-part definition of healing. Adjudicator responses were analyzed to assess reproducibility. Predefined criteria were also included to avoid bias owing to selection, performance, attrition, and reporting.

RESULTS

Rigor and comparability across sites were ensured through investigator training, consistent SOC, data monitoring, and independent statistical and ITT-only analysis. The level of agreement among adjudicators was greater than or equal to 90% for each of the 4-part healing criteria.

CONCLUSIONS

High-level agreement by blinded adjudicators confirmed that DFUs in the HIFLO Trial were consistently assessed for healing without bias, validating the most rigorous assessment criteria to date. The findings reported herein may prove beneficial for others seeking to minimize bias in wound studies.

Reliance on Clinical Signs and Symptoms Assessment Leads to Misuse of Antimicrobials: Post hoc Analysis of 350 Chronic Wounds

Objectives: Bacteria frequently impede wound healing and cause infection. Clinicians rely on clinical signs and symptoms (CSS) to assess for bacteria at the point of care, and inform prescription of antibiotics and other antimicrobials. Yet, robust evidence suggests that CSS has poor sensitivity for detection of problematic bacterial burden and infection, hindering antimicrobial stewardship efforts. This study evaluated CSS-based antimicrobial prescribing practices across 14 wound care centers. Approach: Data were analyzed from the fluorescence assessment and guidance (FLAAG) trial, a study of 350 chronic wounds across 20 clinicians. Clinicians reviewed patient history and assessed for CSS using the International Wound Infection Institute infection checklist. Wounds with >3 criteria or any overwhelming symptom were considered CSS+. Bacterial levels were confirmed with quantitative tissue culture of wound biopsies. Results: Antimicrobials (including dressings, topicals, and systemic antibiotics) were prescribed at a similar rate for wounds identified as CSS+ (75.0%) and CSS- (72.8%, p = 0.76). Antimicrobial dressings, the most frequently prescribed antimicrobial, were prescribed at a similar rate for CSS+ (83.3%) and CSS- (89.5%, p = 0.27) wounds. In 33.3% of patients prescribed systemic antibiotics, no CSS were present. Prescribing patterns did not correlate with bacterial load. Innovation: This study is the first to evaluate antimicrobial prescribing trends in a large, multisite cohort of chronic wound patients. Conclusions: Reliance on CSS to diagnose clinically significant bacterial burden in chronic wounds leads to the haphazard use of antimicrobials. Improved methods of identifying bacterial burden and infection are needed to enhance antimicrobial stewardship efforts in wound care. Clinicaltrials.gov ID. NCT03540004.

Effect of tobacco smoking on outcomes of trabeculectomy

PURPOSE

To evaluate the effect of tobacco smoking on trabeculectomy outcomes.

METHODS

Charts of patients with glaucoma who underwent trabeculectomy performed by a single surgeon between 2007 and 2016 were retrospectively reviewed. Charts were screened for a documented history of smoking status before surgery. Demographic and clinical preoperative variables were recorded. Based on smoking history, subjects were divided into two groups: smokers and nonsmokers. Any bleb-related interventions (e.g., 5-flourouracil injections ± laser suture lysis) or bleb revision performed during the postoperative period were noted. Success was defined as an intraocular pressure >5 mmHg and <21 mm Hg without (complete success) or with (qualified success) the use of ocular hypotensive medications. Failure was identified as a violation of the criteria mentioned above.

RESULTS

A total of 98 eyes from 83 subjects were included. The mean age of the subjects was 70.7 ± 11.09 years, and 53% (44/83) were female. The most common diagnosis was primary open-angle glaucoma in 47 cases (47.9%). The smokers Group included 30 eyes from 30 subjects. When compared with nonsmokers, smokers had a significantly worse preoperative best-corrected visual acuity (p=0.038), greater central corneal thickness (p=0.047), and higher preoperative intraocular pressure (p=0.011). The success rate of trabeculectomy surgery at 1 year was 56.7% in the smokers Group compared with 79.4% in the Group nonsmokers (p=0.020). Smoking presented an odds ratio for failure of 2.95 (95% confidence interval, 1.6-7.84).

CONCLUSION

Smokers demonstrated a significantly lower success rate 1 year after trabeculectomy compared with nonsmokers and a higher requirement for bleb-related interventions.

'I'll put up with things for a long time before I need to call anybody': Face work, the Total Institution and the perpetuation of care inequalities

Failures in fundamental care (e.g. nutrition or pain-relief) for hospitalised patients can have serious consequences, including avoidable deaths. Policy rhetoric of 'shared decision-making' fails to consider how structural constraints and power dynamics limit patient agency in nursing staff-patient interactions. Goffman's concepts of face work, the presentation of self and the Total Institution shaped our analysis of interview and focus group data from hospital patients. Patients avoided threatening 'good' patient and staff face by only requesting missed care when staff face was convincing as 'caring' and 'available' ('engaged'). Patients did not request care from 'distracted' staff ('caring' but not 'available'), whilst patient requests were ignored in Total Institution-like 'dismissive' interactions. This meant patients experienced missed care with both 'distracted' and 'dismissive' staff. Patients with higher support needs were less able to carry out their own missed care to protect staff face, so experienced more serious care omissions. These findings show that many elements of the Total Institution survive in modern healthcare settings despite attempts to support individualised care. Unless nursing staff can maintain face as 'engaged' (despite organisational constraints that can reduce their capacity to do so) patient participation in care decisions will remain at the level of rhetoric.

Can one-step nucleic acid amplification assay predict four or more positive axillary lymph node involvement in breast cancer patients: a single-centre retrospective study

BACKGROUND

One-step nucleic acid amplification (OSNA) assay is a proven, accurate, intraoperative method for the detection of lymph node (LN) metastases. The aim of this study was to assess if the total tumour load (TTL) as calculated by OSNA could be used to predict N2 stage disease, ie ≥4 LN containing metastases, in invasive breast cancer patients.

METHODS

Between 2011 and 2019 at St Richard's Hospital, Chichester, all macro-metastasis-positive OSNA cases for invasive breast cancer were retrospectively reviewed. The association between clinicopathological variables and ≥4 LNs containing metastases was analysed using regression analysis.

RESULTS

In total, 134 patients with positive sentinel lymph node (SLN) on OSNA undergoing axillary node clearance were analysed, 53% of whom had no further positive LN, 25% had ≥4 lymph nodes positive. TTL was calculated as the aggregate of cytokeratin-19 mRNA copy count of all SLN tissue analysed via OSNA. TTL ≥1.1×10⁵copies/μl and lymphovascular invasion (LVI) were both significant predictors of N2 stage disease on both univariate (TTL p=0.04, LVI p=0.005) and multivariate (TTL p=0.008, LVI p=0.039) regression analysis.

CONCLUSION

Our findings show that SLN TTL via intraoperative OSNA assay can predict four or more positive axillary LN involvement in invasive breast cancer. This is important in that it may be used intraoperatively by surgeons to decide on whether to proceed with a full axillary node clearance in order to stage the axilla. Further research is required to shape future guidance.

Restoring Endogenous Repair Mechanisms to Heal Chronic Wounds with a Multifunctional Wound Dressing

Current treatment of chronic wounds has been critically limited by various factors, including bacterial infection, biofilm formation, impaired angiogenesis, and prolonged inflammation. Addressing these challenges, we developed a multifunctional wound dressing-based three-pronged approach for accelerating wound healing. The multifunctional wound dressing, composed of nanofibers, functional nanoparticles, natural biopolymers, and selected protein and peptide, can target multiple endogenous repair mechanisms and represents a promising alternative to current wound healing products.

Body Composition and Dose-limiting Toxicity in Colorectal Cancer Chemotherapy Treatment; a Systematic Review of the Literature. Could Muscle Mass be the New Body Surface Area in Chemotherapy Dosing?

Chemotherapy dosing is traditionally based on body surface area calculations; however, these calculations ignore separate tissue compartments, such as the lean body mass (LBM), which is considered a big pool of drug distribution. In our era, colorectal cancer patients undergo a plethora of computed tomography scans as part of their diagnosis, staging and monitoring, which could easily be used for body composition analysis and LBM calculation, allowing for personalised chemotherapy dosing. This systematic review aims to evaluate the effect of muscle mass on dose-limiting toxicity (DLT), among different chemotherapy regimens used in colorectal cancer patients. This review was carried out according to the PRISMA guidelines. MEDLINE and EMBASE databases were searched from 1946 to August 2019. The primary search terms were 'sarcopenia', 'myopenia', 'chemotherapy toxicity', 'chemotherapy dosing', 'dose limiting toxicity', 'colorectal cancer', 'primary colorectal cancer' and 'metastatic colorectal cancer'. Outcomes of interest were - DLT and chemotoxicity related to body composition, and chemotherapy dosing on LBM. In total, 363 studies were identified, with 10 studies fulfilling the selection criteria. Seven studies were retrospective and three were prospective. Most studies used the same body composition analysis software but the chemotherapy regimens used varied. Due to marked study heterogeneity, quantitative data synthesis was not possible. Two studies described a toxicity cut-off value for 5-fluorouracil and one for oxaliplatin based on LBM. The rest of the studies showed an association between different body composition metrics and DLTs. Prospective studies are required with a larger colorectal cancer cohort, longitudinal monitoring of body composition changes during treatment, similar body composition analysis techniques, agreed cut-off values and standardised chemotherapy regimens. Incorporation of body composition analysis in the clinical setting will allow early identification of sarcopenic patients, personalised dosing based on their LBM and early optimisation of these patients undergoing chemotherapy.

Nanomedicine in Healing Chronic Wounds: Opportunities and Challenges

The poor healing associated with chronic wounds affects millions of people worldwide through high mortality rates and associated costs. Chronic wounds present three main problems: First, the absence of a suitable environment to facilitate cell migration, proliferation, and angiogenesis; second, bacterial infection; and third, unbalanced and prolonged inflammation. Unfortunately, current therapeutic approaches have not been able to overcome these main issues and, therefore, have limited clinical success. Over the past decade, incorporating the unique advantages of nanomedicine into wound healing approaches has yielded promising outcomes. Nanomedicine is capable of stimulating various cellular and molecular mechanisms involved in the wound microenvironment via antibacterial, anti-inflammatory, and angiogenetic effects, potentially reversing the wound microenvironment from nonhealing to healing. This review briefly discusses wound healing mechanisms and pathophysiology and then highlights recent findings regarding the opportunities and challenges of using nanomedicine in chronic wound management.

Lemur catta in small forest fragments: Which variables best predict population viability?

Habitat fragmentation is an increasingly serious issue affecting primates in most regions where they are found today. Populations of Lemur catta (ring-tailed lemur) in Madagascar's south-central region are increasingly restricted to small, isolated forest fragments, surrounded by grasslands or small-scale agriculture. Our aim was to evaluate the potential for population viability of L. catta in nine forest fragments of varying sizes (2-46 ha, population range: 6-210 animals) in south-central Madagascar, using a set of comparative, quantitative ecological measures. We used Poisson regression models with a log link function to examine the effects of fragment size, within-fragment food availability, and abundance of matrix resources (food and water sources) on L. catta population sizes and juvenile recruitment. We found a strong association between overall population size and (a) fragment size and (b) abundance of key food resources Melia azedarach and Ficus spp. (per 100 m along transect lines). Juvenile recruitment was also associated with fragment size and abundance of the two above-mentioned food resources. When the largest population, an outlier, was removed from the analysis, again, the model containing fragment size and abundance of M. azedarach and Ficus spp. was the best fitting, but the model that best predicted juvenile recruitment contained only fragment size. While our results are useful for predicting population presence and possible persistence in these fragments, both the potential for male dispersal and the extent of human disturbance within most fragments play crucial roles regarding the likelihood of long-term L. catta survival. While seven of the nine fragments were reasonably protected from human disturbance, only three offered the strong potential for male dispersal, thus the long-term viability of many of these populations is highly uncertain.

The Quality of Interactions Schedule (QuIS) and person-centred care: Concurrent validity in acute hospital settings

Background

There is a lack of consensus on how the practices of health care workers may be assessed and measured in relation to compassion. The Quality of Interactions Schedule (QuIS) is a promising measure that uses independent observers to assess the quality of social interactions between staff and patients in a healthcare context. Further understanding of the relationship between QuIS and constructs such as person-centred care would be helpful to guide its future use in health research.

Objective

This study aimed to assess the validity of QuIS in relation to person-centred care measured using the CARES® Observational Tool (COT™).

Methods

168 nursing staff-patient care interactions on adult inpatient units in two acute care UK National Health Service hospitals were observed and rated using QuIS and COT™. Analyses explored the relationship between summary and individual item COT™ scores and the likelihood of a negative (lower quality) QuIS rating.

Results

As the degree of person-centred care improved, QuIS negative ratings generally decreased and positive social ratings increased. QuIS-rated negative interactions were associated with an absence of some behaviours, in particular staff approaching patients from the front (relative risk (RR) 3.7), introducing themselves (RR 3.1), smiling and making eye contact (RR 3.4), and involving patients in their care (RR 3.7).

Conclusion

These findings provide further information about the validity of QuIS measurements in healthcare contexts, and the extent to which it can be used to reflect the quality of relational care even for people who are unable to self-report.

Implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings: a pilot RCT and feasibility study

Background

Concerns about the degree of compassion in health care have become a focus for national and international attention. However, existing research on compassionate care interventions provides scant evidence of effectiveness or the contexts in which effectiveness is achievable.

Objectives

To assess the feasibility of implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings and to evaluate its impact on patient care.

Design

Pilot cluster randomised trial (CRT) and associated process and economic evaluations.

Setting

Six inpatient ward nursing teams (clusters) in two English NHS hospitals randomised to intervention (n = 4) or control (n = 2).

Participants

Patients (n = 639), staff (n = 211) and visitors (n = 188).

Intervention

CLECC is a workplace educational intervention focused on developing sustainable leadership and work team practices (dialogue, reflective learning, mutual support) theorised to support the delivery of compassionate care. The control setting involved no planned staff team-based educational activity.

Main outcome measures

Quality of Interaction Schedule (QuIS) for staff–patient interactions, patient-reported evaluations of emotional care in hospital (PEECH) and nurse-reported empathy (as assessed via the Jefferson Scale of Empathy).

Data sources

Structured observations of staff–patient interactions; patient, visitor and staff questionnaires and qualitative interviews; and qualitative observations of CLECC activities.

Results

The pilot CRT proceeded as planned and randomisation was acceptable to teams. There was evidence of potential contamination between wards in the same hospital. QuIS performed well, achieving a 93% recruitment rate, with 25% of the patient sample cognitively impaired. At follow-up there were more positive (78% vs. 74%) and fewer negative (8% vs. 11%) QuIS ratings for intervention wards than for control wards. In total, 63% of intervention ward patients achieved the lowest possible (i.e. more negative) scores on the PEECH connection subscale, compared with 79% of control group patients. These differences, although supported by the qualitative findings, are not statistically significant. No statistically significant differences in nursing empathy were observed, although response rates to staff questionnaire were low (36%). Process evaluation: the CLECC intervention is feasible to implement in practice with medical and surgical nursing teams in acute care hospitals. Strong evidence of good staff participation was found in some CLECC activities and staff reported benefits throughout its introductory period and beyond. Further impact and sustainability were limited by the focus on changing ward team behaviours rather than wider system restructuring. Economic evaluation: the costs associated with using CLECC were identified and it is recommend that an impact inventory be used in any future study.

Limitations

Findings are not generalisable outside hospital nursing teams, and this feasibility work is not powered to detect differences attributable to the CLECC intervention.

Conclusions

Use of the experimental methods is feasible. The use of structured observation of staff–patient interaction quality is a promising primary outcome that is inclusive of patient groups often excluded from research, but further validation is required. Further development of the CLECC intervention should focus on ensuring that it is adequately supported by resources, norms and relationships in the wider system by, for instance, improving the cognitive participation of senior nurse managers. Funding is being sought for a more definitive evaluation.

Trial registration

Current Controlled Trials ISRCTN16789770.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 33. See the NIHR Journals Library website for further project information. The systematic review reported inChapter 2was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, the University of Örebro and the Karolinska Institutet.

The relationship of age, activity, and body size on osteoarthritis in weight-bearing skeletal regions

This study examined the simultaneous impact of multiple underlying factors on OA expression in weight-bearing joints of the vertebrae and lower limb of a modern European skeletal sample (Lisbon and Sassari). OA was evaluated using standard ranked categorical scoring; composite OA scores derived through principal component analysis. Body size was calculated from postcranial measurements; torsional strength (J) of the femoral midshaft was calculated from three-dimensional surface models, size standardized and used as a proxy for activity. A standard multiple regression was applied. In all regions, the linear combination of age, body mass, stature, and J was significantly related to differences in OA. Across all joints, age was the strongest predictor; neither body size, nor activity variables demonstrated a statistical relationship with OA at the lumbar or knee; J demonstrated a negative correlation with pelvic OA. Variation in OA can be explained by age, stature, body mass, and structural adaptation related to habitual use. The negative correlation between femoral torsional strength with OA suggests that long-term, repetitive physical work capacity in childhood may be protective against OA development later in life. The multifactorial aetiology of OA requires incorporating multiple lines of evidence to interpret individual or population health from bone samples.

Restating the Case for a Sharp Population Decline in Lemur catta

As with many other species in the primate order, ring-tailed lemurs (Lemur catta) are threatened with extinction. Our articles documented declines in wild ring-tailed lemur populations and noted that fewer than 2,500 wild ring-tailed lemurs are known to persist in 32 [Gould and Sauther: Primate Conservation 2016; 30: 89-101] and 34 [LaFleur et al.: Folia Primatologica 2017; 87: 320-330] sites. A criticism of our articles [Murphy et al.: International Journal of Primatology 2017; 38: 623-628] suggested that we have inadequately sampled ring-tailed lemur populations and habitats, and misused the literature. We disagree, and provide both a detailed rebuttal and responses to specific critique points herein. Moreover, we restate our case outlining a dramatic decline of ring-tailed lemurs resulting from anthropogenic pressures (deforestation, severe habitat fragmentation, extraction for the pet and bushmeat trades). We pose several thought-provoking questions as to when is the appropriate time for researchers to "sound the alarm" about a species' decline, and remain committed to understanding the drivers of unsustainable exploitation of this emblematic lemur, and preventing their extinction in the wild.

A comparison of the clinical effectiveness and cost of specialised individually delivered parent training for preschool attention-deficit/hyperactivity disorder and a generic, group-based programme: a multi-centre, randomised controlled trial of the New Forest Parenting Programme versus Incredible Years

The objective of this study is to compare the efficacy and cost of specialised individually delivered parent training (PT) for preschool children with attention-deficit/hyperactivity disorder (ADHD) against generic group-based PT and treatment as usual (TAU). This is a multi-centre three-arm, parallel group randomised controlled trial conducted in National Health Service Trusts. The participants included in this study were preschool children (33-54 months) fulfilling ADHD research diagnostic criteria. New Forest Parenting Programme (NFPP)-12-week individual, home-delivered ADHD PT programme; Incredible Years (IY)-12-week group-based, PT programme initially designed for children with behaviour problems were the interventions. Primary outcome-Parent ratings of child's ADHD symptoms (Swanson, Nolan & Pelham Questionnaire-SNAP-IV). Secondary outcomes-teacher ratings (SNAP-IV) and direct observations of ADHD symptoms and parent/teacher ratings of conduct problems. NFPP, IY and TAU outcomes were measured at baseline (T1) and post treatment (T2). NFPP and IY outcomes only were measured 6 months post treatment (T3). Researchers, but not therapists or parents, were blind to treatment allocation. Analysis employed mixed effect regression models (multiple imputations). Intervention and other costs were estimated using standardized approaches. NFPP and IY did not differ on parent-rated SNAP-IV, ADHD combined symptoms [mean difference - 0.009 95% CI (- 0.191, 0.173), p = 0.921] or any other measure. Small, non-significant, benefits of NFPP over TAU were seen for parent-rated SNAP-IV, ADHD combined symptoms [- 0.189 95% CI (- 0.380, 0.003), p = 0.053]. NFPP significantly reduced parent-rated conduct problems compared to TAU across scales (p values < 0.05). No significant benefits of IY over TAU were seen for parent-rated SNAP, ADHD symptoms [- 0.16 95% CI (- 0.37, 0.04), p = 0.121] or parent-rated conduct problems (p > 0.05). The cost per family of providing NFPP in the trial was significantly lower than IY (£1591 versus £2103). Although, there were no differences between NFPP and IY with regards clinical effectiveness, individually delivered NFPP cost less. However, this difference may be reduced when implemented in routine clinical practice. Clinical decisions should take into account parental preferences between delivery approaches.

Optimising impact and sustainability: a qualitative process evaluation of a complex intervention targeted at compassionate care

Background

Despite concerns about the degree of compassion in contemporary healthcare, there is a dearth of evidence for health service managers about how to promote compassionate healthcare. This paper reports on the implementation of the Creating Learning Environments for Compassionate Care (CLECC) intervention by four hospital ward nursing teams. CLECC is a workplace educational intervention focused on developing sustainable leadership and work-team practices designed to support team relational capacity and compassionate care delivery.

Objectives

To identify and explain the extent to which CLECC was implemented into existing work practices by nursing staff, and to inform conclusions about how such interventions can be optimised to support compassionate care in acute settings.

Methods

Process evaluation guided by normalisation process theory. Data gathered included staff interviews (n=47), observations (n=7 over 26 hours) and ward manager questionnaires on staffing (n=4).

Results

Frontline staff were keen to participate in CLECC, were able to implement many of the planned activities and valued the benefits to their well-being and to patient care. Nonetheless, factors outside of the direct influence of the ward teams mediated the impact and sustainability of the intervention. These factors included an organisational culture focused on tasks and targets that constrained opportunities for staff mutual support and learning.

Conclusions

Relational work in caregiving organisations depends on individual caregiver agency and on whether or not this work is adequately supported by resources, norms and relationships located in the wider system. High cognitive participation in compassionate nursing care interventions such as CLECC by senior nurse managers is likely to result in improved impact and sustainability.

The International Consolidated Venous Ulcer Guideline Update 2015: Process Improvement, Evidence Analysis, and Future Goals

In 2015, members of the Association for the Advancement of Wound Care (AAWC), Wound Healing Society, and the Canadian Association for Enterostomal Therapy formed the International Consolidated Guidelines Taskforce to update the AAWC Venous Ulcer Guidelines to the collaborative, intersociety, endorsed International Consolidated Venous Ulcer Guideline. This "guideline of guidelines" integrates recommendations from all relevant, published evidence-based guidelines on venous ulcer care and prevention. The update process was conducted in accordance with the National Guideline Clearinghouse inclusion criteria and was informed by a systematic review of the evidence, with additional content validation of each venous ulcer management recommendation. Twenty-three (23) wound experts participated. Compared to the 2010 version of the guideline, A-level recommendations increased from 62% to 77%, 31 recommendations were removed, and new recommendations included quality of life evaluations and surgical treatment options. Gaps in the evidence and needed areas for research include surgical, topical, and pharmaceutical interventions. Collaboration among societies and stakeholders and rigorous guideline development processes may expedite the implementation of evidence-based practices, fill in research gaps, and provide a powerful unified voice to regulatory and reimbursement agencies with the ultimate goal of improving outcomes for persons with a venous ulcer.

Paternity in wild ring-tailed lemurs (Lemur catta): Implications for male mating strategies

In group-living species with male dominance hierarchies where receptive periods of females do not overlap, high male reproductive skew would be predicted. However, the existence of female multiple mating and alternative male mating strategies can call into question single-male monopolization of paternity in groups. Ring-tailed lemurs (Lemur catta) are seasonally breeding primates that live in multi-male, multi-female groups. Although established groups show male dominance hierarchies, male dominance relationships can break down during mating periods. In addition, females are the dominant sex and mate with multiple males during estrus, including group residents, and extra-group males-posing the question of whether there is high or low male paternity skew in groups. In this study, we analyzed paternity in a population of wild L. catta from the Bezà Mahafaly Special Reserve in southwestern Madagascar. Paternity was determined with 80-95% confidence for 39 offspring born to nine different groups. We calculated male reproductive skew indices for six groups, and our results showed a range of values corresponding to both high and low reproductive skew. Between 21% and 33% of offspring (3 of 14 or three of nine, counting paternity assignments at the 80% or 95% confidence levels, respectively) were sired by extra-troop males. Males siring offspring within the same group during the same year appear to be unrelated. Our study provides evidence of varying male reproductive skew in different L. catta groups. A single male may monopolize paternity across one or more years, while in other groups, >1 male can sire offspring within the same group, even within a single year. Extra-group mating is a viable strategy that can result in extra-group paternity for L. catta males.

Principal component analysis in the evaluation of osteoarthritis

OBJECTIVES

The purpose of this study is to demonstrate advantages of principal component analysis (PCA) as a standardized procedure in the evaluation of osteoarthritis (OA) in a skeletal series to: (1) compute aggregate scores for joint complexes that accurately capture pathological expression, (2) reveal which variables describe the most sample variation in OA, (3) enable inter- and intra-sample comparison of results, and (4) formulate predictive models from component-based arthritic scores.

MATERIALS AND METHODS

The sample (144 males, 145 females) is drawn from a large skeletal cemetery collection of modern Europeans of known sex, age, and occupation. OA data was collected using standard ranked categorical scoring. PCA was conducted separately on lumbar spine, pelvis, and knee regions to generate composite OA scores from eigenequations of the first and second principal components (PC).

RESULTS

Results demonstrate that as severity in OA increases, so does the distribution of OA within the joint surface. In each region, PCA produced the same general pattern with eburnation scoring driving significant changes in composite OA scores, representing earlier to later stages of cartilage degeneration. The distribution of arthritic traits determined by PCA produced an OA score that quantifies the expression of joint changes in varied biological joint structures from most moveable to least mobile, the final stage being joint fusion. OA scores are most highly variable in the lumbar region for both males and females, as compared to the pelvis and knee.

CONCLUSIONS

PCA is a simple, non-parametric method of extracting relevant information from complex OA datasets and summarizes variation based on correlated multi-attributes to reveal a simplified structure of OA expression. Multivariate techniques like PCA should be used to describe discrete OA samples, and are useful to compute population-specific representative measurements for idiopathic joint OA in a skeletal sample.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Clinical interventions for venous leg ulcers: Proposals to improve the quality of clinical leg ulcer research

The present status of clinical leg ulcer healing research was reviewed by 25 experts over 2 days on September 28 and 29, 2015. Multiple clinical effectiveness reviews were presented suggesting that published clinical wound healing research often does not meet present (2015) evidence based standards. Specific areas requiring remediation were highlighted and approaches to overcoming existing challenges were proposed. Participants using anonymous voting technology developed an action plan to resolve perceived deficiencies. Statements were accepted if 75% of participants agreed. Older patients with a high frequency of comorbid conditions posed particular difficulties in designing clinical research protocols and better diagnostic categorization is necessary A standardized model template for collecting information about diagnosis and evaluation of the effect of interventions on healing of all types of leg ulcers was considered a high priority. Such a model template could be modified depending on the specific etiology of the leg ulcers. Generally agreed on quantifiable standards to establish degree of morbidity was considered a high priority. There was universal agreement that sources of funding and conflicts of interest needed to be disclosed in presentations and all publications. All clinical research studies should be registered with appropriate authorities. There was substantial enthusiasm for a clinical research network with quality standards for membership and an advisory research core available to investigators. Such a network should be funded and actively managed to insure long-term viability. The governance of such an entity needs to be established by the wound care community. The present trend to integrate patients into the clinical research process was endorsed and there was enthusiasm to develop patient advocacy for wound healing research.

Quantity and quality of interaction between staff and older patients in UK hospital wards: A descriptive study

Background

The quality of staff-patient interactions underpins the overall quality of patient experience and can affect other important outcomes. However no studies have been identified that comprehensively explore both the quality and quantity of interactions in general hospital settings.

Aims & objectives

To quantify and characterise the quality of staff-patient interactions and to identify factors associated with negative interaction ratings.

Setting

Data were gathered at two acute English NHS hospitals between March and April 2015. Six wards for adult patients participated including medicine for older people (n = 4), urology (n = 1) and orthopaedics (n = 1).

Methods

Eligible patients on participating wards were randomly selected for observation. Staff-patient interactions were observed using the Quality of Interactions Schedule. 120 h of care were observed with each 2 h observation session determined from a balanced random schedule (Monday-Friday, 08:00-22:00 h). Multilevel logistic regression models were used to determine factors associated with negative interactions.

Results

1554 interactions involving 133 patients were observed. The median length of interaction was 36 s with a mean of 6 interactions per patient per hour. Seventy three percent of interactions were categorized as positive, 17% neutral and 10% negative. Forty percent of patients had at least one negative interaction (95% confidence interval 32% to 49%). Interactions initiated by the patient (adjusted Odds Ratio [OR] 5.30), one way communication (adjusted OR 10.70), involving two or more staff (adjusted OR 5.86 for 2 staff, 6.46 for 3+ staff), having a higher total number of interactions (adjusted OR 1.09 per unit increase), and specific types of interaction content were associated with increased odds of negative interaction (p < 0.05). In the full multivariable model there was no significant association with staff characteristics, skill mix or staffing levels. Patient agitation at the outset of interaction was associated with increased odds of negative interaction in a reduced model. There was no significant association with gender, age or cognitive impairment. There was substantially more variation at ward level (variance component 1.76) and observation session level (3.49) than at patient level (0.09).

Conclusion

These findings present a unique insight into the quality and quantity of staff-patient interactions in acute care. While a high proportion of interactions were positive, findings indicate that there is scope for improvement. Future research should focus on further exploring factors associated with negative interactions, such as workload and ward culture.

Treatment of chronic diabetic lower extremity ulcers with advanced therapies: a prospective, randomised, controlled, multi-centre comparative study examining clinical efficacy and cost

Advanced therapies such as bioengineered skin substitutes (BSS) and dehydrated human amnion/chorion membrane (dHACM) have been shown to promote healing of chronic diabetic ulcers. An interim analysis of data from 60 patients enrolled in a prospective, randomised, controlled, parallel group, multi-centre clinical trial showed that dHACM (EpiFix, MiMedx Group Inc., Marietta, GA) is superior to standard wound care (SWC) and BSS (Apligraf, Organogenesis, Inc., Canton, MA) in achieving complete wound closure within 4-6 weeks. Rates and time to closure at a longer time interval and factors influencing outcomes remained unassessed; therefore, the study was continued in order to achieve at least 100 patients. With the larger cohort, we compare clinical outcomes at 12 weeks in 100 patients with chronic lower extremity diabetic ulcers treated with weekly applications of Apligraf (n = 33), EpiFix (n = 32) or SWC (n = 35) with collagen-alginate dressing as controls. A Cox regression was performed to analyse the time to heal within 12 weeks, adjusting for all significant covariates. A Kaplan-Meier analysis was conducted to compare time-to-heal within 12 weeks for the three treatment groups. Clinical characteristics were well matched across study groups. The proportion of wounds achieving complete closure within the 12-week study period were 73% (24/33), 97% (31/32), and 51% (18/35) for Apligraf, EpiFix and SWC, respectively (adjusted P = 0·00019). Subjects treated with EpiFix had a very significant higher probability of their wounds healing [hazard ratio (HR: 5·66; adjusted P: 1·3 x 10(-7) ] compared to SWC alone. No difference in probability of healing was observed for the Apligraf and SWC groups. Patients treated with Apligraf were less likely to heal than those treated with EpiFix [HR: 0·30; 95% confidence interval (CI): 0·17-0·54; unadjusted P: 5·8 x 10(-5) ]. Increased wound size and presence of hypertension were significant factors that influenced healing. Mean time-to-heal within 12 weeks was 47·9 days (95% CI: 38·2-57·7) with Apligraf, 23·6 days (95% CI: 17·0-30·2) with EpiFix group and 57·4 days (95%CI: 48·2-66·6) with the SWC alone group (adjusted P = 3·2 x 10(-7) ). Median number of grafts used per healed wound were six (range 1-13) and 2·5 (range 1-12) for the Apligraf and EpiFix groups, respectively. Median graft cost was $8918 (range $1,486-19,323) per healed wound for the Apligraf group and $1,517 (range $434-25,710) per healed wound in the EpiFix group (P < 0·0001). These results provide further evidence of the clinical and resource utilisation superiority of EpiFix compared to Apligraf for the treatment of lower extremity diabetic wounds.

Comparison of the genetic variation of captive ring-tailed lemurs with a wild population in Madagascar

Genetic variability among captive and wild ring-tailed lemurs (Lemur catta) was assessed using mitochondrial and nuclear DNA data. A 529 bp segment of mtDNA was sequenced and 9 microsatellite loci were genotyped for 286 ring-tailed lemurs. Samples were obtained from the well-studied L. catta population at the Bezà Mahafaly Special Reserve and from captive animals at six institutions worldwide. We found evidence of possible patrilineal contribution but the absence of matrilineal contribution from the Bezà area, and haplotypes not found in Bezà but present in Ambohimahavelona, Andringitra Massif, and other unknown locations, in the sampled captive population, indicating that the founders of the captive population originated from a wide geographic range. Total genetic variation and relatedness in captive L. catta in the six institutions were similar in extent to that of the wild population in Bezà. Based on the diverse origins of the captive population founders our results suggest the erosion of genetic diversity in the captive population. Sampled individuals from the same institution were more closely related to each other than members of a social group in the wild. Individuals housed at different institutions were less closely related than those of different social groups at Bezà, indicating lower genetic exchange between captive institutions than between social groups in a locality in the wild. Our findings underscore the usefulness of genotyping in determining the geographic origin of captive population founders, obtaining pedigree information if paternity is uncertain, and in maximizing preservation of extant genetic diversity in captivity.

Ring-tailed lemurs: a species re-imagined

For over 50 years, ring-tailed lemurs have been studied continuously in the wild. As one of the most long-studied primate species, the length and breadth of their study is comparable to research on Japanese macaques, baboons and chimpanzees. They are also one of the most broadly observed of all primates, with comprehensive research conducted on their behaviour, biology, ecology, genetics, palaeobiology and life history. However, over the last decade, a new generation of lemur scholars, working in conjunction with researchers who have spent decades studying this species, have greatly enhanced our knowledge of ring-tailed lemurs. In addition, research on this species has expanded beyond traditional gallery forest habitats to now include high altitude, spiny thicket, rocky outcrop and anthropogenically disturbed coastal forest populations. The focus of this special volume is to 're-imagine' the 'flagship species of Madagascar', bringing together three generations of lemur scholars.

Genetic Diversity of the Ring-Tailed Lemur (Lemur catta) in South-Central Madagascar

Madagascar's lemurs, now deemed the most endangered group of mammals, represent the highest primate conservation priority in the world. Due to anthropogenic disturbances, an estimated 10% of Malagasy forest cover remains. The endangered Lemur catta is endemic to the southern regions of Madagascar and now occupies primarily fragmented forest habitats. We examined the influence of habitat fragmentation and isolation on the genetic diversity of L. catta across 3 different forest fragments in south-central Madagascar. Our analysis revealed moderate levels of genetic diversity. Genetic differentiation among the sites ranged from 0.05 to 0.11. These data suggest that the L. catta populations within south-central Madagascar have not yet lost significant genetic variation. However, due to ongoing anthropogenic threats faced by ring-tailed lemurs, continued conservation and research initiatives are imperative for long-term viability of the species.

Reproductive Female Feeding Strategies in Spiny Forest-Dwelling Lemur catta in Southern and Southwestern Madagascar: How Do Females Meet the Challenges of Reproduction in this Harsh Habitat?

The spiny forest ecoregion of southern and southwestern Madagascar is characterized by low annual rainfall, high temperatures, short-stature xeric vegetation and lack of canopy. Lemur catta is often the only diurnal primate persisting in this habitat. For reproductive females living in spiny forests, gestation and early-to-mid lactation periods occur during the dry season when food resources are limited. We conducted a between-site comparison of variables important to the feeding ecology of reproductive female L. catta inhabiting spiny forest at 3 sites: Berenty spiny forest (BSF), Cap Sainte-Marie (CSM) and Tsimanampesotse National Park (TNP). We hypothesize that the ability for pregnant and lactating females to adequately obtain plant foods high in protein, low in fiber and with a high water content is crucial to their survival and successful reproduction in spiny habitat. We found favorable or relatively equal protein-to-fiber ratios in plant foods most frequently consumed by reproductive females, and preferred foods contained high water content. Some overlap in preferred plant species at the 3 sites suggests important plant foods for reproductive females inhabiting spiny forests. We suggest that choosing foods high in protein, relatively low in fiber and with high water content are behavioral adaptations allowing female L. catta to reproduce and survive in this habitat.

Genetic Evidence for Male and Female Dispersal in Wild Lemur catta

Lemur catta has traditionally been considered a species with male-biased dispersal; however, occasional female dispersal occurs. Using molecular data, we evaluated dispersal patterns in 2 L. catta populations in southwestern Madagascar: Tsimanampesotse National Park (TNP) and Bezà Mahafaly Special Reserve (BMSR). We also investigated the genetic differentiation between the populations and dispersal partner relatedness. Results showed minor genetic differentiation between the populations (ϴ(ST) = 0.039), which may indicate gene flow historically occurring in this region, made possible by the presence of L. catta groups between the sites. Different patterns of sex-biased dispersal were found between the sites using corrected assignment indices: male-biased dispersal in TNP, and a lack of sex-biased dispersal in BMSR. Observational evidence of female dispersal in BMSR supports these results and may imply intense female resource competition in and around BMSR, because small groups of 2-3 females have been observed dispersing within BMSR and entering the reserve from outside. These dispersing groups largely consisted of mothers transferring with daughters, although we have an aunt-niece pair transferring together. Genetic data suggest that males also transfer with relatives. Our data demonstrate that dispersal partners consist of same-sexed kin for L. catta males and females, highlighting the importance of kin selection.

Chronic wound repair and healing in older adults: current status and future research

Older adults are more likely to have chronic wounds than younger people, and the effect of chronic wounds on quality of life is particularly profound in this population. Wound healing slows with age, but the basic biology underlying chronic wounds and the influence of age-associated changes on wound healing are poorly understood. Most studies have used in vitro approaches and various animal models, but observed changes translate poorly to human healing conditions. The effect of age and accompanying multimorbidity on the effectiveness of existing and emerging treatment approaches for chronic wounds is also unknown, and older adults tend to be excluded from randomized clinical trials. Poorly defined outcomes and variables; lack of standardization in data collection; and variations in the definition, measurement, and treatment of wounds also hamper clinical studies. The Association of Specialty Professors, in conjunction with the National Institute on Aging and the Wound Healing Society, held a workshop, summarized in this article, to explore the current state of knowledge and research challenges, engage investigators across disciplines, and identify research questions to guide future study of age-associated changes in chronic wound healing.

Chronic wound repair and healing in older adults: current status and future research

The incidence of chronic wounds is increased among older adults, and the impact of chronic wounds on quality of life is particularly profound in this population. It is well established that wound healing slows with age. However, the basic biology underlying chronic wounds and the influence of age-associated changes on wound healing are poorly understood. Most studies have used in vitro approaches and various animal models, but observed changes translate poorly to human healing conditions. The impact of age and accompanying multi-morbidity on the effectiveness of existing and emerging treatment approaches for chronic wounds is also unknown, and older adults tend to be excluded from randomized clinical trials. Poorly defined outcomes and variables, lack of standardization in data collection, and variations in the definition, measurement, and treatment of wounds also hamper clinical studies. The Association of Specialty Professors, in conjunction with the National Institute on Aging and the Wound Healing Society, held a workshop, summarized in this paper, to explore the current state of knowledge and research challenges, engage investigators across disciplines, and identify key research questions to guide future study of age-associated changes in chronic wound healing.

A prospective, randomised, controlled, multi-centre comparative effectiveness study of healing using dehydrated human amnion/chorion membrane allograft, bioengineered skin substitute or standard of care for treatment of chronic lower extremity diabetic ulcers

A prospective, randomised, controlled, parallel group, multi-centre clinical trial was conducted at three sites to compare the healing effectiveness of treatment of chronic lower extremity diabetic ulcers with either weekly applications of Apligraf(®) (Organogenesis, Inc., Canton, MA), EpiFix(®) (MiMedx Group, Inc., Marietta, GA), or standard wound care with collagen-alginate dressing. The primary study outcome was the percent change in complete wound healing after 4 and 6 weeks of treatment. Secondary outcomes included percent change in wound area per week, velocity of wound closure and a calculation of the amount and cost of Apligraf or EpiFix used. A total of 65 subjects entered the 2-week run-in period and 60 were randomised (20 per group). The proportion of patients in the EpiFix group achieving complete wound closure within 4 and 6 weeks was 85% and 95%, significantly higher (all adjusted P-values ≤ 0·003) than for patients receiving Apligraf (35% and 45%), or standard care (30% and 35%). After 1 week, wounds treated with EpiFix had reduced in area by 83·5% compared with 53·1% for wounds treated with Apligraf. Median time to healing was significantly faster (all adjusted P-values ≤0·001) with EpiFix (13 days) compared to Apligraf (49 days) or standard care (49 days). The mean number of grafts used and the graft cost per patient were lower in the EpiFix group campared to the Apligraf group, at 2·15 grafts at a cost of $1669 versus 6·2 grafts at a cost of $9216, respectively. The results of this study demonstrate the clinical and resource utilisation superiority of EpiFix compared to Apligraf or standard of care, for the treatment of diabetic ulcers of the lower extremities.

Seasonal patterns of male affiliation in ring-tailed lemurs (Lemur catta) in diverse habitats across southern Madagascar

We examined the mechanisms guiding male affiliative relationships among ring-tailed lemurs (Lemur catta) to investigate the adaptive significance of male social bonds in a female dominant, strictly seasonally breeding strepsirhine primate. To test whether male affiliative relationships were driven by reproductive and/or ecological conditions, we compared the frequency of male affiliation across the annual reproductive cycle in populations of L. catta inhabiting three habitat types found within its geographic range: (1) gallery forest at Beza Mahafaly Special Reserve in southwestern Madagascar; (2) spiny bush at Cap Sainte-Marie (CSM) in southern Madagascar; and (3) rocky-outcrop forest fragments at Anja Reserve and the Tsaranoro Valley in Madagascar’s south-central highlands. Each study period spanned the gestation, lactation/migration, post-migration, and mating periods. Inter-male affiliation rates varied across reproductive periods at each of the four sites, with the highest frequencies being observed during the gestation and lactation/migration periods and the lowest frequencies occurring during the mating period. In contrast, we found no clear patterns in male–female affiliation rates with respect to reproductive period. Comparing the Beza Mahafaly and CSM populations, rates of inter-male affiliation were higher at CSM during the gestation and lactation/migration periods, and rates male–female affiliation were higher at CSM across all seasons except the post-migration period. We suggest that inter-male affiliative relationships in L. catta may provide beneficial social interactions (i.e., grooming, ectoparasite control, predator protection, vigilance against extra-group male agonism) when females are unavailable, particularly during male dispersal, as well as under harsh climatic conditions characteristic of some L. catta habitats.

Information prescriptions: A tool for veterinary practices

The Internet has become a major source of health information and has the potential to offer many benefits for both human and animal health. In order for impact to be positive, however, it is critical that users be able to access reliable, trustworthy information. Although more pet owners are using the Internet to research animal health information than ever before, there remains limited research surrounding their online activities or the ability to influence owners' online search behaviors. The current study was designed to assess the online behaviors and perceptions of pet owners after receiving either general or topic-specific information prescriptions as part of their veterinary appointment. Results indicate that nearly 60% of clients accessed the suggested websites and nearly all of these clients reported positive feelings about this addition to their veterinary services. These results suggest that offering information prescriptions to clients can facilitate better online searches by clients and positively impact both animal health and client satisfaction.