A cost-effectiveness analysis of two different repositioning strategies for the prevention of pressure ulcers.

AIMS: To assess the cost effectiveness of two repositioning strategies and inform the 2014 National Institute for Health and Care Excellence clinical guideline recommendations on pressure ulcer prevention. BACKGROUND: Pressure ulcers are distressing events, caused when skin and underlying tissues are placed under pressure sufficient to impair blood supply. They can have a substantial impact on quality of life and have significant resource implications. Repositioning is a key prevention strategy, but can be resource intensive, leading to variation in practice. This economic analysis was conducted to identify the most cost-effective repositioning strategy for the prevention of pressure ulcers. DESIGN: The economic analysis took the form of a cost-utility model. METHODS: The clinical inputs to the model were taken from a systematic review of clinical data. The population in the model was older people in a nursing home. The economic model was developed with members of the guideline development group and included costs borne by the UK National Health Service. Outcomes were expressed as costs and quality adjusted life years. CONCLUSION: Despite being marginally more clinically effective, alternating 2 and 4 hourly repositioning is not a cost-effective use of UK National Health Service resources (compared with 4 hourly repositioning) for this high risk group of patients at a cost-effectiveness threshold of £20,000 per quality adjusted life years. These results were used to inform the clinical guideline recommendations for those who are at high risk of developing pressure ulcers.

Using a national guideline to prevent and manage pressure ulcers.

Developing pressure ulcers is a painful and distressing event for patients, and one that can be prevented. The National Institute for Health and Care Excellence pressure ulcer guideline has recently been updated to cover the prevention and management of this condition. This article focuses on the recommendations that are relevant to nurses, covering areas such as risk assessment, skin assessment, repositioning, pressure-redistributing devices, dressings, patient and carer information, and training and education. It also identifies what senior nurses and nurse managers must do to ensure their staff can prevent and manage pressure ulcers effectively.

Proteomics analyses of the opportunistic pathogen Burkholderia vietnamiensis using protein fractionations and mass spectrometry.

The main objectives of this work were to obtain a more extensive coverage of the Burkholderia vietnamiensis proteome than previously reported and to identify virulence factors using tandem mass spectrometry. The proteome of B. vietnamiensis was precipitated into four fractions to as extracellular, intracellular, cell surface and cell wall proteins. Two different approaches were used to analyze the proteins. The first was a gel-based method where 1D SDS-PAGE was used for separation of the proteins prior to reverse phase liquid chromatography tandem mass spectrometry (LC-MS/MS). The second method used MudPIT analysis (Multi dimensional Protein Identification Technique), where proteins are digested and separated using cation exchange and reversed phase separations before the MS/MS analysis (LC/LC-MS/MS). Overall, gel-based LC-MS/MS analysis resulted in more protein identifications than the MudPIT analysis. Combination of the results lead to identification of more than 1200 proteins, approximately 16% of the proteins coded from the annotated genome of Burkholderia species. Several virulence factors were detected including flagellin, porin, peroxiredoxin and zinc proteases.

The social and psychological impact of hard-to-heal wounds.

Hard-to-heal wounds typically present a huge challenge to the clinical team charged with their treatment. Wounds that are extremely painful and/or unsightly can have an extreme psychological impact on the patient, and this can be as crucial a consideration as the complexities involved in managing the physical healing. While resource expenditure on hard-to-heal wounds can be quantified, quality of life is less easy to evaluate, but is clearly of paramount importance to the patient. This article examines the experience of a woman treated for basal cell carcinoma of the scalp--both the immediate emotional impact of the individual stages of treatment and the wider impact on her lifestyle and her family. In addition, it considers the case from the perspective of a key member of the clinical team in order to present a rounded account of the cae study from a human perspective. The woman was finally healed using an advanced wound care product, Xelma®. The objectives of the study were to revisit a case study featured in a recent article (Bond et al, 2009) to provide an update on outcomes and to examine the case from the human perspective; to consider the impact of key clinical decisions on the patient's state of mind and emotions,and on the practicalities of everyday life; and to examine the ase from the perspective of a key clinician.

Soil Microbiome Dynamics During Pyritic Mine Tailing Phytostabilization: Understanding Microbial Bioindicators of Soil Acidification.

Challenges to the reclamation of pyritic mine tailings arise from in situ acid generation that severely constrains the growth of natural revegetation. While acid mine drainage (AMD) microbial communities are well-studied under highly acidic conditions, fewer studies document the dynamics of microbial communities that generate acid from pyritic material under less acidic conditions that can allow establishment and support of plant growth. This research characterizes the taxonomic composition dynamics of microbial communities present during a 6-year compost-assisted phytostabilization field study in extremely acidic pyritic mine tailings. A complementary microcosm experiment was performed to identify successional community populations that enable the acidification process across a pH gradient. Taxonomic profiles of the microbial populations in both the field study and microcosms reveal shifts in microbial communities that play pivotal roles in facilitating acidification during the transition between moderately and highly acidic conditions. The potential co-occurrence of organoheterotrophic and lithoautotrophic energy metabolisms during acid generation suggests the importance of both groups in facilitating acidification. Taken together, this research suggests that key microbial populations associated with pH transitions could be used as bioindicators for either sustained future plant growth or for acid generation conditions that inhibit further plant growth.

Soil Lysimeter Excavation for Coupled Hydrological, Geochemical, and Microbiological Investigations.

Studying co-evolution of hydrological and biogeochemical processes in the subsurface of natural landscapes can enhance the understanding of coupled Earth-system processes. Such knowledge is imperative in improving predictions of hydro-biogeochemical cycles, especially under climate change scenarios. We present an experimental method, designed to capture sub-surface heterogeneity of an initially homogeneous soil system. This method is based on destructive sampling of a soil lysimeter designed to simulate a small-scale hillslope. A weighing lysimeter of one cubic meter capacity was divided into sections (voxels) and was excavated layer-by-layer, with sub samples being collected from each voxel. The excavation procedure was aimed at detecting the incipient heterogeneity of the system by focusing on the spatial assessment of hydrological, geochemical, and microbiological properties of the soil. Representative results of a few physicochemical variables tested show the development of heterogeneity. Additional work to test interactions between hydrological, geochemical, and microbiological signatures is planned to interpret the observed patterns. Our study also demonstrates the possibility of carrying out similar excavations in order to observe and quantify different aspects of soil-development under varying environmental conditions and scale.

Incidence of cardiovascular disease in individuals with psoriasis: a systematic review and meta-analysis.

The relationship between psoriasis and increased risk of cardiovascular disease (CVD) is controversial. We critically evaluate 14 cohorts and meta-analyze the magnitude of CVD risk for the primary outcomes of CVD mortality, stroke, and myocardial infarction (MI), and establish subgroup risk for different psoriasis severities and age groups. Increased CVD risk was identified only in individuals with severe psoriasis (defined as requiring systemic therapy or hospital admission): the risk ratio relative to the general population was 1.37 (95% confidence interval (CI) 1.17-1.60) for CVD mortality, 3.04 (95% CI 0.65-14.35) for MI, and 1.59 (95% CI 1.34-1.89) for stroke. The relative risks of CVD were highest in the younger, severe psoriasis population (e.g., 3.10 (95% CI 1.98-4.86) for MI at 30 years), and absolute risks were greatest in older individuals with severe psoriasis (e.g., 23.2 excess MIs per 10,000 person-years at 60 years). Uncertainty remains about whether CVD risk is directly attributable to psoriasis, as the majority of studies failed to adequately adjust for key traditional risk factors.

Profile of lacosamide and its role in the long-term treatment of epilepsy: a perspective from the updated NICE guideline.

AIM: The goal of antiepileptic treatment is to achieve seizure freedom or seizure control. The aim of this paper is to review the evidence for the use of lacosamide for adjunctive treatment of refractory focal seizures with or without secondary generalization, within the scope of the 2012 update of the Clinical Guideline published by the National Institute for Health and Clinical Excellence (NICE). METHODS: Clinical evidence for the use of lacosamide and other antiepileptic drugs (AEDs) was systematically reviewed, evaluated, and presented to the Guideline Development Group. Only randomized clinical trials were included. Outcomes of clinical efficacy (seizure freedom, 50% reduction in seizure frequency, time to first seizure, time to 12-month remission, treatment withdrawal, and time to treatment withdrawal), experience of adverse events, and cognitive and quality of life outcomes were reviewed. A decision model was built to weigh the clinical benefits of each adjunctive AED, measured by seizure control and seizure reduction, compared with the harm from adverse events, as measured by withdrawals from treatment due to adverse events. RESULTS: Lacosamide was included as part of the recommended AEDS to be used in tertiary epilepsy centers. The evidence review showed that more participants who received lacosamide as an adjunctive treatment had at least a 50% reduction in seizure frequency compared with those taking placebo. However, more participants on lacosamide were found to experience adverse events and withdrawal from treatment compared with those on placebo. The cost-effectiveness analysis showed that compared with placebo, the benefits gained from adjunctive lacosamide were modest and uncertain, whereas the costs were significantly high. Compared with other AEDs licensed for adjunctive therapy in focal seizures, lacosamide was associated with fewer quality-adjusted life years and higher costs. Therefore, the Guideline Development Group noted that the balance of benefit and harm needs to be carefully monitored in all patients.

Introducing GRADE across the NICE clinical guideline program.

OBJECTIVES: Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a system for rating the confidence in estimates of effect and grading guideline recommendations. It promotes evaluation of the quality of the evidence for each outcome and an assessment of balance between desirable and undesirable outcomes leading to a judgment about the strength of the recommendation. In 2007, the National Institute for Health and Clinical Excellence began introducing GRADE across its clinical guideline program to enable separation of judgments about the evidence quality from judgments about the strength of the recommendation. STUDY DESIGN AND SETTING: We describe the process of implementing GRADE across guidelines. RESULTS: Use of GRADE has been positively received by both technical staff and guideline development group members. CONCLUSION: A shift in thinking about confidence in the evidence was required leading to a more structured and transparent approach to decision making. Practical problems were also encountered; these have largely been resolved, but some areas require further work, including the application of imprecision and presenting results from analyses considering more than two alternative interventions. The use of GRADE for nonrandomized and diagnostic accuracy studies needs to be refined.