Elizabeth Ruby

Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale.

BACKGROUND There have been no studies that have tested the Braden Scale for predictive validity and established cutoff points for assessing risk specific to different settings. OBJECTIVES To evaluate the predictive validity of the Braden Scale in a variety of settings (tertiary care hospitals, Veterans Administration Medical Centers [VAMCs], and skilled nursing facilities [SNFs]). To determine the critical cutoff point for classifying risk in these settings and whether this cutoff point differs between settings. To determine the optimal timing for assessing risk across settings. METHOD Randomly selected subjects (N= 843) older than 19 years of age from a variety of care settings who did not have pressure ulcers on admission were included. Subjects were 63% men, 79% Caucasian, and had a mean age of 63 (+/-16) years. Subjects were assessed for pressure ulcers using the Braden Scale every 48 to 72 hours for 1 to 4 weeks. The Braden Scale score and skin assessment were independently rated, and the data collectors were blind to the findings of the other measures. RESULTS One hundred eight of 843 (12.8%) subjects developed pressure ulcers. The incidence was 8.5%, 7.4%, and 23.9% in tertiary care hospitals, VAMCs, and SNFs, respectively. Subjects who developed pressure ulcers were older and more likely to be female than those who did not develop ulcers. Braden Scale scores were significantly (p = .0001) lower in those who developed ulcers than in those who did not develop ulcers. Overall, the critical cutoff score for predicting risk was 18. Risk assessment on admission is highly predictive of pressure ulcer development in all settings but not as predictive as the assessment completed 48 to 72 hours after admission. CONCLUSIONS Risk assessment on admission is important for timely planning of preventive strategies. Ongoing assessment in SNFs and VAMCs improves prediction and permits fine-tuning of the risk-based prevention protocols. In tertiary care the most accurate prediction occurs at 48 to 72 hours after admission and at this time the care plan can be refined.

Multi‐site Study of Incidence of Pressure Ulcers and the Relationship Between Risk Level, Demographic Characteristics, Diagnoses, and Prescription of Preventive Interventions

OBJECTIVE: To determine the incidence of pressure ulcers in varied populations, and whether demographic characteristics (age, gender, race) and primary diagnosis are factors in pressure ulcer development when the level of risk for developing ulcers is considered. To determine if there is a difference in the type of preventive services prescribed for persons who do or do not develop pressure ulcers when risk is controlled and whether differences can be related to demographic characteristics.

Introduction of 6-mercaptopurine in Crohn's disease patients during the perioperative period: a preliminary evaluation of recurrence of disease.

BACKGROUND Recurrence of Crohns disease after surgery is a common occurrence, pointing to the need for a strategy to prevent recurrent disease. We report the postoperative course of 10 patients who required intestinal resections for complications related to Crohns disease. METHODS All patients had a Pediatric Crohns Disease Activity Index score of 10 or greater. Among these patients, 5 began treatment with 6-mercaptopurine in the perioperative period. All 10 had received various combinations of prednisone and salicylate compounds. Patients who were given 6-mercaptopurine did not discontinue the medication until 2 years after the surgery. RESULTS To date, none of the five patients who were placed on 6-mercaptopurine have had recurrence of their Crohns disease (mean disease-free period 32.6 +/- 18.4 months). Among those five patients not receiving 6-mercaptopurine there have been three relapses (mean time to relapse 3.7 +/- 1.2 months). Log-rank sum analyses of Kaplan-Meier survival curves show benefit to patients receiving 6-mercaptopurine in preventing relapses after intestinal resection (p < 0.05). CONCLUSIONS Although the underlying pathophysiologic reasons leading to the high relapse rate after intestinal surgery in Crohns disease are unknown, we conclude that treatment with 6-mercaptopurine in the perioperative period may be warranted to help prevent the recurrence of Crohns disease after surgery.

Increased platelet transfusion requirement is associated with multiple organ dysfunctions in patients undergoing hematopoietic stem cell transplantation

Organ dysfunction following hematopoietic stem cell transplantation (HSCT) may be a manifestation of a systemic inflammatory response. We speculate that part of the platelet transfusion requirement in HSCT patients results from this systemic inflammatory response, and increased transfusion requirement would be associated with, or precede, organ dysfunction. We studied 199 adults undergoing autologous (n = 173) or allogeneic (n = 26) HSCT. Patients with CNS (P = 0.008) or pulmonary (P = 0.002) dysfunction, or with VOD (P = 0.05) received a higher mean number of platelet transfusions per week than patients who did not have these dysfunctions. Furthermore, a higher number of platelet transfusions during any 1 week period was significantly associated with development of pulmonary (P = 0.0002) or renal (P < 0.0001) dysfunction in the following week. this predictive value was strongest early in the hsct course, but remained significant over all 4 weeks. in multivariate analysis the number of platelet transfusions during the previous week was independently predictive for development of pulmonary dysfunction in week 2 (P = 0.01) and week 3 (P = 0.055). We believe that occurrence of increased platelet transfusion requirement prior to onset of dysfunction is consistent with the concept that an antecedent inflammatory response results in both platelet consumption and various organ dysfunctions. Increased platelet transfusion requirement may act as an early marker of subsequent organ dysfunction. Additionally, there may be a direct role of platelets in the development and progression of organ dysfunction in HSCT patients.

Anti-Insulin Antibodies Are a Cause of Hypoglycemia Following Pancreas Transplantation

OBJECTIVE Hypoglycemie symptoms have been reported by more than half of pancreas transplantation (PTX) recipients. To better understand the mechanism for the hypoglycemia documented in some of these patients, we studied the glucose and pancreatic hormone response to Sustacal in patients with and without hypoglycemia following PTX. RESEARCH DESIGN AND METHODS Twelve patients with established, repeated episodes of hypoglycemia following PTX (hypo) were case-matched to PTX recipients without hypoglycemie symptoms (control; n = 7). On the day of the study, fasting glucose, free and total immunoreactive insulin (IR1), C-peptide, proinsulin, and glucagon were drawn (time 0); Sustacal was administered; and glucose, free and total IRI, and C-peptide were assayed at 15,30,45, 75,120,150,180, and 240 min. Based on the glucose response to Sustacal, the hypo group was further divided into those whose glucose rose after Sustacal (hypo-high; n = 7) and those with no increase in glucose from baseline concentration (hypo-flat; n = 5). RESULTS Before the administration of Sustacal, the hypo-high group had a lower fasting free/total IRI (0.26 ± 0.06, mean ± SE) than the hypo-flat (0.51 ± 0.02) or control (0.52 ± 0.04) groups (both P < 0.05 compared with hypo-high). The glucose response to Sustacal was greatest in the hypo-high group as defined. Area under the curve (AUC) for total IRI following Sustacal was also greatest in the hypo-high group (P < 0.05 compared with both control and hypo-flat groups), but there was no significant difference in free IRI AUC following Sustacal between the three groups. Two individuals developed hypoglycemia during the Sustacal challenge, both in the hypo-high group. CONCLUSIONS The lower fasting free/total IRI ratio and greater increase in glucose and total IRI in response to Sustacal in the hypo-high group compared with either the hypo-flat or control groups are consistent with the presence of significant quantities of anti-insulin antibodies in the hypo-high group. Because anti-insulin antibodies are, in turn, an established cause of episodic hypoglycemia, this study provides the first data to support the hypothesis that significant quantities of anti-insulin antibodies are a cause of symptomatic hypoglycemia following PTX in some recipients.

Factors predicting morbidity following hematopoietic stem cell transplantation.

Circulating anticoagulants protein C (PC) and antithrombin III (AT) are markers of, and possibly involved in the pathogenesis of, significant organ dysfunction, in patients undergoing autologous peripheral blood stem cell (PSBC) or autologous bone marrow (BM) transplantation. The effect of the stem cell source, the use of hematopoietic growth factors (GFs), and the specific preparative regimen on the incidence of organ system dysfunction or on post-transplant levels of circulating anticoagulants has not been well studied. We analyzed 205 patients in an attempt to correlate organ dysfunction and AT and PC deficiencies with these transplant-specific factors (78 BMT with GM-CSF after transplant, 95 PBSCT without GM-CSF after transplant, and 32 PBSCT with GM-CSF after transplant). Patients transplanted with PBSC had a lower incidence of pulmonary dysfunction (20 vs 40%, P = 0.006) and liver dysfunction (4  vs 13%, P = 0.05) than patients receiving BM. The use of GF after transplant did not influence the development of subsequent organ dysfunction. In multivariate analysis, the stem cell source was again predictive of pulmonary dysfunction. In contrast, although patients transplanted with PBSC also had a lower incidence of PC deficiency (50 vs 81%, P < 0.01) and AT deficiency (20 vs 54%, P < 0.01) as compared with patients receiving BM, use of GM-CSF after transplant was a more significant risk factor for the development of anticoagulant deficiency (PBSC with GF vs PBSC without GF: PC deficiency 50 vs 78%, P = 0.007; AT deficiency 20 vs 47%, P = 0.005). In the multivariate analysis GM-CSF use was the only significant risk factor for development of anticoagulant deficiency. Since the clinical significance of anticoagulant deficiency has been well shown, further studies examining these effects of hematopoietic GFs appear warranted.

Acceptance of International Students: Host and Sojourner Characteristics

This study was designed to investigate how both characteristics of the sojourner and of the host affect how American students regard and treat international students in the United States. Undergraduates (N=198) evaluated college admission applications. All applicant information was held constant except for gender, race, and nationality. After they completed a questionnaire evaluating the foreign applicant, they volunteered to offer various levels of hospitality to foreign students. In terms of host characteristics, the results indicate that women were more favorable than men in their ratings of foreign students, and Minorities (48% of the sample) were more favorable than Whites in their volunteerism. Regarding characteristics of the foreigner, American students responded equally to male and female foreigners; equally to White and Black foreigners; but they evaluated Canadian foreigners more favorably than Algerian ones. There was an interaction between gender of the host and foreigner in a few instances, and several instances of an interaction between race of the host and race of the foreigner. These results partially support the hypotheses and suggest that what makes a difference in how Americans respond to foreigners is cultural similarity and shared ethnic minority status.