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Decubitus Ulcers [keywords]
- [Quality measurement using administrative data in mandatory quality assurance]. [English Abstract, Journal Article]
- Z Evid Fortbild Qual Gesundhwes 2014; 108(8-9):465-9.
For several years, the use of administrative data in mandatory quality measurement has been requested by several stakeholders in Germany. Main advantages of using administrative data include the reduction of documentary expenditures and the possibility to perform longitudinal quality analyses across different healthcare units. After a short introduction, a brief overview of the current use of administrative data for mandatory quality assurance as well as current developments is given, which will then be further exemplified by decubital ulcer prophylaxis. By using administrative data coding expenditures in this clinical area could be reduced by nine million data fields. At the same time the population analysed was expanded resulting in a more than tenfold increase in potentially quality-relevant events. Finally, perspectives, further developments, possibilities as well as limits of quality measurement with administrative data are discussed.
- Plantar pressure as a risk assessment tool for diabetic foot ulceration in egyptian patients with diabetes. [Journal Article]
- Clin Med Insights Endocrinol Diabetes 2014.:31-9.
Diabetic foot ulceration is a preventable long-term complication of diabetes. In the present study, peak plantar pressures (PPP) and other characteristics were assessed in a group of 100 Egyptian patients with diabetes with or without neuropathy and foot ulcers. The aim was to study the relationship between plantar pressure (PP) and neuropathy with or without ulceration and trying to clarify the utility of pedobarography as an ulceration risk assessment tool in patients with diabetes.A total of 100 patients having diabetes were selected. All patients had a comprehensive foot evaluation, including assessment for neuropathy using modified neuropathy disability score (MNDS), for peripheral vascular disease using ankle brachial index, and for dynamic foot pressures using the MAT system (Tekscan). The studied patients were grouped into: (1) diabetic control group (DC), which included 37 patients who had diabetes without neuropathy or ulceration and MNDS ≤2; (2) diabetic neuropathy group (DN), which included 33 patients who had diabetes with neuropathy and MNDS >2, without current or a history of ulceration; and (3) diabetic ulcer group (DU), which included 30 patients who had diabetes and current ulceration, seven of those patients also gave a history of ulceration.PP parameters were significantly different between the studied groups, namely, forefoot peak plantar pressure (FFPPP), rearfoot peak plantar pressure (RFPPP), forefoot/rearfoot ratio (F/R), forefoot peak pressure gradient (FFPPG) rearfoot peak pressure gradient (RFPPG), and forefoot peak pressure gradient/rearfoot peak pressure gradient (FFPPG/RFPPG) (P < 0.05). FFPPP and F/R were significantly higher in the DU group compared to the DN and DC groups (P < 0.05), with no significant difference between DN and DC. FFPPG was significantly higher in the DU and DN groups compared to the DC group (P < 0.05). RFPPP and FFPPG/RFPPG were significantly higher in the DU and DN groups compared to the DC group (P < 0.05) with no significant difference between the DN and DU groups (P > 0.05). FFPPP, F/R ratio, FFPPG, and FFPPG/RFPPG correlated significantly with the severity of neuropathy according to MNDS (P < 0.05). These same variables as well as MNDS were also significantly higher in patients with foot deformity compared to those without deformity (P < 0.05). Using the receiver operating characteristic analysis, the optimal cut-point of PPP for ulceration risk, as determined by a balance of sensitivity, specificity, and accuracy was 335 kPa and was found at the forefoot. Multivariate logistical regression analysis for ulceration risk was statistically significant for duration of diabetes (odds ratio [OR] = 0.8), smoking (OR = 9.7), foot deformity (OR = 8.7), MNDS (OR = 1.5), 2-h postprandial plasma glucose (2 h-PPG) (OR = 0.9), glycated hemoglobin (HbA1c) (OR = 2.1), FFPPP (OR = 1.0), and FFPPG (OR = 1.0).In conclusion, persons with diabetes having neuropathy and/or ulcers have elevated PPP. Risk of ulceration was highly associated with duration of diabetes, smoking, severity of neuropathy, glycemic control, and high PP variables especially the FFPPP, F/R, and FFPPG. We suggest a cut-point of 355 kPa for FFPPP to denote high risk for ulceration that would be more valid when used in conjunction with other contributory risk factors, namely, duration of diabetes, smoking, glycemic load, foot deformity, and severity of neuropathy.
- Clinical and Psychologic Effects of Early Mobilization in Patients Treated in a Neurologic ICU: A Comparative Study. [JOURNAL ARTICLE]
- Crit Care Med 2014 Dec 16.
To determine if an early mobilization protocol increased mobility and improved clinical and psychologic outcomes. Currently, there is minimal research on the effects of early mobilization in patients with primary neurologic injury.Prospective, two-group pre/post comparative design with data collection 4 months pre- and postintervention with a 4-month run-in period.Twenty-two-bed neurologic ICU in a 1,200-bed urban, quaternary-care, academic hospital in Northeast Ohio.Critically ill patients with primary neurologic injury admitted to the neurologic ICU.An early mobility program included a progressive mobility protocol, written orders, and staff (clinical nurse specialist clinical technician) who advocated for and assisted with mobility. Highest mobility achieved was assessed daily for 13 days, clinical outcomes were retrieved from electronic databases, and psychologic profile was collected by valid, reliable questionnaire at/after neurologic ICU discharge. Analyses included comparative statistics and multivariable modeling.Of 637 patients, 260 were preintervention and 377 were postintervention. Patient characteristics were similar between groups, except postintervention group patients had less history of using walking aids and more gait abnormalities, and were less likely to require mechanical ventilation in the neurologic ICU (all p ≤ 0.006). Compared with preintervention, postintervention patients had higher mobility levels and decreased hospital and neurologic ICU length of stay; were more likely to be discharged home (all p ≤ 0.002); had decreased bloodstream infection, hospital-acquired pressure ulcer, and anxiety rates (all p < 0.03); and had no change in mortality, ventilator-associated pneumonia, deep vein thrombosis, depression, and hostility. In multivariable analyses, postintervention patients had higher mobility levels (p < 0.001), had shorter mean hospital and neurologic ICU length of stay (both p < 0.001), and were more likely to be discharged home (p = 0.033) compared with preintervention patients.A neurologic ICU early mobility protocol increased highest neurologic ICU mobility and discharge home and decreased length of stay, but did not improve quality metrics or psychologic profile.
- Recent advances on the association of apoptosis in chronic non healing diabetic wound. [Journal Article, Review]
- World J Diabetes 2014 Dec 15; 5(6):756-62.
Generally, wounds are of two categories, such as chronic and acute. Chronic wounds takes time to heal when compared to the acute wounds. Chronic wounds include vasculitis, non healing ulcer, pyoderma gangrenosum, and diseases that cause ischemia. Chronic wounds are rapidly increasing among the elderly population with dysfunctional valves in their lower extremity deep veins, ulcer, neuropathic foot and pressure ulcers. The process of the healing of wounds has several steps with the involvement of immune cells and several other cell types. There are many evidences supporting the hypothesis that apoptosis of immune cells is involved in the wound healing process by ending inflammatory condition. It is also involved in the resolution of various phases of tissue repair. During final steps of wound healing most of the endothelial cells, macrophages and myofibroblasts undergo apoptosis or exit from the wound, leaving a mass that contains few cells and consists mostly of collagen and other extracellular matrix proteins to provide strength to the healing tissue. This review discusses the various phases of wound healing both in the chronic and acute wounds especially during diabetes mellitus and thus support the hypothesis that the oxidative stress, apoptosis, connexins and other molecules involved in the regulation of chronic wound healing in diabetes mellitus and gives proper understanding of the mechanisms controlling apoptosis and tissue repair during diabetes and may eventually develop therapeutic modalities to fasten the healing process in diabetic patients.
- Endoscopic therapy for esophageal hematoma with blue rubber bleb nevus syndrome. [Journal Article]
- World J Gastrointest Endosc 2014 Dec 16; 6(12):630-4.
A 57-year-old woman previously diagnosed with blue rubber bleb nevus syndrome (BRBNS) reported hematemesis. BRBNS is a rare vascular anomaly syndrome consisting of multifocal hemangiomas of the skin and gastrointestinal (GI) tract but her GI tract had never been examined. An upper gastrointestinal endoscopy revealed a large bleeding esophageal hematoma positioned between the thoracic esophagus and the gastric cardia. An endoscopic injection of polidocanol was used to stop the hematoma from bleeding. The hematoma was incised using the injection needle to reduce the pressure within it. Finally, argon plasma coagulation (APC) was applied to the edge of the incision. The esophageal hematoma disappeared seven days later. Two months after the endoscopic therapy, the esophageal ulcer healed and the hemangioma did not relapse. This rare case of a large esophageal hematoma originating from a hemangioma with BRBNS was treated using a combination of endoscopic therapy with polidocanol injection, incision, and APC.
- Systemic sclerosis induces pronounced peripheral vascular dysfunction characterized by blunted peripheral vasoreactivity and endothelial dysfunction. [JOURNAL ARTICLE]
- Clin Rheumatol 2014 Dec 16.
Systemic sclerosis (SSc) vasculopathy can result in a digital ulcer (DU) and/or pulmonary arterial hypertension (PAH). We hypothesized that bedside brachial artery flow-mediated dilation (FMD) testing with duplex ultrasound could be used in SSc patients to identify features of patients at risk for DU or PAH. Thirty-eight SSc patients were compared to 52 age-matched healthy controls from the VAMC Utah Vascular Research Laboratory. Peripheral hemodynamics, arterial structure, and endothelial function were assessed by duplex ultrasound. A blood pressure cuff was applied to the forearm and 5-min ischemia was induced. Post-occlusion, brachial artery vascular reactivity (peak hyperemia/area under the curve [AUC]), shear rate, and endothelial function (FMD) were measured. SSc patients had smaller brachial artery diameters (p < 0.001) and less reactive hyperemia (p < 0.001), peak shear rate (p = 0.03), and brachial artery FMD (p < 0.001) compared with healthy controls. Brachial artery FMD was lower (p < 0.05) in SSc patients with DU. Tertile analysis suggested the 2 lower FMD tertiles (<5.40 %) had a 40-50 % chance of presenting with DU while the SSc patients with highest FMD tertile (>5.40 %) had less than 15 % chance of DU. All brachial artery FMD measurements were similar between SSc patients with and without PAH (all p > 0.05). Compared to healthy controls, SSc patients had significantly smaller brachial artery diameter and blunted peripheral vascular reactivity and endothelial function. SSc patients with DU have even greater impairments in endothelial function compared to those without DU. FMD testing has clinical utility to identify SSc patients at risk for DU.
- Management of acute aortic syndrome. [REVIEW]
- Nat Rev Cardiol 2014 Dec 16.
Acute aortic syndrome (AAS) encompasses a group of severe, life-threatening disorders of the aorta, including acute aortic dissection, intramural haematoma (IMH), and penetrating aortic ulcer (PAU). The concept of AAS was developed to enable the early identification and definitive treatment of patients with chest pain from an aortic origin. Aortic dissection is the most common form of AAS, followed by IMH and PAU. Congenital cardiovascular defects, genetic syndromes, and nonsyndromic genetic variants have all been linked with the development of AAS. The diagnosis of AAS in the clinic can be made using imaging modalities such as CT, echocardiography, and MRI. The initial management of patients with AAS is focussed on the control of blood pressure to reduce aortic wall stress. A multidisciplinary team is required to assess each patient and decide whether endovascular or open surgical treatment, or further medical management is indicated. The optimal treatment of patients with AAS remains a challenging clinical dilemma, and further studies are required to fully characterize conditions within the AAS spectrum and to design individualized, patient-centred treatment plans.
- Nurses' reported practice and knowledge of wound assessment, assessment tools and documentation in a selected hospital in Lagos, Nigeria. [Journal Article]
- Afr J Med Med Sci 2014 Jun; 43(2):149-57.
Complete wound assessment and accurate documentation are two pivots on which effective wound care is based and wound care is the traditional role of nurses. This study was designed to assess nurses' reported practice and knowledge of wound assessment, assessment tools and documentation.Cross sectional descriptive design was adopted and the study was conducted in National Orthopaedic Hospital, Igbobi (NOHIL) Lagos, Nigeria which was selected because of high incidence of orthopaedic conditions with accompanying wounds of various types. A purposive sample of 251 nurses participated in the study.Findings show less than adequate reported practice and knowledge. Some of the respondents, 83 (33.1%) reported that they were familiar with wound assessment methods. However, only 18 (7.2%), 29 (11.6%) and 7 (2.8%) correctly cited photographic method, physical observation, and tape rule respectively while 21 (25%) of them cited wrong methods such as evaluation of PH and chemical method, and the rest could not cite any method. Majority, 144 (57.4%) reported they were not quite or not at all familiar with Pressure Ulcer Status Tool, and none of the respondents who claimed to be familiar with these tools could answer any questions that tested their knowledge on specific aspects of the tool. What respondents claimed they included in their documentation varies from wound dressing done/wound is clean/wound is healing by 111(44.2%) while 40(16%) of them reported no idea of what to document. Modifiable variables like rank (NOII) and years of experience (1-5 years) were found to significantly affect their reported knowledge of wound assessment and reported practice of wound documentation.Participants in this study are deficient in knowledge and practice of wound assessment and documentation. Utilization of wound assessment tools and continuing professional development for nurses are necessary to improve care outcomes for all patients living with wounds.
- Designing and constructing blood flow monitoring system to predict pressure ulcers on heel. [Journal Article]
- J Biomed Phys Eng 2014 Jun; 4(2):61-8.
A pressure ulcer is a complication related to the need for the care and treatment of primarily disabled and elderly people. With the decrease of the blood flow caused by the pressure loaded, ulcers are formed and the tissue will be wasted with the passage of time.The aim of this study was to construct blood flow monitoring system on the heel tissue which was under external pressure in order to evaluate the tissue treatment in the ulcer.To measure the blood flow changes, three infrared optical transmitters were used at the distances of 5, 10, and 15 mm to the receiver. Blood flow changes in heels were assessed in pressures 0, 30, and 60 mmHg. The time features were extracted for analysis from the recorded signal by MATLAB software. Changes of the time features under different pressures were evaluated at the three distances by ANOVA in SPSS software. The level of significance was considered at 0.05.In this study, 15 subjects, including both male and female, with the mean age of 54±7 participated. The results showed that the signal amplitude, power and absolute signal decreased significantly when pressure on the tissue increased in different layers (p<0.05). Heart rate only decreased significantly in pressures more than 30 mmHg (p=0.02). In pressures more than 30 mmHg, in addition to a decrease in the time features, the pattern of blood flow signal changed and it wasn't the same as no-load signal.By detecting the time features, we can reach an early diagnosis to prognosticate the degeneration of the tissue under pressure and it can be recommended as a method to predict bedsores in the heel.