Examining the accuracy of visual diagnosis of tinea pedis and tinea unguium in aged care facilities.

OBJECTIVE: The aim of this study was to examine the accuracy of visual diagnosis of tinea pedis (Athlete's foot) and tinea unguium (fungal nail infection), as well as to provide information on skin abnormalities that could help identify these diseases in aged care facilities (long-term care facilities (LTCFs) and nursing homes). METHOD: A multicentre, cross-sectional observational study was conducted in a LTCF and two nursing homes. A dermatologist observed the skin abnormalities in the participants' interdigital and plantar areas, to screen for tinea pedis, and in the participants' toenails, to screen for tinea unguium. If abnormalities were noted, samples such as scales or toenails were collected and examined using direct microscopy. The accuracy of the macroscopic observation for each skin abnormality was examined. RESULTS: A total of 173 residents were recruited. The accuracy of clinical diagnosis using macroscopic observation was relatively low. The sensitivities and specificities for clinical diagnosis were 0.37 and 0.95 for tinea pedis in the interdigital areas, 0.47 and 0.94 for tinea pedis in the plantar areas, and 0.80 and 0.61 for tinea unguium in toenails, respectively. Scales in the plantar areas and discoloration of the toenails were more frequently observed in residents with tinea pedis and tinea unguium than in those without them. CONCLUSION: Several skin abnormalities were observed in the residents recruited in this study, but there was insufficient correlation with tinea pedis and tinea unguium to be used for screening.

Inter-rater and intra-rater reliability outcomes of a rapid bacteria counting system with pressure ulcer samples.

OBJECTIVE: Evaluating bacterial load in pressure ulcers (PUs) is key to combat infection; therefore, using technologies to measure bacterial count can be particularly useful. A rapid bacteria counting system was recently developed and introduced to the wound care field. However, its reliability was not established. This cross-sectional study aimed to evaluate the inter-rater and intra-rater reliability of bacterial count using this rapid counting system. METHOD: We took bacterial swabs from patients with category I or greater PUs to assess inter- and intra-rater reliability. An assessor swabbed the longest axis of the PU once and bacterial counts were measured using a rapid bacteria counting system. To confirm the inter-rater and intra-rater reliability, intraclass correlation coefficients (ICCs) were calculated. RESULTS: We took 63 and 57 pairs of bacterial counts from 13 patients with 16 category I or greater PUs to assess inter- and intra-rater reliability, respectively. Overall ICCs [95% confidence intervals (CI)] for the bacterial counts were 0.83 [0.73-0.90, p<0.001, inter-rater reliability, n=63], and 0.89 [0.82-0.94, p< 0.001, intra-rater reliability, n=57]. CONCLUSION: A high level of reliability for counting bacterial numbers in PU sites was confirmed. The results should encourage clinicians and researchers to use this type of device for the real-time assessment of wound bacterial bioburden at the patient's bedside.

Use of smartphone attached mobile thermography assessing subclinical inflammation: a pilot study.

OBJECTIVE: To verify the reliability and validity of FLIR ONE, a device connected to a smartphone, for the assessment of inflammation based on relative temperature increase compared with the thermography routinely used in pressure ulcer (PU) and diabetic foot assessment. METHOD: Participants in this pilot cross-sectional observational study were recruited from the patients in the PU team rounds and the diabetic foot outpatient clinic at the university hospital in January 2015. Cohen's kappa coefficient with its 95% confidence intervals was used to evaluate the criterion-related validity and inter- and intra-rater reliability for the thermal imaging assessment. For assessing criterion-related validity, a hand-held high-end infrared thermography device was used to provide reference data. Comparison of thermal images between the smartphone-connected device and the hand-held device was performed with both a 'predetermined range' and an 'automatically-set range.' For assessing inter-rater reliability, two assessors evaluated the thermal images taken by the mobile thermography. For assessing intra-rater reliability, one assessor evaluated the thermal images twice. The thermal images were shown to the assessors at random. RESULTS: Among 16 thermal images obtained from eight patients, kappa coefficients for each value were as follows: for the predetermined range and automatically-set range, respectively, the criterion-related validity was 1.00 (95% confidence interval 1.00-1.00) and 1.00 (95% confidence interval 1.00-1.00); the inter-rater reliability was 1.00 (95% confidence interval 1.00-1.00) and 1.00 (95% confidence interval 1.00-1.00); and the intra-rater reliability was 1.00 (95% confidence interval 1.00-1.00) and 1.00 (95% confidence interval 1.00-1.00). CONCLUSION: This pilot study suggests that FLIR ONE can work as an alternative device for assessing subclinical inflammation in PUs and the diabetic foot in clinical settings. Our results may facilitate clinicians in accepting the routine use of thermal imaging assessment at the patients' bedside.

Screening for tinea unguium by Dermatophyte Test Strip.

BACKGROUND: The direct microscopy, fungal culture and histopathology that are necessary for the definitive diagnosis of tinea unguium are disadvantageous in that detection sensitivity is affected by the level of skill of the person who performs the testing, and the procedures take a long time. OBJECTIVES: The Dermatophyte Test Strip, which was developed recently, can simply and easily detect filamentous fungi in samples in a short time, and there are expectations for its use as a method for tinea unguium screening. With this in mind, we examined the detection capacity of the Dermatophyte Test Strip for tinea unguium. METHODS: The presence or absence of fungal elements was judged by direct microscopy and Dermatophyte Test Strip in 165 nail samples obtained from residents in nursing homes for the elderly. Moreover, the minimum sample amount required for positive determination was estimated using 32 samples that showed positive results by Dermatophyte Test Strip. RESULTS: The Dermatophyte Test Strip showed 98% sensitivity, 78% specificity, 84·8% positive predictive value, 97% negative predictive value and a positive and negative concordance rate of 89·1%. The minimum sample amount required for positive determination was 0·002-0·722 mg. CONCLUSIONS: The Dermatophyte Test Strip showed very high sensitivity and negative predictive value, and was considered a potentially useful method for tinea unguium screening. Positive determination was considered to be possible with a sample amount of about 1 mg.

Physiological and appearance characteristics of skin maceration in elderly women with incontinence.

OBJECTIVE: To identify the physiological and appearance characteristics of skin maceration caused by urine and/or faeces and determine their suitability as risk indicators for incontinence-associated dermatitis. METHOD: This cross-sectional, comparative study involved sixty-nine elderly women with urinary and/or faecal incontinence who provided informed consent to participate. Exclusion criteria included serious medical problems, acute illness and the presence of damaged skin on the buttocks. The physiological and appearance characteristics of macerated skin on the buttocks of the patients were examined. Stratum corneum and dermis hydration levels, transepidermal water loss and skin pH were used to assess skin condition. Skin morphology (sulcus cutis) was confirmed using images at x15 magnification. The erythema index and white index were used to evaluate colour in the macerated skin areas. RESULTS: Forty-four patients exhibited skin maceration. Stratum corneum and dermis hydration levels were significantly greater in the maceration group than in the non-maceration group, as were transepidermal water loss, skin pH and differences in sulcus cutis interval between the buttock of interest and the subumbilical region. Furthermore, differences in the erythema and white indices between these two regions were significantly higher and lower, respectively, in the maceration group than in the non-maceration group. CONCLUSION: To our knowledge, this is the first report to note that there are interesting changes not only in the epidermal layer but also in the dermis layer in patients with skin maceration. This finding confirmed that skin maceration caused by incontinence is a severe condition. Moreover, the erythema index was the best index for identifying skin maceration caused by incontinence, indicating that it can be used for precise and easy identification of the condition in clinical practice.

Structural changes in dermal collagen and oxidative stress levels in the skin of Japanese overweight males.

OBJECTIVE: It has been reported that obese people have poorly organized dermal collagen structure because of the degradation of collagen fibers, which is caused by an increase in oxidative stress levels associated with the hypertrophy of subcutaneous adipose cells. However, it is unclear whether an increase in oxidative stress levels caused by the accumulation of subcutaneous adipose tissue and a change in the dermal structure also occur in overweight and obese Japanese people. The objectives of this study are to identify structural changes that occur in the dermis and to measure the levels of oxidative stress in Japanese overweight males. METHODS: The overweight group included 43 Japanese male volunteers aged between 25 and 64 years and with a body mass index (BMI) of ≥25 and <30. The control group included 47 male volunteers aged between 22 and 64 years and with BMI of <25. The 20-MHz Dermascan C® ultrasound scanner with software for image analyses was used. Echogenicity of the upper and lower dermis was measured. The mRNA expression level of heme oxygenase-1 (HMOX1) in hair follicles was quantitatively analyzed by real-time reverse transcription polymerase chain reaction (RT-PCR) and was used as a marker of oxidative stress. Ultrasonographic imaging and collection of hair follicles were performed at the same site on the thigh, abdomen, and upper arm. RESULTS: The HMOX1 mRNA expression level in the abdomen and thigh was significantly lower in the overweight group than in the control group. Moreover, the echogenicity of the upper dermis of the abdomen and the lower dermis of the abdomen and thigh was significantly lower in the overweight group than in the control group. CONCLUSION: We detected an increase in oxidative stress levels and a decrease in the density of dermal collagen at the same site on the thigh, abdomen, and upper arm of Japanese overweight males. These findings suggest the fragility of the dermis of Japanese overweight males, which might have been caused by the accumulation of subcutaneous adipose tissue.

A new objective evaluation method for PU cleansing using a rapid bacteria counting system.

OBJECTIVE: To assess a new rapid bacterial counting device for evaluating wound cleansing effectiveness based on dielectrophoretic impedance measurement. METHOD: Three patients with pressure ulcers with undermining were recruited, and pressure ulcer severity assessed using the DESIGN-R tool. The number of bacteria was measured using this new apparatus both before and after wound cleansing, performed by wound, ostomy, and continence nurses using apH-balanced cleanser for periwound skin and with normal saline for the wound bed and undermining area. RESULTS: The results showed that wound cleansing effectively reduced bacterial counts on the periwound skin, wound bed and undermined site, with a median number of bacteria of 3.6×106 CFU/ml before cleansing, which decreased to 1.1×106 CFU/ml after cleansing. CONCLUSION: This pilot study result suggests the usefulness of this new device for assessing the effectiveness of wound cleansing on reduction of bacterial number. Standardisation of wound cleansing technique may be achieved by hands-on education using this apparatus at bedside.

Quantitative estimation of exudate volume for full-thickness pressure ulcers: the ESTimation method.

OBJECTIVE: To develop an equation for the estimation of exudate volume in millilitres, for full-thickness pressure ulcers, according to wound characteristics. METHOD: In a cross-sectional study, 41 patients aged >60 years with 58 full-thickness pressure ulcers were evaluated. Exudate was collected by covering each wound with a transparent occlusive dressing and the accumulated volume was measured to estimate volume per day. The overall severity of each wound was evaluated by the DESIGN-R tool; a model was then developed to estimate the volume of exudate based on these experimental values. Linear regression analyses were performed to evaluate the precision and accuracy of the model. RESULTS: The model, including exudate score, size score, and total score, showed a higher adjusted coefficient of determination (R²=0.66) than the model with only a traditional exudate score (R²=0.57). After adjustment for age, inclusion of interaction terms, and modification of bias, a model with continuous parameters was finally developed: exudate volume per day (ml/day) = exp([0.86×exudate score]+ [0.21×size score]+[0.12×total score]-[0.013×size score×total score]-[0.04×age]-3.60). Furthermore, a categorical model was developed for clinical simplicity of use. The adjusted R2 was increased to 0.73 for the continuous model and to 0.77 for the categorical model. There were no apparent biases (p>0.05) and no correlations between residuals and measured value (p>0.05) in these models. CONCLUSION: The equation, including the exudate score, size score and total score of DESIGN-R, as well as age, is called the ESTimation method. It will be useful for clinicians to predict the absolute volume of exudate and to select appropriate dressings for full-thickness pressure ulcers. DECLARATION OF INTEREST: The authors have nothing to declare.

Predicting delayed pressure ulcer healing using thermography: a prospective cohort study.

OBJECTIVE: To investigate whether thermography can be used to detect latent inflammation in pressure ulcers and predict pressure ulcer prognosis in a clinical setting. METHOD: For this cohort study, we recruited 35 patients with stage II-IV pressure ulcers on the torso, who underwent thermographic assessment on discovery of their pressure ulcer. The patients were followed up for at least 3 weeks. Thermography was performed immediately after dressing removal. Pressure ulcers were classified into two groups depending on whether or not the wound site temperature was lower or higher than the periwound skin: the low temperature group and the high temperature group respectively. A generalised estimation equation was used to estimate the relative risk of delayed healing of pressure ulcers, comparing wounds with high temperatures and low temperatures. RESULTS: Of the 35 patients, 21 had 'low temperature' wounds and 14 had 'high temperature' wounds at baseline. Two patients in the high temperature group presented with overt infection, and were excluded from further analysis. Twenty-two pressure ulcers were considered to heal 'normally' (that is, the wound area reduced by 30% or more within 3 weeks) and 16 did not heal. The baseline DESIGN score (a measure of gross wound status) did not differ in any subscales between the high and low temperature groups. The relative risk for delayed healing in high temperature cases was 2.25 (95% confidence intervals; 1.13-4.47, p=0.021). Sensitivity was 0.56, specificity was 0.82, positive predictive value was 0.75, and negative predictive value was 0.67. CONCLUSION: Our results indicate that using thermography to classify pressure ulcers according to temperature could be a useful predictor of healing at 3 weeks, even though wound appearances may not differ at the point of thermographical assessment. The higher temperature in the wound site, when compared with periwound skin, may imply the presence of critical colonisation, or other factors which disturb the wound healing.

A possible animal model for critical colonisation.

OBJECTIVE: To develop a critical colonisation model in rats that will facilitate investigation of its pathophysiology and the development of new and effective diagnosis and treatment protocols. METHOD: Three groups of rats were given full-thickness dorsal wounds: a control group received phosphate-buffered saline; an experimental group was inoculated with Pseudomonas aeruginosa; an infection group with streptozotocin-induced diabetes was also inoculated with P. aeruginosa. All groups were assessed on a number of parameters at days 1, 3, 5 and 7 following wounding. Parameters included gross observations, histopathological observations, quantification of redness and swelling, serum C-reactive protein (CRP) measurement and tissue bacterial counts. RESULTS: Healing was delayed in the experimental group when compared with the control group, with no signs of inflammation. Although the numbers of bacteria were similar in the experimental and infection groups, polymorphonuclear neutrophil (PMN) infiltration was localised to granulation tissue in the experimental group, whereas it extended to muscular tissue in the experimental group. CRP levels remained low in the experimental group. CONCLUSION: These findings suggest that the inoculation of bacteria provides a possible model of critical colonisation in rats. We believe this will contribute to a better understanding of critical colonisation.

Can ultrasonographic evaluation of subcutaneous fat predict pressure ulceration?

High-resolution ultrasound may be able to detect pressure ulcers before clinical signs emerge. This retrospective study found that one such early indicator is inflammatory oedema in the subcutaneous fat, which resolves as healing occurs.

Ultrasonographic evaluation of an unusual peri-anal induration: a possible case of deep tissue injury.

High-resolution ultrasound produces good quality echo images of skin and subcutaneous lesions. Here, it was used to characterise an atypical induration, which the authors speculate might have been a deep tissue injury.

Assessment of Three Alternating Pressure Sequences Applied to a Dynamic Cushion to Relieve Pressure on Seating Areas / Evaluación de tres secuencias de inflado alternantes aplicadas a un cojín dinámico para la liberación de presión en el área de sentado

Pressure ulcers are injuries to the skin and/or underlying tissues caused by prolonged high pressures on supporting body areas, they affect mainly people with poor mobility that have stayed in seating position for a long time. Reducing the amount and duration of pressure has been widely accepted for minimizing the risk of formation of pressure ulcers. Recently, dynamic cushions have been developed to relieve pressure on supporting areas; nevertheless, there is no sufficient information about the adequate characteristics of alternating sequences for pressure ulcers prevention. Therefore, the aim of this work is to explore three sequences of alternating movements designed for an air cell cushion by comparing pressure redistribution on supporting areas when applied on healthy volunteers. The purpose of these sequences is to redistribute the pressure over a larger contact area. To evaluate the effect of the alternating sequences, eight healthy volunteers were asked to sit on the air cell cushion, and to try the three alternating sequences for 12 minutes, 2 minutes on static mode and 10 minutes on alternating mode. A parameter for quantitative assessment of alternating sequences was proposed in this work by determining the coefficient of variation of interface pressure. Furthermore, the percentage of relative change of coefficient of variation was computed for evaluating performance of the alternating sequences comparing to the static mode. It was found that the three proposed strategies maintained values of interface pressure lower than previous work. Additionally, the relative change allowed to differentiate the effects of alternation of each sequence showing the second strategy as the most effective. The results are encouraging for further studies in subjects who require a wheelchair for mobility.

Las úlceras por presión son lesiones en la piel y tejidos subyacentes, causadas por presiones excesivas y prolongadas en las superficies de apoyo del cuerpo. Estas lesiones afectan principalmente a personas con poca movilidad física, como aquellas que permanecen sentados por largos periodos. Para disminuir el riesgo del padecimiento de estas lesiones, se ha recomendado como punto de partida reducir la magnitud y el tiempo de acción de las presiones en las zonas de apoyo. Se han desarrollado cojines dinámicos para sillas de ruedas, los cuales generan movimientos alternantes en las diferentes zonas de apoyo, producido por la inyección de aire, con el fin de disminuir las presiones en esas zonas. Sin embargo, no se han encontrado referencias de las características adecuadas de las secuencias de movimientos alternantes para prevenir la aparición de esas lesiones. El propósito de este trabajo es evaluar tres secuencias de movimientos alternantes diseñadas para un cojín de aire. La evaluación se realizó comparando la distribución de presiones en zonas de apoyo antes y durante la aplicación de estas secuencias alternantes en personas sanas. Las secuencias propuestas se aplican para el inflado y desinflado de celdas que forman el cojín y fueron diseñadas con el objetivo de distribuir las presiones en un área mayor de apoyo. La prueba se realizó en 8 sujetos sanos, con un tiempo de estudio de 12 minutos para cada secuencia diseñada; 2 minutos en modo estático y 10 minutos en modo alternante. Se propuso determinar el coeficiente de variación para evaluar de forma cuantitativa el efecto de las secuencias alternantes sobre la presión de interfaz. Además se calculó el porcentaje de variación relativa del coeficiente de variabilidad entre los modos basal (estático) y alternante como una herramienta para evaluar el desempeño de las secuencias propuestas en relación a la presión de interfaz. Se encontró que las tres estrategias mantuvieron presiones de interfaz por debajo de los valores reportados en trabajos previos. El porcentaje de variación relativa permitió diferenciar el efecto de la alternancia de cada una de las secuencias propuestas, mostrando la segunda estrategia como la más efectiva. Los resultados obtenidos son alentadores para continuar el estudio en sujetos que requieren una silla de ruedas para su movilidad.

Time course of released atrial natriuretic peptide after acute myocardial infarction.

The plasma concentration of atrial natriuretic peptide (pANP) was investigated at fixed times during 48 h following the onset of an initial attack of mild acute myocardial infarction (AMI) in 11 patients. Six hours after onset, the mean pANP was elevated, but 6 h later pANP had returned to the baseline level. Forty-eight hours after onset the mean pANP increased again. Thus, the curve of the time course of pANP consisted of 2 peaks separated by a dip. Six hours after onset, systemic hemodynamics and humoral factors were measured in 27 patients. At 48 h they were measured in 14 patients. The late elevation of pANP correlated with mean pulmonary arterial wedge pressure (r = 0.63, n = 14, p less than 0.05), while the early elevation of pANP did not (r = 0.31, n = 27, n.s.). The early elevation of pANP correlated with plasma concentrations of both noradrenaline (r = 0.55, n = 27, p less than 0.01) and creatine phosphokinase (r = 0.54, n = 27, p less than 0.01). In addition, noradrenaline levels positively correlated with mean pulmonary arterial wedge pressure (r = 0.38, n = 27, p less than 0.05). The cause of the early elevation of pANP in AMI is unclear, but it is suggested that injury to myocardium and activated sympathetic nerve activity may be responsible in part.