Wound care in hard-to-reach populations: rough sleepers.

People sleeping rough commonly develop wounds and other skin disorders. Wounds vary and develop for multiple reasons. They include acute wounds such as burns, infected injection sites, abscesses and cellulitis, as well as chronic wounds such as pressure ulcers; rough sleepers have a high prevalence of lower limb wounds. Skin and soft tissue infections are common, especially in people who inject drugs via subcutaneous or intramuscular routes. Emergency departments are often the pathways into healthcare for homeless people as traditional health and care systems often fail to meet their needs. Across England, initiatives have been developed to improve access to wound care for those who sleep rough. A case study illustrates the care of a homeless man presenting with a lower limb wound.

'Not the last resort': The impact of an interprofessional training care home initiative on students, staff, and residents.

This paper reports on an innovative interprofessional education (IPE) initiative conducted in three care homes across Greater Manchester in the United Kingdom (UK). Students from a variety of professions including nursing, physiotherapy, social work, podiatry, counseling, and sports rehabilitation worked collaboratively in the homes to address the residents' individual goals. We found that care homes provided students with many opportunities for interprofessional working and learning. Through better understanding the dimensions of different perspectives and approaches, students improved their education and transformed their perceptions of aged care. Having a diverse range of professionals allowed staff to gain insight into the latest evidence-based practice and address the multiple needs of the residents more holistically. Residents gained an enriched sense of meaning and purpose in their daily life by engaging in fulfilling and meaningful activities. The complexities of undertaking an IPE initiative in this setting are also considered and we conclude by proposing important avenues for future research.

Skin tears in mammography: A narrative review.

Skin tears are classed as traumatic wounds mainly caused by shearing and frictional forces. Incidences of skin tears are noted to be significant mostly in the elderly population and those with fragile and vulnerable skin. Individuals undergoing mammography are susceptible to skin tears due to factors associated with skin breakdown such as thinning of the epidermis, use of steroids, presence of moisture, but this, when compounded with the procedure of mammography can increase the risk further. Mammography, an x-ray imaging method, which exerts adequate compression force on the breast tissue for the mammographer to obtain a high-quality image for diagnostic purposes. However, when compression force is applied during mammography resulting incidences of cutaneous skin tears can occur. Lack of and under reporting of skin tears during mammography makes it difficult to ascertain the extent of this problem and scale of its incidence. Therefore, the purpose of this narrative review is to focus on providing an overview of skin tears associated with mammography and a discussion of the current literature with regards to its incidence and diagnosis. In addition, the review will also discuss the theoretical and contextual perspective of the prevention and management strategies associated with skin tears.

Clinimetrics of the Lanarkshire Oximetry Index for patients with leg ulcers: A systematic review and meta-analysis.

Ankle Brachial Pressure Index (ABPI) measurement has long been considered the gold standard of vascular assessment for people with lower limb ulceration. Despite this, only around 15% of patients in the United Kingdom who require an ABPI measurement undergo the assessment. The Lanarkshire Oximetry Index (LOI) is a cheaper and arguably more accessible approach to vascular assessment and was initially proposed as an alternative to the ABPI in 2000. No synthesis of evidence related to the LOI has been performed since its introduction into the literature. Primary studies were sought to determine the clinimetric properties of the LOI and its level of agreement with ABPI assessments. Systematic searches of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, BNI, ProQuest Health and Medicine, Science Direct, Google Scholar and the British Library (online search) were conducted. Reference lists of identified studies were also reviewed to identify additional studies. Three primary studies met the inclusion criteria, reporting data from 307 patients and 584 limbs assessed using both the LOI and ABPI. All three studies reported fair to moderate kappa values for interrater reliability (κ = 0.290-0.747) and statistically significant positive correlation coefficients (r = 0.37, p < 0.001 in two studies) between the LOI and ABPI. The combined data from the three studies indicated a sensitivity of 52% (41.78-62.1, 95% confidence interval [CI]) and specificity of 96.08% (93.4-97.9, 95% CI) for the LOI using the ABPI as a reference. Additional data are required to indicate the safety of the LOI in practice. Data are also required to determine if the LOI is more acceptable to clinicians compared to the ABPI and whether there are any barriers/enablers to its implementation in practice. Given the relatively low specificity of the LOI, it may be beneficial to combine measurement of the LOI with a subjective clinical risk assessment tool to improve the sensitivity of this alternative approach to vascular assessment.

Getting wound care right: evaluation of a week of intensive teaching on wound care for undergraduate nursing students.

INTRODUCTION: Tissue viability skills are essential for nurses, but education on this in undergraduate programmes can be inadequate. After approval of the Future Nurse curriculum in 2019, a small team of staff at the University of Salford developed a Getting Wound Care Right week to improve students' knowledge and clinical skills. METHODS: To evaluate the week, the 250 students who had participated in all activities were invited 6 months after the week to contribute a 250-word reflection for a case series. The aim of this was to understand the impact of the week on participants' knowledge, skills and confidence in caring for patients with wounds and whether it had sparked interest in further learning. RESULTS: Four students contributed reflections, which were overwhelmingly positive. They described the knowledge attained, which included that on anatomy and physiology of the skin and wound healing, evidence-based assessment, treatment and management of wounds, and the impact of wounds on patients' quality of life. Skills gained included those in categorisation of wounds, wound assessment and pressure redistribution when seated. Responses on the impact on clinical practice focused on the importance of multidisciplinary working within wound care, seating provision for pressure ulcer prevention and management, and dressing selection. Negative comments related to students realising that clinical practice could be improved rather than indications that the format is ineffective or inappropriate. Limitations of the evaluation included the small number of participants and a lack of responses from every field of practice. CONCLUSIONS: The Getting Wound Care Right week format is a viable approach to meeting Future Nurse curriculum requirements. The approach could be enhanced by a greater emphasis on the relevance of wound care teaching to children and young people's nursing students. The week improved students' clinical confidence on placements when caring for patients with wounds. Further robust evaluation of the module is needed to confirm the findings of this initial evaluation.

Pressure redistributing static chairs for preventing pressure ulcers.

BACKGROUND: Sitting can be viewed as a therapeutic intervention and an important part of a person's recovery process; but the risk of ulceration must be mitigated. Interventions for ulcer prevention in those at risk from prolonged sitting include the use of specialist cushions and surfaces, especially for wheelchair users. Whilst there is interest in the effects of different pressure redistributing cushions for wheelchairs, the benefits of pressure redistributing static chairs, compared with standard chairs, for pressure ulcer development in at-risk people are not clear. OBJECTIVES: To assess the effects of pressure redistributing static chairs on the prevention of pressure ulcers in health, rehabilitation and social care settings, and places of residence in which people may spend their day. SEARCH METHODS: In June 2021 we searched the following electronic databases to identify reports of relevant randomised clinical trials: the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase and EBSCO CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature). We also searched clinical trials registers for ongoing and unpublished studies, and reference lists of relevant systematic reviews, meta-analyses and health technology reports. There were no restrictions by language, date of publication or study setting. SELECTION CRITERIA: We sought to include published or unpublished randomised controlled trials that assessed pressure redistributing static chairs in the prevention or management of pressure ulcers. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection. We planned that two review authors would also assess the risk of bias, extract study data and assess the certainty of evidence according to GRADE methodology. MAIN RESULTS: We did not identify any studies that met the review eligibility criteria, nor any registered studies investigating the role of pressure redistributing static chairs in the prevention or management of pressure ulcers. AUTHORS' CONCLUSIONS: Currently, there is no randomised evidence that supports or refutes the role of pressure redistributing static chairs in the prevention or management of pressure ulcers. This is a priority area and there is a need to explore this intervention with rigorous and robust research.

Risk factors for the development and evolution of deep tissue injuries: A systematic review.

AIMS: The aim of this systematic review is to identify the current epidemiological evidence indicating the unique risk factors for deep tissue injury (DTI) compared to grade I-IV pressure injury (PI), the proportion of DTI which evolve rather than resolve and the anatomical distribution of DTI. METHODS: A systematic literature search was undertaken using the MEDLINE and CINAHL Plus databases using the search terms 'Deep tissue injury OR DTI [Title/abstract]'. A google scholar search was also conducted in addition to hand searches of relevant journals, websites and books which were identified from reference lists in retrieved articles. Only peer-reviewed English language articles published 2009-2021 were included, with full text available online. RESULTS: The final qualitative analysis included nine articles. These included n = 4 retrospective studies, n = 4 prospective studies and n = 1 animal study. CONCLUSION: The literature indicates that the majority of DTI occur at the heel and sacrum although in paediatric patients they are mainly associated with medical devices. Most DTI are reported to resolve, with between 9.3 and 27% deteriorating to full thickness tissue loss. Risk factors unique to DTI appear to include anaemia, vasopressor use, haemodialysis and nicotine use although it is unclear if these factors are unique to DTI or are shared with grade I-IV PI. Factors associated with deterioration include cooler skin measured using infrared thermography and negative capillary refill. With 100% of DTI showing positive capillary refill in one study resolving without tissue loss (p = 0.02) suggesting this may be an effective prognostic indicator. More prospective studies are required focusing on establishing causal links between risk factors identified in earlier retrospective studies. Ideally these should use statistically powered samples and sufficient follow up periods allowing DTI outcomes to be reached. Further work is also needed to establish reliable diagnostic criteria for DTI in addition to more studies in the paediatric population.

The skin and associated disorders.

This article aims to increase knowledge of the skin and associated disorders. Anatomy and physiology of the skin are briefly reviewed, and reference is made to common skin disorders. The main characteristics of a holistic skin assessment are discussed, and the signs to look for when undertaking an examination. The article concludes with a case study for context and reflection.

Frugal innovation in wound care: a critical discussion of what we can learn from low-resource settings.

Frugal innovation is a common philosophy in low-income settings due to limited access to resources. However, with both the increasing prevalence and clinical acuity of patients with wounds in the UK, it is essential that alongside innovation such as harnessing cutting-edge new technologies, frugal innovation is also pursued. This may improve both economic efficiency and patient outcomes. Frugal innovations were adopted throughout the COVID-19 pandemic and included opportunistic solutions such as video-conferencing services to run clinics. However, there are many more opportunities for frugal innovation in wound care, including the use of smartphone technology, which is already accessible to 99.5% of UK clinicians caring for wounds, or the simplification of wound-assessment processes using pulse oximeters as an alternative to dopplers, as in the Lanarkshire Oximetry Index. This article explores what frugal innovation is and how it could improve UK wound services. The authors invite clinicians working in wound care to consider their access to existing resources that may not be considered useful for wound-care processes and explore how these could be used to improve clinical outcomes.

Persistent COVID-19-associated neurocognitive symptoms in non-hospitalized patients.

As cases of coronavirus disease 2019 (COVID-19) mount worldwide, attention is needed on potential long-term neurologic impacts for the majority of patients who experience mild to moderate illness managed as outpatients. To date, there has not been discussion of persistent neurocognitive deficits in patients with milder COVID-19. We present two cases of non-hospitalized patients recovering from COVID-19 with persistent neurocognitive symptoms. Commonly used cognitive screens were normal, while more detailed testing revealed working memory and executive functioning deficits. An observational cohort study of individuals recovering from COVID-19 (14 or more days following symptom onset) identified that among the first 100 individuals enrolled, 14 were non-hospitalized patients reporting persistent cognitive issues. These 14 participants had a median age of 39 years (interquartile range: 35-56), and cognitive symptoms were present for at least a median of 98 days (interquartile range: 71-120 following acute COVID-19 symptoms); no participants with follow-up evaluation reported symptom resolution. We discuss potential mechanisms to be explored in future studies, including direct viral effects, indirect consequences of immune activation, and immune dysregulation causing auto-antibody production.

Evaluating the impact of the Tissue Viability Seating guidelines.

INTRODUCTION: Internationally, guidelines are developed to ensure safe, effective, person centred, timely, efficient, and effective practice. However, their use in clinical practice is found to be variable. The Tissue Viability Society (TVS) published updated seating guidelines in 2017, yet, little is known about how these guidelines are being used. METHODS: The aim of this evaluation was to gauge the impact of the Tissue Viability Seating Guidelines on clinical practice and policy. A cross-sectional questionnaire was used to elicit the responses from anyone with an interest or role within seating and pressure ulcer prevention and management. The survey was distributed through a variety of methods including email to members of the Tissue Viability Society and social media platforms from September to December 2019. RESULTS: and Discussion: There were thirty-nine responses, the bulk of which were from healthcare professionals across primary and secondary care. All but one respondent was from the United Kingdom. Eleven had incorporated the latest TVS seating guidance into policy and sixteen into practice. The results of our survey demonstrates congruence with the literature as the main themes that emerged included incorporating the guidance into everyday clinical practice, education, and training, and as a resource or dissemination tool. Barriers to implementation included being unaware of the guidelines and unaware of one's own professional and collective organisational responsibility to guideline dissemination. However, many respondents were planning to incorporate the guidelines using a variety of methods. CONCLUSION: This survey has shown there are some examples of successful implementation of the TVS Seating guidelines. Future TVS guidelines should include implementation strategies, interventions, and goals for local champions to ensure barriers to implementation are both assessed and addressed. Future work could also include a trial of the guidelines within a pilot project.

Multiproteinopathy, neurodegeneration and old age: a case study.

A complex spectrum of mixed brain pathologies is common in older people. This clinical pathologic conference case study illustrates the challenges of formulating clinicopathologic correlations in late-onset neurodegenerative diseases featuring cognitive-behavioral syndromes with underlying multiple proteinopathy. Studies on the co-existence and interactions of Alzheimer's disease (AD) with neurodegenerative non-AD pathologies in the aging brain are needed to understand the pathogenesis of neurodegeneration and to support the development of diagnostic biomarkers and therapies.

Extending conceptual understanding: How interprofessional education influences affective domain development.

Interprofessional learning (IPL) can influence affective domain development of students through teaching activities that facilitate learning with, from, and about other professions. Current quantitative evidence offers limited explanation of how this learning is achieved within IPL programmes. This article tests a conceptual framework drawn from theories on IPL and affective domain development (attitudes, values, and behaviours) to explain what works for whom, when, and in what circumstances. The objectives of the study were twofold: to evaluate the impact of the IPL programme on the student's attitudes and values, and to identify behaviour changes in clinical practice towards interprofessional working. Using an action research approach, based in practice, an IPL programme was delivered over 6 weeks. Students from five professions, nursing, radiography, physiotherapy, social work, and podiatry (n = 63), participated over the two action research cycles and in semi-structured focus groups (n = 37). The recorded personal experiences of the IPL activities on the students were examined in relation to the type of activity; impact on the affective domain of learning (attitude, value, or behaviour) and self-reported outcome on application to their practice. Modification in affective domain development was measured to identification or internalisation stage for 30 of the students. Self-reported outcomes on application to practice included direct impact on patient care, personal resilience building, improved communication, and ability to challenge practice. This article presents a conceptual framework not evident in current research, in regard to what IPL works for whom, in what circumstances, and when. IPL activities that address a personal reward or incentive and are delivered over four weeks, imitating 'circles of care,' that explore self-assessment, team building, and reflection can lead to sustained change in values, attitudes, and behaviours.

Developing the tissue viability seating guidelines.

BACKGROUND: Costs for the prevention and management of pressure ulcers have increased significantly with limited published advice from health and social care organisations on seating and preventing pressure ulcers. At the request of the UK Tissue Viability Society the aim of the publication was to develop a practical guide for people, carers and health and social care professionals on how the research and evidence base on pressure ulcer prevention and management can be applied to those who remain seated for extended periods of time. METHODS AND FINDINGS: The evidence base informing the guidelines was obtained by applying a triangulation of methods: a literature review, listening event and stakeholder group consultation. The purpose was to engage users and carers, academics, clinicians, inspectorate and charities, with an interest in seating, positioning and pressure management to: gather views, feedback, stories, and evidence of the current practices in the field to create a greater awareness of the issue. CONCLUSION: The new guidelines are inclusive of all people with short and long-term mobility issues to include all population groups. The document includes evidence on where pressure ulcers develop when seated, risk factors, best possible seated position and what seat adjustments are required, the ideal seating assessment, interventions, self-help suggestions and key seating outcomes. The updated TVS CPGs have been informed by the best available evidence, the insights and wisdom of experts, stakeholders and people who spend extended periods of time sitting.

Global landscape of HIV-human protein complexes.

Human immunodeficiency virus (HIV) has a small genome and therefore relies heavily on the host cellular machinery to replicate. Identifying which host proteins and complexes come into physical contact with the viral proteins is crucial for a comprehensive understanding of how HIV rewires the host's cellular machinery during the course of infection. Here we report the use of affinity tagging and purification mass spectrometry to determine systematically the physical interactions of all 18 HIV-1 proteins and polyproteins with host proteins in two different human cell lines (HEK293 and Jurkat). Using a quantitative scoring system that we call MiST, we identified with high confidence 497 HIV-human protein-protein interactions involving 435 individual human proteins, with ∼40% of the interactions being identified in both cell types. We found that the host proteins hijacked by HIV, especially those found interacting in both cell types, are highly conserved across primates. We uncovered a number of host complexes targeted by viral proteins, including the finding that HIV protease cleaves eIF3d, a subunit of eukaryotic translation initiation factor 3. This host protein is one of eleven identified in this analysis that act to inhibit HIV replication. This data set facilitates a more comprehensive and detailed understanding of how the host machinery is manipulated during the course of HIV infection.

Evaluating the impact of WaterCell® Technology on pressure redistribution and comfort/discomfort of adults with limited mobility.

AIM OF THE STUDY: The aim of the study was to evaluate the effect of WaterCell® Technology on pressure redistribution and self-reported comfort and discomfort scores of adults with mobility problems who remain seated for extended periods of time. METHODS: Twelve participants, were recruited and ranged in gender, age, height, weight, and body mass index. Five were male, seven were female, and five were permanent wheelchair users. Each participant was randomly allocated a chair, whose seat comprised of visco-elastic memory foam, high-elastic reflex foam, and watercells, to trial for a week. Data collected at day one and day seven included: interface pressure measurements taken across the gluteal region (peak and average); physiological observations of respiratory rate, pulse rate, and blood pressure; skin inspection and comfort and discomfort scores. RESULTS: Watercell® technology was found to offer lower average pressures than those reported to cause potential skin injury. Peak pressure index findings were comparative to other studies. No correlation was found between discomfort intensity rating and pressure redistribution. Discomfort intensity rating was low for all participants and general discomfort ranged from very low to medium. Physiological observations decreased for 50% of participants over the seven days. CONCLUSION: From our study we have found that WaterCell® technology offers comparable pressure redistribution for people with a disability who need to sit for prolonged periods of time and the chairs were found to be comfortable.

Purulent Skin and Soft Tissue Infections, Challenging the Practice of Incision and Drainage: A Scoping Review.

Aim: To generate a landscape of the current knowledge in the interventional management and outcomes of purulent skin and soft tissue infections. Design: This study is a scoping review. Methods: Electronic searches were undertaken using CINAHL, Medline, Cochrane Library, British Nursing Index, Science Direct, the National Health Service knowledge and library hub, ClinicalTrials.gov, and MedNar. The population, concept, context framework, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews were utilised, supporting a rigorous appraisal and synthesis of literature. Data Sources. The initial search and synthesis of literature were completed in January 2022 with repeat searches completed in March 2022 and July 2023. There were no imposed chronological parameters placed on the returned literature. Results: Nineteen papers were reviewed. Incision and drainage with primary closure, needle aspiration, loop drainage, catheter drainage, and suction drainage are viable adjuncts or alternatives to the traditional surgical management of skin and soft tissue abscesses. Conclusion: Despite the empirically favourable alternatives to the incision and drainage technique demonstrated, this does not appear to be driving a change in clinical practice. Future research must now look to mixed and qualitative evidence to understand the causative mechanisms of incision and drainage and its ritualistic practice. Implications. Ritual surgical practices must be challenged if nurses are to improve the treatment and management of this patient group. This will lead to further practice innovation. Impact: This study explored the challenges posed to patients, clinicians, nurses, and stakeholders, resulting from the ritualistic practice of the incision and drainage technique in purulent skin or soft tissue abscesses. Empirically and holistically viable alternatives were identified, impacting all identified entities and recommending a wider holistic study. Reporting Method. Adherence to EQUATOR guidance was achieved through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

Reflections on an interprofessional student placement initiative in care homes.

Interprofessional learning can offer students from different disciplines an opportunity to learn from, with and about each other. Additionally, practice placements in care home settings can offer students a rich learning experience. In 2021, a pilot interprofessional student placement initiative in care homes took place in the Manchester area, with three care homes and 17 students from a range of health and social care disciplines. In this article, the members of the core operational group that implemented the initiative reflect on their experiences. Using the 'What? So what? Now what?' reflective framework, they describe the context of the initiative, explore the lessons learned and make recommendations for future initiatives. The authors' intention is to inspire other educators to consider offering interprofessional placements to students, recognise the value of care homes as placement settings, and acknowledge the benefits of using reflection-in-action and reflective frameworks in healthcare education and practice.