Shinji Iizaka

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.

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.

Clinical wound assessment using DESIGN‐R total score can predict pressure ulcer healing: Pooled analysis from two multicenter cohort studies

There are few clinical tools with both predictive validity for pressure ulcer healing and availability in broad populations. We evaluated whether the total scores from DESIGN‐R tool could predict pressure ulcer healing. We followed 3,196 patients with pressure ulcers from two multicenter cohort studies until wound healing, patient death, or discharge. Wound severity was evaluated by DESIGN‐R tool from 0 (healed) to 66 (greatest severity). In the multivariate Cox proportional hazard model, higher DESIGN‐R total scores at baseline were associated with lower healing rates (hazard ratio 0.90, 95% confidence interval 0.89–0.92), independent of the patients characteristics, setting types, and wound depth or location. DESIGN‐R had discriminative value for wound healing up to 90 days; the area under the receiver‐operating characteristics curve from univariate analysis was 0.81 for healing within 30 days and 0.74 for healing within 30–90 days. The cutoff points were 9 for healing within 30 days and 18 within 30–90 days (positive and negative predictive value 78.8 and 74.1%; 63.9 and 81.1%, respectively). These points were validated for both superficial and deep ulcers. DESIGN‐R can be a useful tool to predict pressure ulcer healing for a wide range of patient populations, settings, and wound locations.

Preventive Effects of Salacia reticulata on Obesity and Metabolic Disorders in TSOD Mice.

The extracts of Salacia reticulata (Salacia extract), a plant that has been used for the treatment of early diabetes, rheumatism and gonorrhea in Ayurveda, have been shown to have an anti-obesity effect and suppress hyperglycemia. In this study, the effects of Salacia extract on various symptoms of metabolic disorder were investigated and compared using these TSOD mice and non-obese TSNO mice. Body weight, food intake, plasma biochemistry, visceral and subcutaneous fat (X-ray and CT), glucose tolerance, blood pressure and pain tolerance were measured, and histopathological examination of the liver was carried out. A significant dose-dependent decline in the gain in body weight, accumulation of visceral and subcutaneous fat and an improvement of abnormal glucose tolerance, hypertension and peripheral neuropathy were noticed in TSOD mice. In addition, hepatocellular swelling, fatty degeneration of hepatocytes, inflammatory cell infiltration and single-cell necrosis were observed on histopathological examination of the liver in TSOD mice. Salacia extract markedly improved these symptoms upon treatment. Based on the above results, it is concluded that Salacia extract has remarkable potential to prevent obesity and associated metabolic disorders including the development of metabolic syndrome.

Exploring the prevalence of skin tears and skin properties related to skin tears in elderly patients at a long-term medical facility in Japan.

The identification of appropriate skin tear prevention guidelines for the elderly requires clinicians to focus on local risk factors such as structural alterations of the epidermis and dermis related to skin tears. The aim of this cross‐sectional study is to explore the prevalence of skin tears and to explore skin properties related to skin tears in elderly Japanese patients at a long‐term medical facility. After doing the prevalence study, 18 participants with skin tears and 18 without were recruited and an evaluation of their skin properties using 20‐MHz ultrasonography, skin blotting and also Corneometer CM‐825, Skin‐pH‐meterPH905, VapoMeter, Moisture Meter‐D and CutometerMPA580 was undertaken. A total of 410 patients were examined, the median age was 87 years and 73·2% were women. The prevalence of skin tears was 3·9%, and 50% of skin tears occurred on the dorsal forearm. The changes in skin properties associated with skin tears included increased low‐echogenic pixels (LEP) by 20‐MHz ultrasonography, decreased type IV collagen and matrix metalloproteinase‐2, and increased tumour necrosis factor‐α by skin blotting. In conclusion, this study suggests that increased dermal LEP, including solar elastosis, may represent a risk factor for skin tears; this indicates that skin tear risk factors might not only represent chronological ageing but also photoageing.

Evaluating the effect of the new incentive system for high-risk pressure ulcer patients on wound healing and cost-effectiveness: A cohort study

OBJECTIVE To evaluate the effectiveness and cost-effectiveness of new incentive system for pressure ulcer management, which focused on skilled nurse staffing in terms of rate of healing and medical costs. DESIGN, SETTING AND PARTICIPANTS A prospective cohort study included two types of groups: 39 institutions, which introduced the new incentive system, and 20 non-introduced groups (control). Sixty-seven patients suffering from severe pressure ulcers in the introduced group and 38 patients in the non-introduced group were included. Wound healing and medical costs were monitored weekly for three weeks by their skilled nurses in charge. MAIN OUTCOME MEASURES Healing status and related medical costs. RESULTS The introduced group showed significantly higher rate of healing compared with the control group at each weekly assessment. Multiple regression analysis revealed that the introduction of the new incentive system was independently associated with the faster healing rate (beta=3.44, P<.001). The budget impact analysis demonstrated that introducing this system could reduce cost of treating severe pressure ulcers by 1.776 billion yen per year. CONCLUSIONS The new incentive system for the management of pressure ulcers, which focused on staffing with skilled nurses can improve healing rate with reduced medical cost.

Aging enhances maceration-induced ultrastructural alteration of the epidermis and impairment of skin barrier function.

BACKGROUND Skin maceration is recognized as a risk factor for the development of certain skin lesions. In health care settings, incontinence-associated skin maceration is highly prevalent in the elderly. However, the effect of senescence on maceration has not been fully elucidated. OBJECTIVE To reveal the enhancement of the maceration-induced ultrastructural alteration and barrier function of the epidermis by aging. METHODS Skin maceration was reproduced by exposure to agarose gel in human and rat. The ultrastructural alterations in human and rat tissue were observed by transmission electron microscopy. The skin barrier function was evaluated by noninvasive methods in human, and by the transdermal penetration of small- and large-fluorescent molecules in rat. In order to reveal the effect of aging on the skin maceration, we compared these parameters between young and aged rats. RESULTS In macerated skin, we observed expansion of the interstices of the stratum corneum, spinosum, and basale of the epidermis; disruption of the intercellular lipid structure in the stratum corneum; a decreased number of cell processes in the stratum spinosum and basale. The transdermal penetration test in the rat using two types of fluorescein indicated that maceration disrupted skin barrier function. Furthermore, senescence-enhanced ultrastructural and functional alterations were revealed in the rodent studies. CONCLUSION This study demonstrates that aging enhances skin maceration. Considering that maceration is a risk factor for the skin damage, the development of technology to promote skin barrier recovery after maceration in the elderly is warranted.

Do nutritional markers in wound fluid reflect pressure ulcer status

Evaluation of wound fluid characteristics for pressure ulcer (PU) assessment in clinical settings remains subjective, requiring considerable expertise. This cross‐sectional study focused on nutritional markers in wound fluid as possible objective tools and investigated whether they reflect the PU status according to the healing phase, infection, and granulation, especially after adjusting for serum values. Twenty‐eight patients with 32 full‐thickness PUs were studied. The concentration of albumin, total protein, glucose, and zinc in wound fluid were measured. For PU status, the healing phases and infection were evaluated by clinical signs, and the degree of granulation tissue formation was determined as the hydroxyproline concentration. The wound fluid/serum ratio for albumin was significantly lower during the inflammatory phase than during the proliferative phase (p=0.020). Infected wound fluid contained less glucose (0.3–1.0 mmol/L) than noninfected ones did (5.0–7.6 mmol/L) in an intraindividual comparison of three cases. The wound fluid/serum ratio for glucose was negatively correlated with hydroxyproline level in the proliferative phase (ρ=−0.73, p=0.007), while zinc level in wound fluid showed a positive correlation (ρ=0.61, p=0.028). Our results suggest that these traditional nutritional markers in wound fluid, especially wound fluid/serum ratio may be useful to evaluate local PU status.

Estimation of protein loss from wound fluid in older patients with severe pressure ulcers

OBJECTIVE Protein loss from wound fluid is usually recognized as one of the factors contributing to the deterioration of the nutritional status in older patients with severe pressure ulcers. We quantified the protein loss owing to pressure ulcers and investigated associations with wound-related factors and nutritional status. METHODS This cross-sectional study included 25 patients (>or=60 y) from 10 institutions, with full-thickness pressure ulcers. Wound fluid was collected once after accumulating beneath a film dressing. The amount of protein loss per day was estimated by the volume of wound fluid per hour and the total protein concentration in the wound fluid. Wound evaluations and nutritional assessments were performed. Correlations between variables were obtained using Spearmans rank correlation. RESULTS The median age of the patients was 79 y (range 61-100), and median body mass index was 19.6 kg/m(2) (12.2-24.9). The median amount of protein loss was 0.2g/d (0.04-2.1), which corresponded to 0.01 g x kg(-1) x d(-1) (<0.01-0.04) and 0.6% (0.1-13.8) of protein intake. Four wounds characterized as infected or surgically debrided lost 1.5-2.1g of protein per day, which was substantially higher than other wounds lost. Protein loss was correlated with wound severity including area, depth, the wound severity score, and infectious markers (all Ps<0.05), but not with body mass index or arm muscle circumference (P>0.05). CONCLUSION The amount of protein loss could be small and thus may not be related directly to nutritional status, although it increased as the wound became more severe.