Epidemiology of Incontinence-Associated Dermatitis and Intertriginous Dermatitis (Intertrigo) in an Acute Care Facility.

PURPOSE: The purpose of this study was to measure the prevalence of incontinence-associated dermatitis (IAD) and intertriginous dermatitis (ITD) upon admission, and the incidence of hospital-acquired IAD and ITD in a sample of acutely ill adults. DESIGN: This was a descriptive, retrospective-cohort observational study. SUBJECTS AND SETTING: The sample comprised 417 adults admitted to an urban community hospital licensed for 249 acute and 52 acute rehabilitation beds in Charleston, South Carolina, and referred to WOC nurses for evaluation and treatment. METHODS: Prevalence and incidence rates were calculated from data previously collected for quality improvement purposes from January 1, 2014, to December 31, 2016, by the WOC nurses and documented in a secure, password-protected electronic spreadsheet. The prevalence of IAD/ITD was calculated as the proportion of patients diagnosed with IAD/ITD on admission to our facility. The incidence of IAD and ITD was calculated as percentage of patients who developed IAD/ITD during the course of their hospital stay. All units in the hospital were included. RESULTS: The mean prevalence of IAD present on admission was 16%; the prevalence decreased over the data collection period; it was 21% in 2014, 15% in 2015, and 13% in 2016. The mean incidence of hospital-acquired IAD during the data collection period was 23%; the highest rate (26%) occurred in 2016. Patients classified as normal weight from their body mass index and patients 60 years and older had the highest incidence of hospital-acquired IAD. The mean prevalence of ITD for patients admitted to the hospital was 40% for the 3-year time; annual rates varied from a low of 36% in 2015 to a high of 42% in 2016. The mean incidence of hospital-acquired ITD was 33% over the data collection period; mean incidence rates were 32% in 2014, 39% in 2015, and 29% in 2016. The incidence of ITD was higher in patients classified as obese based on body mass index in patients 60 years and older. The most common location was the gluteal cleft. CONCLUSIONS: The prevalence of IAD fell within the range of prior epidemiologic studies, but the facility-acquired IAD incidence rates were higher than other studies based in the acute care setting. The prevalence of ITD was higher than rates reported in prior studies; we searched the literature and found no previous reports of ITD occurrences over the course of a hospital stay. Additional research regarding IAD prevention and ITD in the gluteal cleft is needed. Data collection regarding IAD and ITD prevalence and incidence could be incorporated into the data collection tool used for pressure injury data collection for the National Database of Nursing Sensitive Indicators.

Decreasing Incontinence-Associated Dermatitis in the Surgical Intensive Care Unit: A Quality Improvement Project.

PURPOSE: The purpose of this quality improvement (QI) project was to determine if use of an algorithm focusing on skin care in patients with fecal and urinary incontinence reduces the rate of hospital-acquired incontinence-associated dermatitis (IAD) over a period of 4 months. PARTICIPANTS AND SETTING: The QI setting was an 18-bed surgical intensive care unit (SICU) in an acute care urban hospital located in the southeastern United States. Two hundred eleven patients participated in this pre/postintervention QI project. APPROACH: The algorithm for skin care used evidence-based bundled interventions for patients with fecal and urinary incontinence. The project comprised education of the SICU nursing staff in January 2018 and implementation of the algorithm from February 5, 2018, to June 5, 2018. Weekly chart reviews were conducted to determine algorithm compliance, documentation of fecal and urinary incontinence, and accuracy of IAD documentation. Descriptive statistics were used to determine the rate of hospital-acquired IAD, algorithm compliance, and average length of time from admission to the onset of hospital-acquired IAD. OUTCOMES: Seventy-nine individuals with incontinence were included in the 3-month preintervention period and 132 individuals with incontinence in the 3-month postintervention period. We observed a 24% reduction in the rate of hospital-acquired IAD following implementation of the algorithm (29% vs 5%). The average length of time from admission to the onset of hospital-acquired IAD increased from 15 days in February 2018 to 25 days in May 2018. IMPLICATIONS FOR PRACTICE: Our experience with this QI project suggest that IAD can be identified and managed at the bedside by first clinical nursing staff without expertise in skin assessment and wound care.

Incontinence-Associated Dermatitis and Intertriginous Dermatitis as Nurse-Sensitive Quality Indicators: A Delphi Study.

PURPOSE: This purpose of this study was to determine whether consensus exists concerning the need to collect epidemiologic data about 2 forms of moisture-associated skin damage, incontinence-associated dermatitis (IAD) and intertriginous dermatitis (ITD), and whether these data should be part of data routinely collected as part of the National Database of Nursing Quality Indicators (NDNQI). DESIGN: Modified Delphi technique. SAMPLE AND SETTING: Questionnaires were sent via e-mail to 50 identified experts, with an initial response of 17. Thirteen clinical experts responded to the second round and 11 responded to a third round. METHODS: Items on the questionnaires were investigator-developed. Consensus was defined as 80% or more agreement. Three rounds of questionnaires were employed to attempt consensus. Descriptive statistics were performed using mean and standard deviation for continuous data and frequencies and percentages for categorical data. Qualitative data were analyzed question by question by the primary researcher using content analysis. RESULTS: Consensus was achieved indicating that individual facilities should regularly collect data about IAD prevalence or incidence. Consensus was not reached about the need to regularly collect data about ITD prevalence or incidence. Panelists also failed to reach consensus that IAD or ITD prevalence or incidence should be incorporated into the NDNQI indicators. CONCLUSION: Panelists did not reach consensus that IAD or ITD epidemiologic data should be incorporated on the NDNQI. Additional research is needed, particularly in the area of ITD, before benchmarks can be established regarding these data as nurse-sensitive indicators of quality care.

Medical Device-Related Pressure Injuries in Long-term Acute Care Hospital Setting.

PURPOSE: The purpose of this study was to examine the epidemiology of medical device-related pressure injuries (MDRPIs) in 3 long-term acute care hospitals (LTACHs). DESIGN: Retrospective descriptive study. SUBJECTS AND SETTING: The sample comprised 304 adult inpatients at 3 geographically diverse LTACHs: Spaulding Hospital for Continued Medical Care, Drake Center, and Bethesda Hospital. The facilities are located in the Northeastern, Southeastern, and Midwestern United States. METHODS: Hospital-acquired pressure injury (HAPI) data and MDRPI data were collected and reported for the 3 LTACHs from July 1, 2009, to June 30, 2010. Data were collected by the wound nurses at 2 of the facilities on a daily or weekly basis and quarterly at the remaining site. RESULTS: One hundred forty-two MDRPIs occurred during data collection, representing an occurrence rate of (47%). The proportion of MDRPIs and HAPIs at each of the LTACHs was 38%, 50%, and 47%, respectively. The most commonly reported medical devices causing pressure injury were respiratory devices, splints and braces, and tubing. CONCLUSIONS: The MDRPI rate identified in the LTACH setting was higher than rates reported in the literature. This study's findings confirm the importance of monitoring MDRPIs in order to implement appropriate prevention strategies.

Evaluation of brief treatment of symptoms of psychological trauma among veterans residing in a homeless shelter by use of Accelerated Resolution Therapy.

BACKGROUND: Posttraumatic stress disorder (PTSD) is prevalent in both homeless and nonhomeless veterans. PURPOSE: To examine unique characteristics of being homeless that may influence PTSD treatment completion and clinical success. METHODS: Twenty-three veterans who were homeless and residing in a homeless shelter, along with 94 veterans from the community, were enrolled to receive one to five sessions of Accelerated Resolution Therapy (ART), an emerging trauma-focused therapy for symptoms of PTSD. Rates of treatment completion with ART and acute and 6-month change in symptoms of PTSD were compared in an observational (nonrandomized) manner by housing status. FINDINGS: Compared to veterans recruited from the community, veterans residing in the homeless shelter were older and presented with more extensive psychopathology yet had less combat exposure while being more likely to have experienced sexual assault. Rates of treatment completion were 52.2% (12 of 23) among homeless veterans compared to 81.9% (77 of 94) among veterans from the community (p = .005). Among treatment completers, both groups received an average of four sessions of ART. Reduction of symptoms of PTSD was substantial and nonsignificantly greater among homeless veterans vs. those treated from the community (p = .14), as were comorbidity reductions in depression, anxiety, sleep quality, pain, and improved quality of life. Results at 6-month posttreatment follow-up were similar. CONCLUSIONS: Although limited by small sample size and a nonrandomized design, ART appears to be an effective, brief treatment for symptoms of PTSD among veterans residing in a homeless shelter. However, development of effective strategies to maximize treatment completion among homeless veterans is needed.

Revisiting colostomy irrigation: a viable option for persons with permanent descending and sigmoid colostomies.

Colostomy irrigation (CI) is the regular irrigation of the bowel for persons with a permanent colostomy of the descending or sigmoid colon. Although this technique was first described in the 1920s, a recent study of 985 WOC nurses found that almost half (47%) do not routinely teach CI to persons with colostomies. In a systematic review (Evidence-Based Report Card) published in this issue of the Journal, we summarized current best evidence concerning the effect of CI on bowel function and found that irrigation reduces the frequency of bowel elimination episodes and allows some patients to reduce or eliminate ongoing use of a pouching system. This article describes techniques for teaching CI and discussed additional findings associated with CI.

Does colostomy irrigation affect functional outcomes and quality of life in persons with a colostomy?

BACKGROUND: Colostomy irrigation may be used by patients with colostomies to regulate bowel evacuations by stimulating emptying of the colon at regularly scheduled times. OBJECTIVE: This Evidence-Based Report Card reviews the effect of colostomy irrigation on frequency of bowel evacuation, flatus production, odor, and health-related quality of life. SEARCH STRATEGY: We systematically reviewed the literature for studies that evaluated health-related quality of life in persons aged 18 years or older with colostomies of the sigmoid or descending left colon. A professional librarian performed the literature search, which yielded 499 articles using the search terms "colostomy," "colostomies," "therapeutic irrigation," "irrigation," and "irrigator." Following title and abstract reviews, we identified and retrieved 4 studies that met inclusion criteria. FINDINGS: Colostomy irrigation reduces the frequency of bowel evacuations when compared to spontaneous evacuation and containment using a pouching system. Regular irrigation is associated with reductions in pouch usage. This change in bowel evacuation function frequently results in absence of bowel evacuations for 24 hours or longer, enabling some to discontinue ongoing use of a pouching system. Subjects using CI report reductions in flatus and odors associated with presence of a colostomy. One study was identified that found persons using CI reported higher health-related quality of life than did those who managed their colostomies with spontaneous evacuation using the Digestive Disease Quality of Life-15, but no differences were found when health-related quality of life was measured using the more generic instrument, the Medical Outcomes Study: Short Form-36. CONCLUSION: Instruction on principles and techniques of colostomy irrigation should be considered when managing patients with a permanent, left-sided colostomy.

Transplacental transfer of Azithromycin and its use for eradicating intra-amniotic ureaplasma infection in a primate model.

BACKGROUND: Our goals were to describe azithromycin (AZI) pharmacokinetics in maternal plasma (MP), fetal plasma (FP), and amniotic fluid (AF) following intra-amniotic infection (IAI) with Ureaplasma in pregnant rhesus monkeys and to explore concentration-response relationships. METHODS: Following intra-amniotic inoculation of Ureaplasma parvum, rhesus monkeys received AZI (12.5 mg/kg every 12 hours intravenously for 10 days; n = 10). Intensive pharmacokinetic sampling of MP, FP, and AF was scheduled following the first (ie, single) dose and the last (ie, multiple) dose. Noncompartmental and pharmacokinetic modeling methods were used. RESULTS: The AF area under the concentration-time curve at 12 hours was 0.22 µg×h/mL following a single dose and 6.3 µg×h/mL at day 10. MP and AF accumulation indices were 8.4 and 19, respectively. AZI AF half-life following the single dose and multiple dose were 156 and 129 hours, respectively. The median MP:FP ratio in concomitantly drawn samples was 3.2 (range, 1.3-9.6; n = 9). Eradication of U. parvum occurred at 6.6 days, with a 95% effective concentration (EC95) of 39 ng/mL for the maximum AZI AF concentration. CONCLUSIONS: Our study demonstrates that a maternal multiple-dose AZI regimen is effective in eradicating U. parvum IAI by virtue of intra-amniotic accumulation and suggests that antenatal therapy has the potential to mitigate complications associated with U. parvum infection in pregnancy, such as preterm labor and fetal sequelae.

Inhibiting the cGAS-STING Pathway in Ulcerative Colitis with Programmable Micelles.

Ulcerative colitis is a chronic condition in which a dysregulated immune response contributes to the acute intestinal inflammation of the colon. Current clinical therapies often exhibit limited efficacy and undesirable side effects. Here, programmable nanomicelles were designed for colitis treatment and loaded with RU.521, an inhibitor of the cyclic GMP-AMP synthase-stimulator of interferon genes (cGAS-STING) pathway. STING-inhibiting micelles (SIMs) comprise hyaluronic acid-stearic acid conjugates and include a reactive oxygen species (ROS)-responsive thioketal linker. SIMs were designed to selectively accumulate at the site of inflammation and trigger drug release in the presence of ROS. Our in vitro studies in macrophages and in vivo studies in a murine model of colitis demonstrated that SIMs leverage HA-CD44 binding to target sites of inflammation. Oral delivery of SIMs to mice in both preventive and delayed therapeutic models ameliorated colitis's severity by reducing STING expression, suppressing the secretion of proinflammatory cytokines, enabling bodyweight recovery, protecting mice from colon shortening, and restoring colonic epithelium. In vivo end points combined with metabolomics identified key metabolites with a therapeutic role in reducing intestinal and mucosal inflammation. Our findings highlight the significance of programmable delivery platforms that downregulate inflammatory pathways at the intestinal mucosa for managing inflammatory bowel diseases.

Maternal azithromycin therapy for Ureaplasma intraamniotic infection delays preterm delivery and reduces fetal lung injury in a primate model.

OBJECTIVE: We assessed the efficacy of a maternal multidose azithromycin (AZI) regimen, with and without antiinflammatory agents to delay preterm birth and to mitigate fetal lung injury associated with Ureaplasma parvum intraamniotic infection. STUDY DESIGN: Long-term catheterized rhesus monkeys (n = 16) received intraamniotic inoculation of U parvum (10(7) colony-forming U/mL, serovar 1). After contraction onset, rhesus monkeys received no treatment (n = 6); AZI (12.5 mg/kg, every 12 h, intravenous for 10 days; n = 5); or AZI plus dexamethasone and indomethacin (n = 5). Outcomes included amniotic fluid proinflammatory mediators, U parvum cultures and polymerase chain reaction, AZI pharmacokinetics, and the extent of fetal lung inflammation. RESULTS: Maternal AZI therapy eradicated U parvum intraamniotic infection from the amniotic fluid within 4 days. Placenta and fetal tissues were 90% culture negative at delivery. AZI therapy significantly delayed preterm delivery and prevented advanced fetal lung injury, although residual acute chorioamnionitis persisted. CONCLUSION: Specific maternal antibiotic therapy can eradicate U parvum from the amniotic fluid and key fetal organs, with subsequent prolongation of pregnancy, which provides a therapeutic window of opportunity to effectively reduce the severity of fetal lung injury.

Incontinence-associated dermatitis in a long-term acute care facility.

PURPOSE: The objectives of this study were to (1) measure the prevalence of incontinence-associated dermatitis (IAD) and pressure ulcers (PUs) on admission to a long-term acute care (LTAC) facility; (2) identify factors associated with IAD and PU on admission to an LTAC facility; and (3) measure the incidence of incontinence and PUs in LTAC patients. DESIGN: This was a longitudinal, repeated-measures study; data were collected over a 12-week period. SUBJECTS AND SETTING: One hundred seventy-one patients, with a median age of 55 years. Fifty-four women and 117 men were evaluated. The sample comprises all patients admitted to the 4 LTAC units at the Drake Center in Cincinnati, Ohio. METHODS: Patients were examined using the "Hospital Survey on Incontinence and Perineal Skin Injury" instrument within 24 hours of admission and they were reevaluated weekly using the same tool until discharge. All data were collected by the Drake Center Advanced Wound Team. Prevalence was defined as the frequency of PUs or IAD identified at admission. Incidence was calculated using the formula: the number of new IAD cases/the number of patients without IAD on admission. Pressure ulcer incidence was measured using 2 formulas: (1) the number of patients with new PUs/the number of all patients who did not have PU on admission and (2) the number of patients with new PUs or a PU in a new location/the number of all patients. RESULTS: Thirty-nine out of 171 patients had IAD on admission, yielding a prevalence of 22.8%. Sixty of 171 patients had a PU on admission, yielding a prevalence of 35.1%. Ten of 132 patients who did not have IAD at admission developed IAD during follow-ups, yielding a 7.6% incidence. Two PU incidence rates were measured; those patients without PUs on admission 3.6% (4/111) and all patients 8.2% (14/171). CONCLUSION: The LTAC admission PU prevalence rate in this study was greater than that reported previously in acute or long-term care settings. The LTAC PU incidence rate was less than those reported for both acute and long-term care settings. The LTAC IAD admission prevalence rate closely reflected the acute care rate but was substantially higher than the long-term care rate.

A Human Oral Fluid Assay for D- and L- Isomer Detection of Amphetamine and Methamphetamine Using Liquid-Liquid Extraction.

Medical providers are increasingly confronted with clinical decision-making that involves (meth)amphetamines. And clinical laboratories need a sensitive, efficient assay for routine assessment of D- and L-isomers to determine the probable source of these potentially illicit analytes. This paper presents a validated method of D- and L-isomer detection in human oral fluid from an extract used for determination of a large oral fluid assay (63 analytes) on an older AB SCIEX 4000 instrument. Taken from the positive extract, D- and L-analytes were added. The method for extraction included addition of internal standard and a 2-step liquid-liquid extraction and dry-down step to concentrate and clean the samples. The samples were suspended in 50% MeOH in water, diluted with mobile phase, with separation and detection accomplished using LC-MS/MS to determine analyte concentration. Once samples were confirmed positive for (meth)amphetamine from the large oral fluid assay, they were further examined for the enantiomeric forms with 50 µl aliquots of the standards and samples of interest combined with 450 µl of D- and L-assay mobile phase, then analyzed using chiral column separation, and LC-MS/MS detection with standard curve spanning the range from 2.5 to 1000 ng/mL. The result is a sensitive and accurate detection of D- and L-isomers of amphetamine and methamphetamine in human oral fluid performed on an older model mass spectrometer (AB SCIEX 4000). The novelty of this assay is twofold (a) the 2-step liquid-liquid extraction and dry-down step to concentrate and clean the samples, and (b) its adoption characteristics as a reflex test from a large ODT panel without the need to invest in newer or expensive LC-MS/MS instruments. Finally, this assay also has potential to add a valuable option to high-throughput laboratories seeking a D- and L-testing alternative to urine drug testing methods.

Does PTSD impair cognition beyond the effect of trauma?

This systematic review analyzed data from studies examining memory and cognitive function in subjects with posttraumatic stress disorder (PTSD), compared with subjects exposed to trauma (but without PTSD). Based on analysis of 21 articles published in English from 1968 to 2009, the conclusion is that individuals with PTSD, particularly veterans, show signs of cognitive impairment when tested with neuropsychological instruments, more so than individuals exposed to trauma who do not have PTSD.

The role of cognitions in imagery rescripting for posttraumatic nightmares.

Despite growing support for the use of imagery rescripting to treat posttraumatic nightmares (PTNMs), its underlying mechanisms have not been examined. This secondary data analysis piloted the proposal that modification of posttraumatic cognitions is a mechanism of change when using a manualized PTNM imagery rescripting intervention. Significant linear reductions in posttraumatic cognitions were observed from baseline through 6-month follow-up evaluations. Change in total negative cognitions was significantly correlated with change in posttraumatic stress disorder symptoms. Initial amount of change in subscale scores also predicted the amount of distal change observed at the 6-month follow-up. These findings provide preliminary evidence that trauma-related cognitions may improve over time as a result of imagery rescripting.

Therapist fidelity with an exposure-based treatment of PTSD in adults with schizophrenia or schizoaffective disorder.

This study examined therapists' fidelity to a manualized, multicomponent cognitive-behavioral intervention for posttraumatic stress disorder (PTSD), including exposure therapy, among public sector patients with a psychotic disorder. Independent raters assessed therapists' competence and adherence, rating 20% of randomly selected audio taped sessions (n=57 sessions, coded by two raters, with strong interrater agreement). Adherence ratings indicated that therapists complied well with the protocol, and competency ratings typically averaged "very good" or higher (6 on 7-point Likert scale). Findings suggest that therapists can effectively deliver a manualized cognitive-behavioral intervention for PTSD, with exposure therapy, to patients with severe mental illness without compromise to the structure of sessions and/or the therapeutic relationship.

Negative pressure wound therapy overlay technique with collagen dressings for nonhealing wounds.

BACKGROUND: Our clinical experience suggests that the effectiveness of negative pressure wound therapy is enhanced by adding collagen alginate to the dressing regimen, applying foam over areas that are undermined or tunneled, and approximating and securing wound edges prior to applying foam. CASES: The use of this combined technique is described in 4 cases, including 2 patients with spinal cord injury and category IV pressure ulcers and 2 patients with extensive postsurgical wounds. CONCLUSION: Our outcomes demonstrate the feasibility of this technique and suggest that patients with significant wound size benefit from adding collagen alginate to negative pressure wound therapy and by applying foam over areas that are undermined or tunneled and/or approximating and securing wound edges prior to applying foam.

Initiation of the expression of peroxisome proliferator-activated receptor gamma (PPAR gamma) in the rat ovary and the role of FSH.

PPARgamma is highly expressed in granulosa cells by 23 days post-partum (pp) and is down-regulated in response to the LH surge. We tested the hypothesis that high levels of FSH during the neonatal period trigger the expression of PPARgamma. To determine when PPARgamma expression is initiated, ovaries were collected from neonatal rats. Messenger RNA for PPARgamma was undetectable on day 1, low from days 5-14, and increased by day 19 pp (p < 0.05). PPARgamma was detected in select granulosa cells in primary/early secondary follicles. Messenger RNA for the FSH receptor was detected as early as day 1 and remained steady throughout day 19 pp. The FSH receptor was detected by immunoblot analysis in ovaries collected 1, 2, and 5-9 days pp. In a subsequent experiment, neonatal rats were treated with acyline (GnRH antagonist) which significantly reduced FSH (p < 0.05) but not levels of mRNA for PPARgamma. The role of FSH in the induction of PPARgamma expression was further assessed in ovarian tissue from FORKO mice. Both mRNA and protein for PPARgamma were identified in ovarian tissue from FORKO mice. In summary, the FSH/FSH receptor system is present in granulosa cells prior to the onset of expression of PPARgamma. Reducing FSH during the neonatal period, or the ability to respond to FSH, did not decrease expression of mRNA for PPARgamma. These data indicate that FSH is not a primary factor initiating the expression of PPARgamma and that other agents play a role in activating its expression in the ovary.

Pharmacologic aspects of new antiretroviral drugs.

The biggest challenge facing highly antiretroviral-experienced patients and their caregivers is the diminishing number of therapeutic options available that sustain activity despite increasing numbers of drug-resistance mutations. New options in antiretroviral treatment have been introduced: two new members of traditional antiretroviral classes (darunavir and etravirine) and two drugs with novel mechanisms of action (raltegravir and maraviroc). Each was approved for use in treatment-experienced patients. A fifth drug-containing efavirenz, tenofovir, and emtricitabine (Atripla; Bristol-Myers Squibb, New York, NY, and Gilead Sciences, Foster City, CA)-is a novel coformulation of existing drugs from two different classes, simplifying administration with the intent of increasing adherence. Because successful management of HIV infection requires the simultaneous use of three or more drugs, understanding the pharmacologic aspects of coadministration is critical. This review summarizes the pharmacokinetic properties affecting the administration of these recently approved drugs in light of highly active antiretroviral treatment guidelines.