Hiromi Sanada

A dressing history

Over the past 30 years as caregivers, clinicians have been exposed to a plethora of new advanced wound dressings. The moist wound care revolution began in the 1970s with the introduction of film and hydrocolloid dressings, and today these are the traditional types of dressings of the advanced dressing categories. Wound‐healing science has progressed significantly over the same period, as a result of intense clinical and scientific research around these product introductions. Today, the clinician understands moist wound healing, occlusion, cost effectiveness, wound bed preparation and MMP activity to name but a few of the many concepts in wound care that have flourished as a result of technology and product advancement. This review article presents a condensed history of dressing development over the past 30 years. However, in addition, such advancement is discussed in respect to its adoption in different parts of the world. The largest single markets of the world are generally the United States of America and Europe; as such, the development of both practice and technology generally begins there. Much has been written about these markets in previous review articles. For the purposes of this review, the development of wound care and the maturing of practice is discussed in respect to Canada, Japan and Australia representing smaller geographical areas where the development has been more recent but nonetheless significant.

Ultrasound assessment of deep tissue injury in pressure ulcers: possible prediction of pressure ulcer progression.

Background: The concept of deep tissue injury under intact skin helps us understand the pathogenesis of pressure ulcers, but the best method for detecting and evaluating deep tissue injury remains to be established. Methods: Intermediate-frequency (10-MHz) ultrasonography was performed to evaluate deep tissue injury. The authors analyzed 12 patients (nine male patients and three female patients aged 16 to 92 years) who showed deep tissue injury–related abnormal findings on ultrasonography at the first examination and were followed up until the pressure ulcer reached a final stage. Results: The stage of ulcer worsened in six of 12 cases compared with baseline, and healed in the remaining six patients. The authors recognized four types of abnormal signs unique to deep tissue damage in ultrasonography: unclear layered structure, hypoechoic lesion, discontinuous fascia, and heterogeneous hypoechoic area. Unclear layered structure, hypoechoic lesion, discontinuous fascia, and heterogeneous hypoechoic area were detected at the first examination in 12, 10, seven, and five patients, respectively. Unclear layered structure and hypoechoic lesion were more commonly seen in pressure ulcers in deep tissue injury than the other features, but the follow-up study suggested that discontinuous fascia and heterogeneous hypoechoic area are more reliable predictors of future progression of pressure ulcers. Conclusions: The use of intermediate-frequency ultrasound reliably identified deep tissue injury and was believed to contribute to prevention and treatment of pressure-related ulcers. The results suggest that specific ultrasonographic characteristics may predict which pressure ulcers will progress.

Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus

Pressure ulcer prevalence and incidence data are increasingly being used as indicators of quality of care and the efficacy of pressure ulcer prevention protocols. In some health care systems, the occurrence of pressure ulcers is also being linked to reimbursement. The wider use of these epidemiological analyses necessitates that all those involved in pressure ulcer care and prevention have a clear understanding of the definitions and implications of prevalence and incidence rates. In addition, an appreciation of the potential difficulties in conducting prevalence and incidence studies and the possible explanations for differences between studies are important. An international group of experts has worked to produce a consensus document that aims to delineate and discuss the important issues involved, and to provide guidance on approaches to conducting and interpreting pressure ulcer prevalence and incidence studies. The groups main findings are summarised in this paper.

The impact of malnutrition and nutrition-related factors on the development and severity of pressure ulcers in older patients receiving home care

BACKGROUND & AIMS To investigate the impact of nutritional status and nutrition-related factors on the development and severity of pressure ulcers acquired in the home care setting. METHODS Two hundred and seven home care offices in Japan were selected at random and 290 patients with home-acquired pressure ulcers and 456 patients without pressure ulcers were analyzed. Data on nutritional status, caregiver knowledge, and health professionals nutritional management were collected. Pressure ulcers were categorized as superficial or full-thickness. RESULTS Malnutrition was significantly and most strongly associated with higher rate of the pressure ulcer after adjusting for other risk factors (OR, 2.29; 95% CI, 1.53-3.44). Assessment of the patients nutritional status and adequate dietary intake by a health professional were significantly associated with lower odds for developing pressure ulcers (OR, 0.43, 0.47; 95% CI, 0.27-0.68, 0.28-0.79, respectively). Malnutrition was also significantly and most strongly associated with more severe pressure ulcers (OR, 1.88; 95% CI, 1.03-3.45). Assessment of a caregivers nutritional knowledge by a health professional was a significant preventive factor for severe pressure ulcers. CONCLUSION The quality of home care for risk factors such as pressure redistribution has improved, making nutritional management a more crucial factor in pressure ulcer prevention.

Comprehensive assessment of nutritional status and associated factors in the healthy, community-dwelling elderly.

Background:  Malnutrition among the elderly has become a serious problem as their population increases in Japan. To approach the risk of malnutrition in the healthy, community‐dwelling elderly is important for early prevention of malnutrition. The nutritional status and mutable associated factors with poor nutritional status specific to the healthy elderly were examined comprehensively.

Development of the DESIGN‐R with an observational study: An absolute evaluation tool for monitoring pressure ulcer wound healing

DESIGN is a seven‐item (depth, exudates, size, inflammation/infection, granulation, necrosis, and pocket) monitoring scale for pressure ulcers developed in 2002 by the scientific education committee of the Japanese Society of Pressure Ulcers. DESIGN is a very useful tool for chronological monitoring of each pressure ulcer, but a key limitation of this tool is its inability to compare the wound‐healing process among different pressure ulcers in different patients due to a lack of statistical item weighting. Our aim was to weight DESIGN items by statistical analysis and develop a new validated tool to overcome this limitation. Subjects comprised 3,601 patients with pressure ulcers. Patients were followed every week during the study period. To establish the weighting of each item and grade, we estimated the probabilities of wound healing at 12‐month follow‐up using multivariable Coxs regression analysis. Weighting (−β value) for each item in order of the highest rank was: pocket, 2.289; size, 1.573; inflammation/infection, 0.778; granulation tissue, 0.682; exudate, 0.543; and necrotic tissue, 0.529. Based on these findings, a new, validated “DESIGN‐Rating tool” for monitoring the progression of pressure ulcer healing was developed, implying the development of an absolute evaluation tool and clinical indicator to assess the quality of medical care.

Development of a new risk assessment scale for predicting pressure ulcers in an intensive care unit

AIMS AND OBJECTIVES The study aimed to evaluate the predictive validity and accuracy of a new pressure ulcer risk assessment scale in two Indonesia intensive care units (ICUs). BACKGROUND Several risk assessment scales have been designed to identify patients at risk of developing pressure ulcers in ICU. However, the relative weight of each variable that contributes to pressure ulcer development in these scales is not described to enable designing of a risk assessment scale. Currently, the risk factors contributing to pressure ulcer development include interface pressure, body temperature and cigarette smoking. DESIGN A prospective cohort study was conducted in two ICUs in Pontianak, Indonesia. METHODS A total of 253 patients were recruited to the study from both hospitals. Data collection included new risk assessment scale [i.e. the Suriadi and Sanada (S.S.) scale] scoring, demographic, pressure ulcer severity scores (based on the National Pressure Ulcer Advisory Panel) and skin condition measures. Using the S.S. scale, trained data collectors scored patients once and assessed the body temperature daily until patients were discharged. Additionally, daily data were also collected in relation to the patients skin condition and stage of pressure ulcer. RESULTS Out of the 253 patients, 72 (28.4%) developed pressure ulcers. In ICU A, the incidence was 27%; pressure ulcers developed into stage I (41.7%), stage II (45.8%), stage III (10.4%) and stage IV (2.1%). In ICU B, the incidence was 31.6%; the development of pressure ulcers was 48% in stage I and 52% in stage II. Using the predictive validity test, the S.S. scale balanced sensitivity (81%) and specificity (83%) at a cut-off score of 4. The area under the receiver-operating characteristic curve was 0.888 (confidence interval: 0.84-0.93). CONCLUSION The S.S. scale was found to be a valid risk assessment tool to identify the patients at risk of developing pressure ulcers in Indonesia ICU.

Incidence and risk factors of pressure ulcers in seven neonatal intensive care units in Japan: a multisite prospective cohort study

This study aims to clarify (i) the incidence of pressure ulcers in neonates admitted to the neonatal intensive care units (NICUs) and (ii) risk factors of pressure ulcer development. All infants admitted to the NICU and kept in incubators from seven hospitals during the study period were recruited to the study. Each infant was given skin examination every day by nurses, and risk factors were collected three times a week by one researcher. The incidence of the pressure ulcers was calculated, and the risk factors for pressure ulcers were determined by using univariate and multivariate analysis. Eighty‐one infants were involved in the study. A total of 14 pressure ulcers occurred in 13 infants during the 11‐month study period, the incidence was 0·01 persons per day and cumulative incidence rate was 16·0%. Seven (50·0%) of 14 pressure ulcers were located on the nose. Multivariate analysis identified the following risk factors: skin texture (Dubowitz neonatal maturation assessment scale: skin texture score of 1 point or lower) [odds ratio 7·6; 95% confidence interval (CI) 1·58 –36·71, P = 0·012] and endotracheal intubation usage (odds ratio 4·0; 95% CI 1·04–15·42, P = 0·042).

Ultrasonographic and thermographic screening for latent inflammation in diabetic foot callus

AIMS Inflammation within the diabetic foot callus may be an earliest, predicting symptom of foot ulcer developing later. The purpose of this study was to identify latent inflammation within the foot callus using thermography and ultrasonography, and to investigate relationship between the inflammatory findings in callus and presence or absence of diabetes. METHODS This was a cross-sectional study of 60 cases with asymptomatic foot callus; the 30 diabetic patients and the 30 non-diabetic matched volunteers. Inflammation was defined using physiological imaging techniques; as skin temperature elevation in thermography and low echoic lesion in ultrasonography. RESULTS Sixty-three and ninety-four calli were observed in the diabetic and non-diabetic groups, respectively. The inflammation signs were detected by both of the two techniques in 10% of the calli in the diabetic group. No inflammation was noted in the non-diabetic group (p=0.014). CONCLUSIONS The inflammation signs presented here were specifically observed in the diabetic group. We consider that the physiological imaging techniques may be valuable screening tools for potential risk of diabetic foot ulcers.

Skin fragility in obese diabetic mice: possible involvement of elevated oxidative stress and upregulation of matrix metalloproteinases

Abstract:  The purpose of this study was to test the hypothesis that obese diabetic mice exhibit marked skin fragility, which is caused by increased oxidative stress and increased matrix metalloproteinase (MMP) gene expression in the subcutaneous adipose tissue. Scanning electron microscopy of skin samples from Tsumura‐Suzuki obese diabetic (TSOD) mice revealed thinner collagen bundles, and decreased density and convolution of the collagen fibres. Furthermore, skin tensile strength measurements confirmed that the dorsal skin of TSOD mice was more fragile to tensile force than that of non‐obese mice. The mRNA expressions of heme oxygenase 1 (Hmox1), a marker of oxidative stress, Mmp2 and Mmp14 were increased in the adipose tissue of TSOD mice. Antioxidant experiments were subsequently performed to determine whether the changes in collagen fibres and skin fragility were caused by oxidative stress. Strikingly, oral administration of the antioxidant dl‐α‐tocopherol acetate (vitamin E) decreased Hmox1, Mmp2 and Mmp14 mRNA expressions, and improved the skin tensile strength and structure of collagen fibres in TSOD mice. These findings suggest that the skin fragility in TSOD mice is associated with dermal collagen damage and weakened tensile strength, and that oxidative stress and MMP overexpression in the subcutaneous adipose tissue may, at least in part, affect dermal fragility via a paracrine pathway. These observations may contribute to novel clinical interventions, such as dietary supplementation with antioxidants or application of skin cream containing antioxidants, which may overcome skin fragility in obese patients with diabetes.