Junko Sugama

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.

The Loss of MCP-1 Attenuates Cutaneous Ischemia–Reperfusion Injury in a Mouse Model of Pressure Ulcer

The formation of pressure ulcers is dependent on multiple factors including ischemia-reperfusion (IR). This study assessed the mechanism of a previously reported murine model of cutaneous IR injury. Three cycles of IR (days 1-3) by external application of two magnetic plates were performed to induce pressure ulcer formation. Increased infiltration of neutrophils and macrophages, and augmented expression of proinflammatory cytokines and inducible nitric oxide synthase (iNOS), were observed during IR cycles. In this model, monocyte chemoattractant protein-1 (MCP-1) was remarkably increased at day 1 in the skin followed by inflammatory cell infiltration. Therefore, IR cycles were performed in MCP-1-deficient (MCP-1(-/-)) mice to evaluate the role of this chemokine in pressure ulcer development. MCP-1(-/-) mice showed reduced macrophage infiltration and expression of tumor-necrosis factor-alpha (TNF)-alpha and iNOS during IR cycles leading to attenuated apoptosis and skin injury. Importantly, MCP-1 played a role in apoptosis and injury via inducing iNOS during the reperfusion rather than the ischemic period. These findings indicate that MCP-1 may be a critical factor for macrophage recruitment and subsequent skin inflammation and injury during IR cycles. We propose that this is a useful model for investigating the mechanism of pressure ulcer formation using various transgenic mice.

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).

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.

Randomised controlled trial to evaluate a new double-layer air-cell overlay for elderly patients requiring head elevation

A clinical investigation was conducted concerning the effects of a newly designed double-layer air-cell overlay in preventing the onset of pressure ulcers for patients with a Braden scale score of < or = 16, and who require a head-elevated position of 45 degrees or higher. A randomised controlled trial was undertaken involving 82 patients from a general hospital ward using one of the following three support surfaces: a double-layer air-cell overlay, a single-layer air-cell overlay or a standard hospital mattress. A significantly lower percentage of patients using the double-layer air-cell overlay developed pressure ulcers (3.4%) compared to 19.2% and 37.0% for those patients using the single-layer air-cell overlay and standard mattress respectively. Based on these findings, a double-layer air-cell overlay should be more effective in preventing the onset of pressure ulcers than either a single-layer air-cell overlay or a standard hospital mattress for subjects requiring head elevation.

Skin injuries caused by medical adhesive tape in older people and associated factors.

AIM AND OBJECTIVES This study was designed to investigate the status of skin injuries in older individuals caused by adhesive tape and the associated factors for skin injury. BACKGROUND Older individuals are susceptible to skin injuries caused by medical adhesive tape. However, the current status of such skin injuries and the associated factors involved has not been clearly elucidated. DESIGN Prospective cohort design, using comparative and descriptive statistical tests. METHODS The subjects were 155 patients aged 65 or older who were admitted to a long-term care facility and required the use of medical adhesive tape. Patients who showed no skin injuries were selected and the incidence rate and status of skin injuries that occurred during the eight-week study period were investigated. The skin injuries observed were classified by a dermatologist. The associated factors were examined statistically. Informed consent was obtained from all patients. RESULTS Skin injuries developed at 34 sites in 24 subjects. The cumulative incidence rate was 15.5%, and the incidence density was 38.0/1000 person-days. Many of the skin injuries occurred around pressure ulcers and intravenous hyperalimentation sites. Other prevalent areas included the buttocks and back, where tape is commonly used. The skin injuries were classified as contact dermatitis (70.6%), trauma (20.6%) and infection (8.8%). The ratio of skin contamination and skin mobility in patients with contact dermatitis was significantly higher than in patients without skin injury. CONCLUSION The highest incidence rate was observed in the buttock area of patients with pressure ulcers. The incidence rate of contact dermatitis was the highest. RELEVANCE TO CLINICAL PRACTICE Skin care to minimise contamination and more effective ways of applying medical adhesive tape may be needed to prevent contact dermatitis.

Risk factors in the development of pressure ulcers in an intensive care unit in Pontianak, Indonesia

The purpose of this study was to identify risk factors associated with the presence of pressure ulcer development in adult patients at an intensive care unit hospital in Indonesia. The prospective cohort design was conducted in this study. A total of 105 patients participated and a pressure ulcer developed in 35 patients. The initial analysis identified several variables as significant risk factors for pressure ulcer development (interface pressure, fecal incontinence, skin moisture, diastolic blood pressure, smoking and body temperature). However, when entered into a final multivariate analysis, four factors, interface pressure [odds ratio (OR) 17·6, 95% confidence interval (CI) 4·1, 74·3], skin moisture (OR 8·2, 95% CI 2·2, 30·9), smoking (12·7, 95% CI 2·8, 56·7) and body temperature (OR 102·0, 95% CI 7·7, 98·8) were found to be significant. The results suggest that interface pressure measured using a multipad pressure evaluator, skin moisture measured by a moisture checker, thermometer for body temperature and smoking status are adequate instruments for the prediction of pressure ulcer development.

Prognosis of stage I pressure ulcers and related factors

The prognosis of stage I pressure ulcers cannot be predicted; therefore, nursing interventions for preventing their deterioration have not been clearly established. This study describes the clinical course of stage I pressure ulcers and prospectively investigates the factors related to their deterioration. Thirty‐one stage I pressure ulcers in 30 patients in a long‐term care facility were studied, and morphological changes were assessed every day until the ulcers healed or deteriorated. The physiological changes were assessed by ultrasonography and thermography. Twenty ulcers healed, and 11 deteriorated. The characteristics of deterioration were as follows: (1) double erythema; (2) non blanchable erythema across the whole area determined by glass plate compression; (3) erythema away from the tip of the bony prominence; and (4) expanding erythema on the following day. We analysed the sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio for the diagnostic utility of the indicators of deterioration double erythema and distance from the tip of bony prominence, which can be instantly assessed without the use of any special device. The values were 36·4%, 95·0%, 80·0%, 73·1% and 7·28, respectively. These results suggest that clinicians can predict the prognosis of stage I pressure ulcers by initial assessment and provide appropriate care based on the assessment.