Age-Specific Probability of 4 Major Health Outcomes in Children with Spina Bifida

OBJECTIVE

This study aimed to estimate the age-specific probability of 4 health outcomes in a large registry of individuals with spina bifida (SB).

METHODS

The association between age and 4 health outcomes was examined in individuals with myelomeningocele (MMC, n = 5627) and non-myelomeningocele (NMMC, n = 1442) from the National Spina Bifida Patient Registry. Sixteen age categories were created, 1 for each year between the ages of 5 and 19 years and 1 for those aged 20 years or older. Generalized linear models were used to calculate the adjusted probability and 95% prediction intervals of each outcome for each age category, adjusting for sex and race/ethnicity.

RESULTS

For the MMC and NMMC groups, the adjusted coefficients for the correlation between age and the probability of each outcome were -0.933 and -0.657 for bladder incontinence, -0.922 and -0.773 for bowel incontinence, 0.942 and 0.382 for skin breakdown, and 0.809 and 0.619 for lack of ambulation, respectively.

CONCLUSION

In individuals with SB, age is inversely associated with the probability of bladder and bowel incontinence and directly associated with the probability of skin breakdown and lack of ambulation. The estimated age-specific probabilities of each outcome can help SB clinicians estimate the expected proportion of patients with the outcome at specific ages and explain the probability of the occurrence of these outcomes to patients and their families.

Decreasing Skin Breakdown Around Central Lines in Patients Receiving Thiotepa Prior to Bone Marrow Transplantation

Skin breakdown occurring around central line dressings increases the risk for infection and bacteremia in all patients. The risk is magnified when experienced in pediatric patients receiving marrow-ablative therapy. A staff nurse on an inpatient pediatric oncology and bone marrow transplant unit noted an increased incidence of skin breakdown around central line dressings in patients receiving Thiotepa prior to bone marrow transplantation. Although there is a wealth of information surrounding routine care of central venous access devices, there is little evidence surrounding care with impaired skin integrity. A staff nurse turned to expert opinion and consensus revealed the use of nonocclusive dressings for central lines. A new protocol for changing central line dressings was developed to decrease the rate of skin breakdown. The protocol utilized gauze and a self-adherent wrap instead of tape to secure central lines. Bone marrow transplant staff nurses were educated prior to the practice change, and compliance was monitored through observation and review of documentation in the electronic medical record. A retrospective chart review compared the rate of skin breakdown and central line associated blood stream infections pre- and postpractice change. The overall percentage of skin breakdown surrounding central lines was reduced by over 80%.

Prevention and Care for Incontinence-Associated Dermatitis Among Older Adults: A Systematic Review

Background

The prevalent rate of incontinence-associated dermatitis (IAD) trends upward in older populations. Skin breakdown from IAD impacts the quality of life of older adults and reflects the quality of care in hospitals and long-term care facilities. Specific and appropriate interventions for prevention and care are needed. This systematic review aims to review optimal strategies for prevention and care for older adults with IAD.

Methods

PubMed, CINAHL, SCOPUS, Medline, ProQuest, ThaiLIS, ThaiJo, and E-Thesis were searched for articles published between January 2010 and December 2020. Only articles focusing on older adults were included for the review.

Results

Eleven articles met the inclusion/exclusion criteria. Interventions for the prevention and care of IAD among older adults were categorized as assessment, incontinence management/causative factors management, cleansing, application of medical products for both skin moisturizing and skin barrier, body positioning, nutrition promotion, health education and training, and outcome evaluation. Specific prevention and care strategies for older adults with IAD included using specific assessment tools, applying skin cleansing pH from 4.0 to 6.8, body positioning, and promoting food with high protein. Other strategies were similar to those reported for adult patients.

Conclusion

The systematic review extracted current and specific prevention and care strategies for IAD in older adults. The prevention and care strategies from this systematic review should be applied in clinical practice. However, more rigorous research methodology is recommended in future studies, especially in examining intervention outcomes. Nurses and other health professionals should be educated and trained to understand the causes of IAD in older adults and the specific prevention and care strategies for this population. Because older adults are prone to skin damage, and this type of skin breakdown differs from pressure ulcers, the tools for assessment and evaluation, and the strategies for prevention and care require special attention.

Prospero Registration Number

CRD42021251711.

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Retrospective chart review of minor tibial fractures in preschoolers: immobilisation and complications

OBJECTIVE

To compare the treatment practices (immobilisation vs non-immobilisation) of toddler fractures and other minor tibial fractures (both proven and suspected) in preschoolers, aged 9 months-4 years, and examine rates of ED re-presentations and complications.

METHODS

Retrospective chart review of presentations of minor tibial fractures, both proven (radiologically confirmed) or suspected (negative X-ray but clinical evidence of bony injury), in children aged 9 months-4 years presenting to a single tertiary level paediatric ED from May 2016 to April 2018. Data collected included treatment practices, subsequent unscheduled re-presentations (including reasons) and complications (defined as problems relating to the injury that required further active care).

RESULTS

A search of medical records yielded 240 cases: 102 had proven fractures (spiral, buckle or Salter-Harris II) and 138 were diagnosed with a suspected fracture. 73.5% of proven fractures were immobilised, predominantly with backslabs. 79% of suspected fractures were treated with expectant observation without immobilisation. Patients treated with immobilisation were more likely to re-present to ED compared with non-immobilised patients (18/104, 17.3% vs 9/136, 6.6% RR 2.62, 95% CI 1.23 to 5.58). 21 complications were seen in 19/104 (18.3%) immobilised patients. There were eight skin complications (complication rate of 7.7%) and 11 cast issues (complication rate of 10.6%). Two (1.5%) of the 136 patients had complications related to pain or limp. Pain was uncommonly found, although follow-up was not universal.

CONCLUSION

In our centre, proven minor tibial fractures were more likely to receive a backslab, whereas for suspected fractures, expectant observation without immobilisation was performed. Although there is potential bias in the identification of complications with immobilisation, the study suggests that non-immobilisation approach should be investigated.

Skin breakdown of the feet in patients with spina bifida: Analysis of risk factors

PURPOSE

Recent studies on patients with spina bifida have noted an increased incidence of skin breakdown with more proximal functional neurologic level. We hypothesized that there would be an inverse relationship between skin breakdown of the foot and severity of functional level of lesion, because patients with more caudal levels of lesion spend more time ambulating.

METHODS

The National Spina Bifida Patient Registry (NSBPR) at Children's of Alabama was queried for the presence of skin breakdown of the foot, ambulatory status, functional neurologic level, and diagnosis of myelomeningocoele (MMC) vs. non-myelomeningocoele (non-MMC). Univariate and multivariate analysis were performed.

RESULTS

Of 491 total patients, 378 were MMC and 113 were non-MMC. Eighty-five of 378 (22.5%) patients with MMC and 5 of 113 (4.4%) non-MMC patients reported skin breakdown (p= 0.009). Thoracic and lumbar levels were compared to the sacral level for statistical analysis. Skin breakdown occurred in 26.2% of thoracic (p= 0.001), 33.3% of high-lumbar (p= 0.001), 21.5% of mid-lumbar (p= 0.008), 26.2% of low-lumbar (p= 0.001), and 6.1% of sacral level patients. Ambulatory status was not significant on multivariate analysis.

CONCLUSION

A diagnosis of MMC is a significant, independent risk factor for skin breakdown of the foot. Compared to sacral level, thoracic and lumbar levels of function were also independently significant. Ambulatory status was not significant.

Prevalence, clinical consequences and management of acute faecal incontinence with diarrhoea in the ICU: The FIRST™ Observational Study

There are limited data on the incidence and management of acute faecal incontinence with diarrhoea in the ICU. The FIRST™ Observational Study was undertaken to obtain data on clinical practices used in the ICU for the management of acute faecal incontinence with diarrhoea in Germany, UK, Spain and Italy. ICU-hospitalised patients ≥18 years of age experiencing a second episode of acute faecal incontinence with diarrhoea in 24 h were recruited, and management practices of acute faecal incontinence with diarrhoea were recorded for up to 15 days. A total of 372 patients had complete data sets; the mean duration of study was 6.8 days. At baseline, 40% of patients experienced mild or moderate-to-severe skin excoriation, which increased to 63% in patients with acute faecal incontinence with diarrhoea lasting >15 days. At baseline, 27% of patients presented with a pressure ulcer, which increased to 37%, 45% and 49% at days 5, 10 and 15, respectively. Traditional methods (pads, sheets and tubes) were more commonly used compared to faecal management systems during days 1-4 (76% vs. 47% faecal management system), while the use of a faecal management system increased to 56% at days 5-9 and 61% at days 10-15. At baseline, only 26% of nurses were satisfied with traditional management methods compared to 69% with faecal management systems. For patients still experiencing acute faecal incontinence with diarrhoea after 15 days, 82% of nurses using a faecal management systems to manage acute faecal incontinence with diarrhoea were satisfied or very satisfied, compared to 37% using traditional methods. These results highlight that acute faecal incontinence with diarrhoea remains an important healthcare challenge in ICUs in Europe; skin breakdown and pressure ulcers remain common complications in patients with acute faecal incontinence with diarrhoea in the ICU.

Treatment-related risk factors for development of skin breakdown in subjects with acute respiratory failure undergoing noninvasive ventilation or CPAP

BACKGROUND

Noninvasive ventilation (NIV) has been recognized as an effective strategy in preventing endotracheal intubation in subjects with acute respiratory failure (ARF). Some interface-related complications have also been recognized, such as skin breakdown (SB). The aim of this study was to determine the frequency of SB and identify potential treatment-related risk factors for its development in adults with ARF undergoing NIV or CPAP.

METHODS

A cross-sectional study was conducted in a general hospital. Subjects were retrospectively enrolled in this study if they were > 18 y old and developed ARF caused by any condition in which NIV or CPAP was indicated for at least one application for a period longer than 2 h. The outcomes were the prevalence of SB and the evaluation of related risk factors. Data were extracted from the electronic medical records. A stepwise forward logistic regression model was used to identify independent risk factors for SB development.

RESULTS

A total of 375 subjects (160 males) met the inclusion criteria and were enrolled in the study. Fifty-four subjects (14.4%) developed SB. The mean number of applications of NIV or CPAP carried out for > 2 h was higher in subjects with SB (7.1 ± 13.3 h) than in those without SB (4.4 ± 13.3 h) (P = .03). Subjects with SB also presented a higher total duration of NIV use (44.6 ± 118.5 h) compared with subjects without SB (21.8 ± 45.5 h) (P = .01). Subjects who developed SB presented a higher use of oronasal mask (92.6%) compared with the group that did not (21.5%) (P < .001).

CONCLUSIONS

In patients with ARF undergoing NIV or CPAP, oronasal mask use for > 26 h was independently associated with development of SB.