Positron emission tomography study of effects of two pressure-relieving support surfaces on pressure ulcer development.

OBJECTIVE: To study the pathophysiological cascade of pressure ulcer (PU) development consisting of tissue deformation, inflammation and hypoxia. METHOD: In this crossover study, deformation was measured with computerised tomography (CT) linked with contact area reflecting immersion and envelopment. Inflammation and hypoxia were measured using subepidermal moisture (SEM), skin temperature and tissue perfusion with positron emission tomography. These variables were investigated under 90 minutes of pressure exposure caused by two functionally different support surfaces-a regular foam mattress and a minimum pressure air (MPA) mattress. RESULTS: A total of eight healthy volunteers took part in the study. There was major tissue deformation when the participants lay on a foam mattress while the tissues retained their original shape on the MPA mattress (p<0.0001). During the pressure exposure, the skin temperature increased significantly on both support surfaces but the final temperature on the foam mattress was about 1oC higher than on the MPA mattress (p<0.0001). SEM increased on both support surfaces compared with an unexposed reference site, but the cause may be different between the two support surfaces. Tissue perfusion was lowest in the skin followed by subcutaneous tissues and highest in the muscles. The pressure exposure did not cause any substantial changes in perfusion. The results showed that tissue deformation was more pronounced, the support surface contact area (envelopment), was smaller and the skin temperature higher on the foam mattress than on the MPA mattress, without significant differences in tissue perfusion. CONCLUSION: In this study, the MPA mattress support surface had mechanobiological properties that counteracted tissue deformation and thereby may prevent PUs.

The Association Between Pressure Ulcer/Injury Development and Short-term Mortality in Critically Ill Patients: A Retrospective Cohort Study.

Pressure ulcers/injuries (PU/Is) affect the social, mental, and physical well-being of patients; increase treatment costs; prolong hospital stays; increase patient risk for infections; and may independently decrease life expectancy. PURPOSE: The aim of this retrospective study was to examine the association between PU/I development and mortality in a large cohort of consecutively admitted critically ill patients. METHODS: Data from adult patients ( >18 years of age) admitted to an intensive care unit (ICU) between 2010 and 2013 were extracted from the ICU electronic clinical information system. Patients were excluded if they had a PU/I present on admission, no recorded admission modified Jackson/Cubbin (mJ/C) or Sequential Organ Failure Assessment (SOFA) score, or their ICU outcome was undetermined. The mJ/C risk scale (score range 9-48) was used to assess the PU/I risk (the lower the score, the higher the PU/I risk), the SOFA score (score range 0-24; the higher the SOFA score, the sicker the patient, with a higher risk of death) was used to assess the severity of the condition and outcome. ICU outcome was defined as 1) moved from the ICU to a ward/recovering or 2) no response to ICU treatment/deceased. All data were transferred to statistical software for analysis. Logistic regression analysis was used to examine the outcome related to PU/I development, SOFA, and mJ/C scores. Descriptive contingency tables of different scenarios were used to further evaluate relationships among different risk factors related to mortality; the Wald χ2 test was used to assess the statistical significance of the contingency tables. RESULTS: Of the 6582 patients admitted, 6089 were included for analysis. Two hundred, one (201) had a PU/In on admission, 212 had missing mJ/C or SOFA scores, and ICU outcome was undetermined in 80 patients. Patient mean age was 61.1 ± 15.8 (range 18-94) years; 3891 (63.9%) were male, average length of stay (LOS) was 3.6 days, denoted by quartile (Q) (median 1.58 days; Q1: 0.9, Q3: 3.9 days), and 1589 (26.1%) stayed 3 days or more in the ICU. The incidence of PU/I was 6.9% (423 patients), and ICU mortality rate was 9.1% (n=553). The mean LOS of patients with PU/I was 13.35 ± 15.56 days (median 8.95, Q1: 4.88, Q3: 16.2) and 2.84 ± 3.87 days for patients with no PU/I (median: 1.20, Q1: 0.90, Q3: 3.17; P <.0001). Mean LOS was 3.42 ± 5.95 days (median: 1.30, Q1: 0.90, Q3: 3.70) among recovering and 5.00 ± 7.17 days among deceased patients (median 2.56, Q1: 1.26, Q3: 6.40; P <.0001). The proportion of patients with an admission mJ/C score of 29 or less ranged from 48.8% to 51.5%, and the mean SOFA score was 7.0 ± 3.2. PU/I development and SOFA or mJ/C scores were independent predictors of mortality. The probability of a negative outcome was higher in persons with PU/Is compared to persons with no PU/Is. Persons with lower SOFA scores (ie, less severely ill patients) and higher mJ/C scores for each factor separately (ie, at low risk of PU/I development) each factor separately had a lower mortality risk. CONCLUSION: PU/I development in critically ill patients treated at an ICU is an independent predictor of mortality, even though the PU/I incidence and hospital mortality were relatively low. The ICU admission SOFA and mJ/C score also were independent prognosticators of ICU mortality. Future research could focus on the role of different steps in the cascade of PU/I development, especially to the role of inflammation.

Sequential Organ Failure Assessment (SOFA) to Predict Pressure Ulcer Risk in Intensive Care Patients: A Retrospective Cohort Study.

Pressure ulcer (PU) risk assessment practices in adult intensive care unit (ICU) patients remain varied. PURPOSE: The authors assessed the performance of the Sequential Organ Failure Assessment (SOFA) scale and its subcategories in predicting the development of PUs. METHODS: A retrospective cohort study was conducted of all adult patients admitted to the mixed medical-surgical ICU of a Finnish tertiary referral hospital between January 2010 and December 2012. Data (diagnoses, demographics, clinical information, treatments, and instrument scores) were retrieved from the ICU database. Wilcoxon and chi-squared tests were used to examine patient subgroup (medical or surgical ICU and intensive care or high-dependency care patients), length of ICU stay (LOS), modified Jackson/Cubbin (mJ/C) scores and SOFA subcategory variables, and first-day SOFA scores. PU association was determined by logistical regression. RESULTS: Among the 4899 patients in the study population, the overall PU incidence of acquired PUs was 8.1%. Medical patients had significantly more PUs (145/1281; 11.3%) than surgical patients (212/3468; 6.1%) (P <.0001). In all subgroups, significantly more patients with PUs had higher SOFA scores (mean 8.24) than patients without PUs (mean 6.74) (P =.001). The difference persisted when patients with LOS ≥3 days in the ICU were considered. Among the SOFA subcategories, the Glasgow Coma score, renal and respiratory disorders, and hypotension were significantly (P <.0001) linked to PU development. First-day total SOFA score and its cardiovascular and respiratory subcategory scores were the most important predictors of PUs. CONCLUSION: The total SOFA score provides an additional tool to assess PU risk in ICUs and should be used together with the Braden or the mJ/C Scale.

Iron deficiency without anemia - a clinical challenge.

One should always consider iron deficiency (without anemia) as the cause of persisting, unexplained unspecific, often severe, symptoms, regardless of the primary underlying disease. The symptoms of iron deficiency may arise from the metabolic systems where many proteins are iron containing. Long-standing iron deficiency may be challenging to treat.

Therapeutic hypothermia and pressure ulcer risk in critically ill intensive care patients: A retrospective study.

OBJECTIVE: To examine the role of therapeutic hypothermia in pressure ulcer development in critically ill patients. RESEARCH METHODOLOGY: Retrospective study in a mixed intensive care unit over 2010-2013. The incidences of pressure ulcers among patients treated with therapeutic hypothermia (n = 148) and the non-hypothermia patient population (n = 6197) were compared. RESULTS: Patients treated with hypothermia developed more pressure ulcers (25.0%) than the non-hypothermia group 6.3% (p < 0.001). More patients in the hypothermia group were rated as the high pressure ulcer risk group, as defined by the modified Jackson/Cubbin (mJ/C) risk score ≤29 than the rest of the patients. Among the therapeutic hypothermia patients more pressure ulcers tended to emerge in the lower risk group (mJ/C score ≥30) (p = 0.056). Intensive care mortality was higher in the hypothermia (24.3%) than the non-hypothermia group (9.3%, p < 0.0001). CONCLUSION: Patients treated with therapeutic hypothermia should be considered at high risk for pressure ulcer development and should be managed accordingly. The hypothermia may not as such increase the risk for pressure ulcers, but combined with the severity of the underlying illness, may be more likely. The pressure ulcer risk in this patient group cannot be reliably assessed by the Jackson/Cubbin risk scale.

Performance of different support surfaces during experimental resuscitation (CPR).

The relationship between the efficacy of resuscitation and the mattresses and backboards used in acute care units, has been studied previously. However, few reports focus on the relative efficacy of resuscitation when using mattresses with different modes of function. This study examines the performance of different support surfaces during experimental cardiopulmonary resuscitation (CPR). The surfaces included a hard surface, a higher specification foam mattress, a dynamic, alternating pressure mattress, and a dynamic, reactive minimum pressure air mattress system. A pressure sensitive mat was placed between the mattresses and each surface and the efficacy of resuscitation measured using differences in compression frequency, compression depth and hands-on time. Our results suggest that the efficacy of resuscitation is dependent on the mode of action of the mattress, while adequate compression frequency and depth do not have a significant effect. In the open system alternating mattress, deflation of the mattress using the CPR function improved the stability of the resuscitation in our study, especially in situations where the height of the air mattress is greater than 20-25 centimeters. Using our experimental system, resuscitation on a closed air system mattress optimally combined stability and effort, while the CPR function converts the air system of the mattress to open, which impairs its functionality during resuscitation. These results indicate that resuscitation is dependent of the mode of action of the mattress and whether the mattress-specific CPR function was used or not. However, the interactions are complex and are dependent on the interaction between the body and the mattress, i.e. its immersion and envelopment properties. Furthermore, this study casts doubt on the necessity of the CPR function in air mattresses.

Critical Evaluation of the Jackson/Cubbin Pressure Ulcer Risk Scale - A Secondary Analysis of a Retrospective Cohort Study Population of Intensive Care Patients.

Although the Jackson/Cubbin pressure ulcer (PU) risk scale performs best among risk scales used in intensive care units (ICUs), its performance was not fully satisfactory. In 2010, a minimally modified Jackson/Cubbin (mJ/C) PU risk scale was introduced to formalize PU risk assessment in a large medical-surgical ICU in Finland. The purpose of this secondary analysis was to examine whether individual categories of the mJ/C scale have similar weight and whether the scores within each category (from 1 to 4; 1 equaling highest risk and 4 equaling lowest risk) are linear, as is assumed for the original and modified scales. Using data from a cohort of 1,616 consecutively admitted patients retrieved from the ICU database, a detailed secondary analysis of each of the 12 main scoring categories of the Jackson/Cubbin risk scale was performed using logistic regression and analysis of linearity and weight. Of the 1,616 admitted patients, 168 developed a PU during their ICU stay. Among the risk categories, body mass index, nutrition, respiration, age, and transportation during the 48 hours before scoring did not contribute significantly (P >0.05) to the total risk score or the actual development of a PU. The 7 other main categories - incontinence, mobility, medical history, oxygen requirement, need for assistance with hygiene, hemodynamics, and general skin condition - were the main risk contributors. Although only the linearity of the different categories correlated significantly with the predictive value of the categories, the linearity as well as the weights of the categories were at variance from what was assumed originally. The mJ/C scale needs refinement to be a more accurate instrument for PU risk assessment of ICU patients. Not all mJ/C categories were found to contribute to the risk and, when they do, their weight and linearity vary from what has been assumed. The categories respiration and oxygen requirement and the categories mental condition, mobility, and hygiene may overlap. The importance of the incontinence category depends on the frequency of urinary and fecal incontinence management system usage. A simpler, more valid and more sensitive risk assessment scale than the current Jackson/Cubbin scale is needed for ICU patients.

An overview of polyurethane foams in higher specification foam mattresses.

Soft polyurethane foams exist in thousands of grades and constitute essential components of hospital mattresses. For pressure ulcer prevention, the ability of foams to control the immersion and envelopment of patients is essential. Higher specification foam mattresses (i.e., foam mattresses that relieve pressure via optimum patient immersion and envelopment while enabling patient position changes) are claimed to be more effective for preventing pressure ulcers than standard mattresses. Foam grade evaluations should include resiliency, density, hardness, indentation force/load deflection, progressive hardness, tensile strength, and elongation along with essential criteria for higher specification foam mattresses. Patient-specific requirements may include optimal control of patient immersion and envelopment. Mattress cover characteristics should include breathability, impermeability to fluids, and fire safety and not affect mattress function. Additional determinations such as hardness are assessed according to the guidelines of the American Society for Testing and Materials and the International Organization for Standardization. At this time, no single foam grade provides an optimal combination of the above key requirements, but the literature suggests a combination of at least 2 foams may create an optimal higher specification foam mattress for pressure ulcer prevention. Future research and the development of product specification accuracy standards are needed to help clinicians make evidence-based decisions about mattress use.

Concordance of Shape Risk Scale, a new pressure ulcer risk tool, with Braden Scale.

The occurrence of pressure ulcers was examined in a cross-sectional study in 23 health care facilities and in home care involving 548 patients. The screening of pressure ulcer risk was assessed simultaneously using the Braden Scale and the new Shape Risk Scale (SRS), and the results were compared. The overall prevalence of pressure ulcers in the study population was 15·5% (85/548). The Braden Scale was performed as described in the literature. The direct concordance of the Braden and SRS scales was 46%. In more than 90% of cases, the SRS classified patients as well as or better than the Braden Scale. The SRS allocates patients significantly different from the Braden Scale into the risk categories, especially the difference is significant between the low and medium-risk categories. The greatest advantage of SRS to Braden Scale is that it correctly identifies patients with low risk of pressure ulcers. It is interesting that the two risk scores, taking into consideration the basically different pathophysiological factors, can still give rather similar results. The users considered that both scales are easy to use.

[Concurrent subacute thyroiditis and Graves disease]. / Samanaikainen subakuutti kilpirauhastulehdus ja Basedowin tauti.

The diagnosis of subacute thyroiditis is based on typical symptoms and findings, including thyroid pain, high fever, tenderness on palpating the thyroid gland, transient symptoms of thyrotoxicosis, and hypersedimentation. The doctor responsible for the diagnosis is in most cases able to treat the illness without special examinations. In cases with an atypical clinical picture or a poor therapeutic response a specialist consultation is recommended. Diseases of the thyroid gland may exist concurrently. Concurrent occurrence of the Hashimoto disease and Graves disease is well known. In this paper, a patient with concurrent subacute thyroiditis and Graves disease is described.

[Elevation of hepatic enzyme values in hyperthyroidism]. / Maksa-arvojen suureneminen hypertyreoosin yhteydessä.

Serum or plasma alanine aminotransferase (ALAT) activity may sometimes exhibit even considerable increases in connection with hyperthyroidism and present a diagnostic as well as a therapeutic problem. Open questions include whether the hepatic change is related to a primary disease, and how to select treatment. We report two patients, in whom carbimazole medication initiated for Graves' disease normalized elevated ALAT values.

[Pressure ulcer--occurrence, pathophysiology and prevention]. / Painehaava--esiintyminen, patofysiologia ja ehkäisy.

Pressure ulcers occur in approx. 5 to 15% of patients in home care, health care facilities and hospitals. Pressure ulcers are painful, decrease the quality of life, increase the susceptibility to infections, risk of death and nursing workload and cause significant costs. Their prevention would actually be much cheaper than their treatment. Pathogenetic mechanisms involved in pressure ulcers are very complicated, and ulcers of various degrees are likely to develop by different mechanisms. A pressure ulcer can develop very rapidly. It can, however, be prevented, making it a formidable challenge.

Naturally occurring human autoantibodies recognize a fetal brain antigen identified as microtubulus associated protein 1B.

We have recently reported naturally occurring autoantibodies against a large fetal brain antigen (FBA). Now we describe the process of purification and identification of this particular FBA. The brains of newborn rabbits were solubilized and purified with preparative gel electrophoresis. The protein fractions were concentrated and desalted and the fractions were tested by a known positive serum. On membrane digestion of the FBA-band gave a twelve amino acid sequence that resulted in best identity score for mouse, rat and human microtubule-associated protein (MAP) 1B: a member of the microtubule-associated protein family. Monoclonal anti-MAP1B recognized a band in immunoblots of the brain homogenate and of the partially purified fractions with the same electrophoretic mobility as that recognized by a known anti-FBA positive serum. When adult rabbit brain was used as an antigen, the anti-MAP1B failed to recognize any bands on immunoblots. MAP lB has not been previously known as an autoantigen, even though many structural proteins of the neuronal cytoskeleton are known to be targets of naturally occurring autoantibodies. MAP 1B is a functionally important regulatory protein in the developing brain; thus autoantibodies against MAP1B may affect the normal development.