Overcoming the Challenge of Support Surface Selection: Utilization of Standards.

ABSTRACT: Selecting the appropriate support surface for patients continues to challenge clinicians and facilities. The Support Surface Standards Committee has developed and published test methods that allow for informed comparisons among support surface characteristics. The first published standards address the performance characteristics of immersion/envelopment, shear/friction, and microclimate management. This article describes the full body support surface standards development and provides guidance on the use of the outcomes from those standard tests for clinicians and facilities to make more informed choices for patients and patient populations.

Comparing Pressure Injury Incidence Based on Repositioning Intervals and Support Surfaces in Acute Care Settings: A Quasi-Experimental Pragmatic Study.

OBJECTIVE: To compare pressure injury (PI) incidence based on repositioning intervals and support surfaces in acute care settings. METHODS: This pragmatic, quasi-experimental trial recruited a total of 251 critically ill patients who were at low or moderate risk for PI development. Participants were assigned to three interventions: a 2-hour repositioning interval using an air mattress, a 2-hour repositioning interval using a foam mattress, or a 3-hour repositioning interval using a foam mattress. Data were collected by nurses every shift over the course of 14 days. Pressure injury incidence was analyzed using a χ2 test. RESULTS: There were no statistically significant differences in PI incidence between the groups with a 2-hour repositioning interval. However, the PI incidence in the group using a foam mattress with a 3-hour repositioning interval was significantly lower than in the group using an air mattress with a 2-hour repositioning interval (odds ratio, 0.481; 95% confidence interval, 0.410-0.565). CONCLUSIONS: The findings showed that PIs decreased when the repositioning interval was extended from every 2 hours to every 3 hours while using foam mattresses. This study suggests that a 3-hour repositioning interval using a foam mattress could be applied to reduce the risk of PI development for patients at low or moderate risk.

Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries.

INTRODUCTION: Many hospital settings are adopting a zero-tolerance policy towards pressure injury (PI) development; this requires good planning and the implementation of care, as the incidence of PIs reflects the quality of care given in a hospital or facility. AIM: To identify common contributing factors towards the development of PIs in a geriatric rehabilitation hospital and improve patient safety through the reduction of hospital-acquired PIs. METHOD: This was done using root cause analysis (RCA). All patients who developed a Stage 3 or 4 deep tissue injuries or unstageable hospital-acquired PI between December 2017 and April 2018 PIs were investigated using RCA. The RCA was facilitated through the use of a contributing framework developed by the National Pressure Ulcer Advisory Panel which guides investigations of different areas of care. Qualitative and quantitative data was collected from several sources and placed in a timeline to reconstruct the series of events. The investigator then identified if the PI was avoidable or not by comparing the evidence with pre-set criteria. Content analysis was further used to analyse the themes retrieved. RESULTS: A variety of root causes were common amongst all the cases. These included both flaws in the system, such as poor equipment and inadequate educational programmes, as well as human factors such as a lack of basic routine care. No skin assessment was being performed (n = 0) apart from the assessment done on admission. Documentation of action planning when it comes to PI prevention was also missing (n = 0). It was identified that 7 patients were mobilized on admission while the others (n = 3) had a delay in mobilisation, due to some fragmentation in care. There was no documentation of patient and relative education on the prevention of PIs (n = 0). All the patients were provided with the right pressure redistributing mattress however, some mattresses were bottoming out. Some causes overlapped, with system defects like lack of protocols, equipment and tools pushing human errors to occur. This created a series of events leading to the adverse event. The identification of these factors helped to provide an understanding of the changes that are needed to reduce future harm and improve patient safety. CONCLUSION: Recommendations were proposed to reduce contributing factors to the development of hospital-acquired PIs. These include audits to reinforce adherence to hospital guidelines, streamlining of the documentation system, investment in new equipment and improvements to educational programmes. The recommendations implemented resulted in a decreased incidence rate of HAPIs.

Use of a Support Surface Standard to Test the Effects of a Turning and Positioning Device Versus Low-Air-Loss Therapy on Temperature and Humidity.

BACKGROUND: Turning and repositioning devices (TRDs) help to reduce strain on caregivers, but clinicians question their effects on humidity and temperature (microclimate) at the skin surface that may increase risk of pressure ulcers. OBJECTIVE: To pilot the use of a standard test for support surfaces to compare microclimate at the skin surface in three scenarios: (1) on a low-air-loss (LAL) surface, (2) on a representative TRD with a basic underpad (TRDU) placed on a LAL surface, and (3) on a negative control with full occlusion. The results are designed to inform clinical decision-making in using a TRD on a LAL surface and the viability of using this test to study TRDs. DESIGN: Measuring humidity and temperature at the device-surface interface using a heated moisture-exuding bronze thermodynamic human model in a laboratory setting. MAIN OUTCOME MEASURE: Humidity and temperature levels across 3 hours 15 minutes of continuous loading with a 45-second complete unloading to simulate a position change at 3 hours. MAIN RESULTS: Relative humidity on the TRDU was below that on the LAL surface for the first 110 minutes and was markedly lower than the negative control for the remainder of humidity testing. Temperature on the TRDU was well below the negative control and negligibly higher than the surface alone throughout testing. The position change enhanced the effects of the TRDU. CONCLUSIONS: The support surface standard test appears useful in evaluating TRDs. This TRD along with the basic underpad is more comparable to a LAL surface than to full occlusion in managing the microclimate of the skin and pressure ulcer risk.

How Clean Is the Linen at My Hospital? The Mucorales on Unclean Linen Discovery Study of Large United States Transplant and Cancer Centers.

Mucormycosis outbreaks have been linked to contaminated linen. We performed fungal cultures on freshly-laundered linens at 15 transplant and cancer hospitals. At 33% of hospitals, the linens were visibly unclean. At 20%, Mucorales were recovered from >10% of linens. Studies are needed to understand the clinical significance of our findings.

Thermal Suit or Forced Air Warming in Prevention of Perioperative Hypothermia: A Randomized Controlled Trial.

PURPOSE: To prevent perioperative hypothermia, forced air warming blanket was compared with a passive insulation suit. DESIGN: Prospective, open, randomized controlled trial. METHODS: Thirty patients were scheduled for orthopedic spinal surgery. The intervention group (group TS) received the thermal suit T-Balance before premedication and throughout the perioperative period, whereas the control group (group C) received forced air warming (FAW) during surgery. FINDINGS: No statistically significant difference (ns) was found between the groups for core temperature 30 minutes after induction of general anesthesia. Perioperative hypothermia occurred in 10 (66.7%) patients in group TS and 6 (40%) in group C (ns). For hypothermic patients, re-establishment of normothermia took significantly longer in group TS, mean 108 ± 111 minutes, than in group C, 33 ± 59.5 minutes (P = .03). CONCLUSIONS: The thermal suit did not prevent hypothermia in this study. FAW was significantly more efficient in re-establishing normothermia.

Evaluation of Warming Effectiveness on Physiological Indices of Patients Undergoing Laparoscopic Cholecystectomy Surgery: A Randomized Controlled Clinical Trial.

PURPOSE: The present study aimed to evaluate the impact of warming on physiological indices of patients undergoing laparoscopic cholecystectomy. DESIGN: The study was a three-group randomized controlled clinical trial. METHODS: In the present study, 96 patients were assigned to three groups: forced-air warming system group; warmed intravenous fluid group; and control group. The intervention was performed immediately after the anesthesia induction. Physiological indices (core body temperature, blood pressure, and heart rate) were evaluated at 15-minute intervals, and postoperative shivering was also recorded. FINDINGS: The mean systolic blood pressure and the mean heart rate were significantly different in each warming group before, during, and after surgery, but the three groups had no significant differences in terms of physiological indices at any time (P > .05). Postoperative shivering was not seen in any group. CONCLUSIONS: Both interventions had similar effects on physiological indices. Therefore, the recommendation is to use the warming method according to patient's other conditions.

Preventing Inadvertent Hypothermia in Patients Undergoing Major Spinal Surgery: A Nonrandomized Controlled Study of Two Different Methods of Preoperative and Intraoperative Warming.

PURPOSE: To evaluate if a Full Access Underbody (FAU) blanket used preoperatively and intraoperatively in patients undergoing major spinal surgery prevents hypothermia compared with current practice and to explore patients' experiences of comfort. DESIGN: A nonrandomized controlled trial. METHODS: Sixty patients were included, 30 in each group. Temperature was assessed on arrival, after connecting to the bladder catheter, and at the start and end of surgery. In the FAU group, comfort was evaluated at arrival and after 10 minutes of prewarming. FINDINGS: The incidence of hypothermia at the start of surgery was significantly lower (relative risk [95% confidence interval], 0.28 [0.13 to 0.59]). Before prewarming, 77% felt comfortable, 20% cold, and 3% hot. After prewarming 60% felt comfortable, 37% hot, and 3% very hot. CONCLUSIONS: Patients using the FAU blanket had a 72% lower incidence of hypothermia at the start of the operation. Attention to thermal comfort during surgery is important.

Support surfaces for treating pressure ulcers.

BACKGROUND: Pressure ulcers are treated by reducing pressure on the areas of damaged skin. Special support surfaces (including beds, mattresses and cushions) designed to redistribute pressure, are widely used as treatments. The relative effects of different support surfaces are unclear. This is an update of an existing review. OBJECTIVES: To assess the effects of pressure-relieving support surfaces in the treatment of pressure ulcers. SEARCH METHODS: In September 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: We included published or unpublished randomised controlled trials (RCTs), that assessed the effects of support surfaces for treating pressure ulcers, in any participant group or setting. DATA COLLECTION AND ANALYSIS: Data extraction, assessment of 'Risk of bias' and GRADE assessments were performed independently by two review authors. Trials with similar participants, comparisons and outcomes were considered for meta-analysis. Where meta-analysis was inappropriate, we reported the results of the trials narratively. Where possible, we planned to report data as either risk ratio or mean difference as appropriate. MAIN RESULTS: For this update we identified one new trial of support surfaces for pressure ulcer treatment, bringing the total to 19 trials involving 3241 participants. Most trials were small, with sample sizes ranging from 20 to 1971, and were generally at high or unclear risk of bias. PRIMARY OUTCOME: healing of existing pressure ulcersLow-tech constant pressure support surfacesIt is uncertain whether profiling beds increase the proportion of pressure ulcer which heal compared with standard hospital beds as the evidence is of very low certainty: (RR 3.96, 95% CI 1.28 to 12.24), downgraded for serious risk of bias, serious imprecision and indirectness (1 study; 70 participants).There is currently no clear difference in ulcer healing between water-filled support surfaces and foam replacement mattresses: (RR 0.93, 95% CI 0.63 to 1.37); low-certainty evidence downgraded for serious risk of bias and serious imprecision (1 study; 120 participants).Further analysis could not be performed for polyester overlays versus gel overlays (1 study; 72 participants), non-powered mattresses versus low-air-loss mattresses (1 study; 20 participants) or standard hospital mattresses with sheepskin overlays versus standard hospital mattresses (1 study; 36 participants).High-tech pressure support surfacesIt is currently unclear whether high-tech pressure support surfaces (such as low-air-loss beds, air suspension beds, and alternating pressure surfaces) improve the healing of pressure ulcers (14 studies; 2923 participants) or which intervention may be more effective. The certainty of the evidence is generally low, downgraded mostly for risk of bias, indirectness and imprecision.Secondary outcomesNo analyses were undertaken with respect to secondary outcomes including participant comfort and surface reliability and acceptability as reporting of these within the included trials was very limited.Overall, the evidence is of low to very low certainty and was primarily downgraded due to risk of bias and imprecision with some indirectness. AUTHORS' CONCLUSIONS: Based on the current evidence, it is unclear whether any particular type of low- or high-tech support surface is more effective at healing pressure ulcers than standard support surfaces.

The Efficacy of a Viscoelastic Foam Overlay on Prevention of Pressure Injury in Acutely Ill Patients: A Prospective Randomized Controlled Trial.

PURPOSE: The purpose of this study was to compare a viscoelastic foam overlay (VEFO) to a standard hospital mattress for pressure injury (PI) prevention. We also compared interface pressures (IPs) of the VEFO to our facility's standard hospital mattress. DESIGN: Prospective, randomized controlled trial. SUBJECTS AND SETTING: Data analysis was based on 110 participants (55 in each group) who were 19 years or older, had a Braden Scale for Pressure Sore Risk score of 16 or less, and were cared for on a neurology, oncology, or pulmonology inpatient care unit. The research setting was the Samsung Medical Center in Seoul, South Korea. METHODS: Participants were divided into 2 groups: the experimental group were based on a VEFO on top of the standard hospital mattress used in our facility. Participants in the control group were placed on a standard hospital mattress with/without air overlay. All patients were given standard nursing care for prevention of PI. Skin assessments were completed daily over a period of 2 weeks. In addition, we compared IPs of the standard hospital mattress and the VEFO in participants randomly allocated to the intervention group. Interface pressure was measured over the sacral/coccygeal area with subjects in the supine position. Pressures were measured immediately before and immediately following placement of the VEFO and just before data collection began. Data were collected between October 2013 and November 2014. Pressure injury incidence was compared between groups using the χ test, and IPs were compared using the paired t test. INSTRUMENTS: Pressure injury development was determined using the staging system described in guidelines from the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance in 2014. Interface pressure was measured using a device manufactured for this purpose. RESULTS: The incidence of PI development was significantly lower in subjects assigned to the experimental group as compared to those in the control group (3.6%-27.3% over the 2-week data collection period; P = .001). The maximum IP was significantly lower on the VEFO with standard hospital mattress than on the standard hospital mattress (paired t = 8.87, P < .001). CONCLUSIONS: Patients managed with a VEFO had a significantly lower incidence of PI than those managed with a standard hospital mattress. Additional research is needed to further characterize the efficacy of the VEFO, its effect on PI healing, and its effect of PI prevention in high-risk populations such as critically ill patients.

Effect of sand and rubber surface on the lying behavior of lame dairy cows in hospital pens.

Housing lame cows in designated hospital pens with a soft surface may lessen the pain the animals feel when lying and changing position. This study investigated the effect of the lying surface on the behavior of lame cows in hospital pens. Thirty-two lame dairy cows were kept in individual hospital pens, provided with either 30-cm deep-bedded sand or 24-mm rubber mats during 24 h in a crossover design. On each surface, the lying behavior of each cow was recorded during 18 h. On deep-bedded sand, cows lay down more and changed position more often than when housed on the rubber surface. Furthermore, a shorter duration of lying down and getting up movements and a shorter duration of lying intention movements were observed. These results suggest that lame dairy cows are more reluctant to change position on rubber compared with sand, and that sand is more comfortable to lie on. Thus, deep bedding such as sand may provide better lying comfort for lame cows than an unbedded rubber surface.

An evaluation of a novel alternating mattress and cushion technology.

Pressure ulcer prevention and management remain a challenge across all health-care settings, and the incidence and prevalence of pressure ulcers in nursing homes and residential homes continues to remain unknown. The use of suitable support surfaces has been found to be beneficial in the prevention and management of pressure ulcers. Carrying out a holistic assessment of the patient and recording the patient's at-risk score would help the clinician to determine the most suitable pressure-relieving surface for the patient. The clinician's clinical experience and judgment are also important. The Domus Auto (by APEX) mattress system and Dynamic Seat Cushion (by APEX) are effective dynamic, support surfaces in the prevention and management of pressure ulceration. They meet the recommendations by both national and international guidelines; they also partly fulfil the SSKIN bundle. From a four-week evaluation carried out in a nursing home, it has been demonstrated that, together with regular assessments and repositioning of the patients, these devices are useful tools in preventing patients' risk of tissue damage and improving the patients' quality of life.

Improving the quality of sleep with an optimal pillow: a randomized, comparative study.

Because sleep comprises one-third of a person's life, using an optimal pillow for appropriate neck support to maintain cervical curve may contribute to improve quality of sleep. Design of orthopedic pillow conforms to orthopedic guidelines to ensure the right support of the cervical curve. The aim of this study was to investigate effect of different pillow shape and content on cervical curve, pillow temperature, and pillow comfort. A feather pillow is regarded as a standard pillow, and a memory foam pillow is one of the most popular pillows among pillow users. We, therefore, compared these two pillows with an orthopedic pillow. Twenty healthy subjects (10 men and 10 women; age range, 21-30 years) participated in the study. Each subject was asked to assume the supine position with 3 different pillows for 30 minute in each trial and then cervical curve, pillow temperature, and pillow comfort were measured. When comparing the cervical curve of the 3 different pillows, that of the orthopedic pillow was significantly higher than that of the other 2 pillows (p < 0.001). The degree of temperature increase was significantly lower for the orthopedic pillow than for the memory foam and feather pillows (p < 0.001). The visual analog scale (VAS) score of pillow comfort was significantly higher in orthopedic pillow than the other 2 pillows. This study shows that pillow shape and content plays a crucial role in cervical curve, pillow temperature, and pillow comfort and orthopedic pillow may be an optimal pillow for sleep quality.

Comparative occipital pressure mapping in the operating room.

BACKGROUND: Hospital-acquired occipital pressure injuries are a preventable cause of morbidity and mortality in the perioperative setting. PURPOSE: To find the occipital cushion/pillow with the lowest measured peak pressures and the highest measured surface area using pressure mapping technology. MATERIALS AND METHODS: A quality improvement project involving 3 operating room staff volunteers was conducted using pressure mapping. Five different pillows were tested based on what the study location commonly used and had available. The pillows included: standard pillow with pillowcase, non-powered fluidized positioner, medium-sized (17 × 17 × 1.5 inches) static seat cushion placed under the shoulders and head, pediatric-sized (13 × 13 × 2 inches) static air cushion placed under the head, and foam donut. RESULTS: The non-powered fluidized positioner had the highest average pressure and peak pressure for all 3 volunteers. The medium static air seat cushion had the lowest average and peak pressures for 2 out of 3 volunteers. None of the head cushions consistently demonstrated a larger surface area of pressure distribution. CONCLUSIONS: The medium-sized static air seat cushion, placed under the shoulders and head, demonstrated the most favorable pressure redistribution properties. The non-powered fluidized positioner demonstrated the least favorable pressure redistribution properties.

Flammability of topical preparations and surgical dressings in cutaneous and laser surgery: a controlled simulation study.

BACKGROUND: Surgical fires are a rare, but serious complication of dermatologic procedures involving electrosurgical and laser devices. Given the lack of data regarding basic fire safety principles, many dermatologists remain unaware of this potential risk. OBJECTIVE: We evaluated the flammability of topical preparations and surgical drapes commonly encountered in the immediate operative field during cutaneous and laser surgery. METHODS: Surgical dressings, drapes, and pork belly skin were examined for fire risk upon exposure to isopropyl alcohol, chlorhexidine gluconate, and aluminum chloride under dry, saturated, and damp conditions. Both electrosurgery and a carbon-dioxide laser were used as ignition sources. RESULTS: At least some char was observed in 86 of 126 simulated conditions (68%). Flames occurred in 2 test conditions: dry underpad drapes and cotton balls exposed to the carbon-dioxide laser. In general, drapes and dressings dampened or saturated with isopropyl alcohol failed to ignite with electrofulguration or electrodessication, although sparks and moderate char developed on pork belly skin and the underpad drape. Materials dampened or saturated with chlorhexidine gluconate, which contains isopropyl alcohol, generated less smoke and char compared with materials exposed to aluminum chloride, which does not contain alcohol. LIMITATIONS: Future studies may assess the flammability of materials in the setting of oxygen supplementation. CONCLUSION: In common cutaneous surgical environments, electrosurgery or ablative laser may lead to char and rarely to fire. Char may be seen in up to two thirds of simulated conditions, and in a minute proportion of conditions, fire is observed.

Support surfaces for treating pressure ulcers.

BACKGROUND: Pressure ulcers are treated by reducing pressure on the areas of damaged skin. Special support surfaces (including beds, mattresses and cushions) designed to redistribute pressure, are widely used as treatments. The relative effects of different support surfaces are unclear. OBJECTIVES: To assess the effects of pressure-relieving support surfaces in the treatment of pressure ulcers. SEARCH METHODS: We searched: The Cochrane Wounds Group Specialised Register (searched 15 July 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (2007 to July Week 1 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, July 14, 2011); Ovid EMBASE (2007 to 2011 Week 27); EBSCO CINAHL (2007 to 14 July 2011). The reference sections of included studies were also searched. SELECTION CRITERIA: We included published or unpublished randomised controlled trials (RCTs), that assessed the effects of support surfaces for treating pressure ulcers, in any patient group or setting, that reported an objective measure of wound healing. DATA COLLECTION AND ANALYSIS: Data extraction and assessment of risk of bias were performed independently by two review authors. Trials with similar patients, comparisons and outcomes were considered for pooled analysis. Where pooling was inappropriate the results of the trials were reported narratively. Where possible, the risk ratio or mean difference was calculated for the results of individual studies. MAIN RESULTS: We identified 18 trials of support surfaces for pressure ulcer treatment, involving 1309 participants with samples sizes that ranged from 14 to 160. Of three trials comparing air-fluidized devices with conventional therapy, two reported significant reductions in pressure ulcer size associated with air-fluidized devices. Due to lack of reported variance data we could not replicate the analyses. In relation to three of the trials that reported significant reductions in pressure ulcer size favouring low air loss devices compared with foam alternatives, we found no significant differences. A small trial found that sheepskin placed under the legs significantly reduced redness and similarly a small subgroup analysis favoured a profiling bed compared with a standard bed in terms of the healing of existing grade 1 pressure ulcers. Poor reporting, clinical heterogeneity, lack of variance data and methodological limitations in the eligible trials meant that no pooled comparisons were undertaken. AUTHORS' CONCLUSIONS: There is no conclusive evidence about the superiority of any support surface for the treatment of existing pressure ulcers. Methodological issues included variations in outcomes measured, sample sizes and comparison groups. Many studies had small sample sizes and often there was inadequate description of the intervention, standard care and co-interventions. Individual study results were often inadequately reported, with failure to report variance data common, thus hindering the calculation of mean differences. Some studies did not report P values when reporting on differences in outcomes. In addition, the age of some trials (some being 20 years old), means that other technologies may have superseded those investigated.Further and rigorous studies are required to address these concerns and to improve the evidence base before firm conclusions can be drawn about the most effective support surfaces to treat pressure ulcers.

Improving identification and documentation of pressure ulcers at an urban academic hospital.

BACKGROUND: A two-year quality improvement campaign at a teaching hospital was launched to improve the identification and accurate documentation of pressure ulcers (PUs) after the Centers for Medicare & Medicaid Services (CMS) changed reimbursement regarding hospital-acquired PUs. METHOD: The campaign consisted of (1) reference materials, (2) new documentation templates, (3) staff education, and (4) hospitalwide mattress replacement. RESULTS: The campaign significantly increased the proportion of PUs completely documented by nurses from 27% to 55% following mattress replacement and resident education (odds ratio [OR] 3.68; p = .001; 95% confidence interval [CI]:1.68-8.08). A similar improvement was observed for physician documentation, increasing from 12% to 36% following the same interventions; however, this change was not statistically significant (OR 2.11; p = .12; 95% CI:0.82-5.39). These improvements were short-lived because of the implementation of electronic medical records (EMRs) for nursing notes. Although the percentage of PUs completely documented by nurses decreased following EMR implementation, it increased in the following months to above the precampaign baseline as nurses adapted to the new documentation system. However, after EMR implementation, complete PU documentation by physicians decreased to a nadir of 0% and did not recover. CONCLUSIONS: A multicomponent campaign to improve the quality of PU documentation by both physicians and nurses can yield positive gains. However, these improvements were short-lived because of EMR implementation, which acutely worsened documentation of PUs. This emphasizes the importance of frequent and repeated interventions to sustain quality improvement successes.

A study on cow comfort and risk for lameness and mastitis in relation to different types of bedding materials.

The aim was to obtain data regarding the effects of 4 freestall bedding materials (i.e., box compost, sand, horse manure, and foam mattresses) on cow comfort and risks for lameness and mastitis. The comfort of freestalls was measured by analyzing the way cows entered the stalls, the duration and smoothness of the descent movement, and the duration of the lying bout. The cleanliness of the cows was evaluated on 3 different body parts: (1) udder, (2) flank, and (3) lower rear legs, and the bacteriological counts of the bedding materials were determined. The combination of the cleanliness of the cows and the bacteriological count of the bedding material provided an estimate of the risk to which dairy cows are exposed in terms of intramammary infections. The results of the hock assessment revealed that the percentage of cows with healthy hocks was lower (20.5 ± 6.7), the percentage of cows with both damaged and swollen hocks was higher (26.8 ± 3.2), and the severity of the damaged hock was higher (2.32 ± 0.17) on farms using foam mattresses compared with deep litter materials [i.e., box compost (64.0 ± 10.4, 3.5 ± 4.7, 1.85 ± 0.23, respectively), sand (54.6 ± 8.2, 2.0 ± 2.8, 1.91 ± 0.09, respectively), and horse manure (54.6 ± 4.5, 5.5 ± 5.4, 1.85 ± 0.17, respectively)]. In addition, cows needed more time to lie down (140.2 ± 84.2s) on farms using foam mattresses compared with the deep litter materials sand and horse manure (sand: 50.1 ± 31.6s, horse manure: 32.9 ± 0.8s). Furthermore, the duration of the lying bout was shorter (47.9 ± 7.4 min) on farms using foam mattresses compared to sand (92.0 ± 12.9 min). These results indicate that deep litter materials provide a more comfortable lying surface compared with foam mattresses. The 3 deep litter bedding materials differed in relation to each other in terms of comfort and their estimate of risk to which cows were exposed in terms of intramammary infections [box compost: 17.8 cfu (1.0(4)) ± 19.4/g; sand: 1.2 cfu (1.0(4)) ± 1.6/g; horse manure: 110.5 cfu (1.0(4)) ± 86.3/g]. Box compost had a low gram-negative bacterial count compared with horse manure, and was associated with less hock injury compared with foam mattresses, but did not improve lying behavior (lying descent duration: 75.6 ± 38.8s, lying bout duration: 46.1 ± 18.5 min). Overall, sand provided the best results, with a comfortable lying surface and a low bacterial count.

Personal protection by long-lasting insecticidal hammocks against the bites of forest malaria vectors.

OBJECTIVE: In Southeast Asia, malaria vectors bite outside the houses before bedtime, and forest dwellers rarely use insecticide-treated nets (ITNs). Thus, we tested the protection of long-lasting insecticidal hammocks (LLIH) using Olyset technology against exophagic vectors in two forest villages of Cambodia. METHODS: In each village, we conducted two entomological surveys (middle and end of the rainy season), each lasting 10 consecutive nights. These comprised human landing collections during the whole night by people sitting outside in the hammocks. Five households were selected per village, and for each household, two fixed positions were allocated: one for the control and one for the treated hammock. RESULTS: In total, 6449 mosquitoes were collected from control hammocks compared to 4481 in treated hammocks. Personal protection conferred by the hammocks was 46% (CI 95%: 35-55%) against the bites of Anopheles minimus. A significant reduction of An. dirus bites (46% CI 95%: 25-62%) was only observed at the end of the rainy season. An. maculatus and culicines bites were only reduced in one of the two study sites. CONCLUSION: Even if this LLIH is not inducing full protection against the bites of malaria vectors, it could prove effective in protecting forest workers and villagers before sleeping time. LLIH can be an additional and valuable tool in eliminating artemisinin-resistant malaria in the region.