Feasibility of implementing a remote system for lymphoedema conservative therapy: a case study.

BACKGROUND: Poor access to lymphoedema specialists and communication between them and patients prevents appropriate lymphoedema management. Therefore, development and dissemination of remote systems is necessary to improve care in rural areas with limited medical personnel or access to medical coordination. AIMS: The authors evaluated the elements required for providing patient education on conservative therapy for lymphoedema, to determine the feasibility of remote management. METHODS: The study involved connecting a health professional in a local clinic (point A) treating a patient with lymphoedema, who was present alongside the clinician, with a specialist certified lymphoedema therapist (CLT) located remotely in a university (point B). FINDINGS: The CLT was able to greet, interview and provide guidance to the patient on conservative therapy. Direct contact with the patient was not possible, which limited visualisation, palpation, leg circumference measurement, and lymphatic drainage management. CONCLUSION: The findings suggest that remote a lymphoedema management approach involving conservative therapy benefits both patients and health professionals, particularly in rural regions. Future studies are needed to confirm the effectiveness of this approach to confirm adequate treatment.

Need for a consensus definition of chronic dehydration: A scoping review.

Dehydration is common in older adults and impacts their clinical outcomes. Chronic dehydration is especially important as it has been under-recognized. This scoping review aimed to summarize the available definitions of chronic dehydration to identify gaps between each definition and discuss future research needs. Four databases (Pubmed, CINAHL, Cochrane Library, Science Direct) were systematically searched for peer-reviewed articles that clearly described the definition of chronic dehydration published from inception to June 8th, 2023. Two researchers reviewed the articles independently, and any disagreement was solved upon discussion. We identified five articles with a wide range of subjects from children to older adults. Chronic dehydration was defined as a state of persistently elevated blood urea levels; weight loss ≥ 1% as a result of fluid loss; a ratio of blood urea nitrogen to creatinine > 20; serum osmolarity ≥ 295 mOsm/kg; and a dehydrated state lasting 72 hours or longer. The definition varied among studies, indicating the need to establish an international consensus on the definition of chronic dehydration.

Attitudes, expectations, and lived experiences of cancer patients receiving dendritic cell vaccine therapy in Japan.

Objective: Immunotherapeutic approaches to cancer, such as dendritic cell vaccine therapy, promise to improve survival rate but may present unique challenges to patients. However, there is no research on the lived experiences of cancer patients receiving dendritic cell vaccine therapy. The aim of this study was to explore the attitudes, expectations, and experiences of cancer patients receiving dendritic cell vaccine therapy in Japan. Methods: This was an exploratory qualitative study. A descriptive phenomenological approach was used to investigate the experiences of eight advanced-stage cancer patients (median age: 59.5 years). Data were collected between July 2018 and March 2020 using in-depth semi-structured interviews. Data were analyzed according to Colaizzi's seven-step phenomenological strategy, and EQUATOR's Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines for qualitative studies were followed. Results: Four themes emerged from the data analysis: strong concerns about chemotherapy, faith in dendritic cell vaccine therapy, motivation to succeed, and physical and mental changes. The first two themes related to pretreatment attitudes and expectations. The latter two themes expressed participants' experiences during and after therapy. Conclusions: Dendritic cell vaccine therapy patients expressed fears about the effects of standard treatment, and hope and uncertainty regarding immunotherapy treatment decisions and efficacy. The findings suggest that such patients require nursing care that includes prevention and reduction of chemotherapy side effects, careful observation of patients' well-being, management of patients' expectations and uncertainty, formation of patient-health care practitioner partnerships, and team medicine.

Patient experience of negative pressure wound therapy: A qualitative study.

AIM: This study aimed to clarify the treatment experience of patients undergoing negative pressure wound therapy (NPWT). DESIGN: This study used a qualitative design. METHODS: Seventeen inpatients were semi-structured interviewed about their experiences of treatment with negative pressure wound therapy. RESULTS: Inpatients' answers were categorized into seven themes: pain and discomfort associated with treatment, physical limitations owing to attached device, mental burden owing to the odour and noises of the attached device, social limitations owing to the attached device, advances in medical care and science, device personification and mixed feelings towards medical staff. The patients were able to tolerate the aforementioned limitations while feeling attachment and gratitude towards the device created through advances in medical care and science, and towards medical staff who helped them heal. In the future, we plan to develop an NPWT care guide.

Nationwide time-series surveys of pressure ulcer prevalence in Japan.

OBJECTIVE: The Japanese Society of Pressure Ulcers (JSPU) has two purposes: first, to improve knowledge and skills among health professionals related to preventing and managing pressure ulcers (PUs); and second, to represent those in the field managing PUs, including with government and health authorities. Since 2006, JSPU has conducted fact-finding surveys about every four years to identify PU prevalence in Japan (2006, 2010, 2013 and 2016). Based on the prevalence identified by these surveys, an attempt was made to validate the achievements of JSPU's activities. METHOD: Information from one-day surveys of hospitals, long-term care health facilities, long-term care welfare facilities, and home visit nursing care stations was analysed. We used generalised estimating equations to estimate the proportions of PUs and their 95% confidence intervals (CIs) for each survey. RESULTS: A total of 662,419 patients in 2631 facilities participated in the surveys. The estimated proportions for all facilities (95% CI) in chronological order, from the first to the fourth survey, were: 2.67% (2.52-2.83); 2.61% (2.43-2.80); 1.99% (1.83-2.17); and 1.79% (1.65-1.94), respectively. In all facility types, the proportion of PUs was lower in the fourth survey than the first survey. CONCLUSION: The proportion of PUs showed a decreasing trend and was low according to global standards, demonstrating the efficacy of JSPU's activities.

Temperament and professional quality of life among Japanese nurses.

Aim: To investigate associations between temperament and professional quality of life among Japanese nurses. Design: A descriptive-correlational study using self-administered anonymous questionnaires. Methods: Questionnaires were collected from 1,267 nurses. We used analysis of covariance to examine associations between tendencies of temperament (depressive, cyclothymic, hyperthymic, irritable and anxious) and professional quality of life subscales (compassion satisfaction, burnout, compassion fatigue) first for all participants and then again after dividing the participants into two groups based on years of experience. Results: Nurses' professional quality of life was associated with innate temperament and years of experience. Nurses with any of depressive, cyclothymic, irritable, or anxious tendencies showed significantly lower compassion satisfaction and higher burnout and compassion fatigue than those without these tendencies. Nurses with hyperthymic tendencies showed significantly higher compassion satisfaction and lower burnout than those without the tendency.

Pre-collecting lymphatic vessels form detours following obstruction of lymphatic flow and function as collecting lymphatic vessels.

BACKGROUND: Previously, we showed that lymphatic vessels (LVs) formed detours after lymphatic obstruction, contributing to preventing lymphedema. In this study, we developed detours using lymphatic ligation in mice and we identified the detours histologically. METHODS AND RESULTS: Under anesthesia, both hindlimbs in mice were subcutaneously injected with Evans blue dye to detect LVs. We tied the right collecting LV on the abdomen that passes through the inguinal lymph node (LN) at two points. The right and left sides comprised the operation and sham operation sides, respectively. Lymphography was performed to investigate the lymph flow after lymphatic ligation until day 30, using a near-infrared fluorescence imaging system. Anti-podoplanin antibody and 5-ethynyl-2'-deoxyuridine (EdU) were used to detect LVs and lymphangiogenesis. Within 30 days, detours had developed in 62.5% of the mice. Detours observed between two ligation sites were enlarged and irregular in shape. Podoplanin+ LVs, which were located in the subcutaneous tissue of the upper panniculus carnosus muscle, connected to collecting LVs at the upper portion from the cranial ligation site and at the lower portion from the caudal ligation site. EdU+ cells were not observed in these detours. The sham operation side showed normal lymph flow and did not show enlarged pre-collecting LVs until day 30. CONCLUSIONS: Detours after lymphatic ligation were formed not by lymphangiogenesis but through an enlargement of pre-collecting LVs that functioned as collecting LVs after lymphatic ligation. Further studies are required to explore the developmental mechanism of the lymphatic detour for treatment and effective care of lymphedema in humans.

Venipuncture-Induced Hematomas Alter Skin Barrier Function in the Elderly Patients.

We aimed to compare the barrier function of the skin site with the color of hematoma induced by venipuncture and the area surrounding the skin site to help improve skin care for hospitalized elderly patients. There were 50 patients with a median age of 84 years who were included in the analysis. There was no significant difference between the hematoma site-induced venipuncture and the area surrounding the hematoma site in terms of transepidermal water loss and skin sebum level. The status of stratum corneum hydration and skin elasticity on the hematoma sites was significantly lower than that on nonhematoma sites. The median skin pH was significantly higher on hematoma sites than that on nonhematoma sites. The study variables did not reveal any significant correlation with the intensity of skin erythema. These findings showed that hematoma formation in the subcutaneous tissue affected the skin barrier function and that these sites need moisturizing skin care regardless of the intensity of skin erythema.

Evaluation of the Predictive Validity of Thermography in Identifying Extravasation With Intravenous Chemotherapy Infusions.

Early detection of extravasation is important, but conventional methods of detection lack objectivity and reliability. This study evaluated the predictive validity of thermography for identifying extravasation during intravenous antineoplastic therapy. Of 257 patients who received chemotherapy through peripheral veins, extravasation was identified in 26. Thermography was performed every 15 to 30 minutes during the infusions. Sensitivity, specificity, positive predictive value, and negative predictive value using thermography were 84.6%, 94.8%, 64.7%, and 98.2%, respectively. This study showed that thermography offers an accurate prediction of extravasation.

The reliability and validity of color indicators using digital image analysis of peristomal skin photographs: results of a preliminary prospective clinical study.

Accurate assessment is necessary to evaluate peristomal skin condition, but objective methods are lacking. The purpose of this prospective, repeated-measures study was to evaluate the reliability and validity of color indicators using digital image analysis of peristomal skin photographs. The 6-month study was conducted among 21 patients (mean age 65.1 years old, 15 men) with ostomies (14 colostomies, six ileostomies, and one urostomy) at four outpatient clinics. Photographs taken by nurses of the peristomal area using point-and-shoot cameras were processed using digital image analysis, which involved color calibration, image processing, and indicator calculation. An erythema index (EI), melanin index (MI), and hypopigmentation index were created to represent increased degrees of red, black, and white color, respectively, and their average values in the peristomal region of an image were calculated relative to values for intact skin. Reproducibility was evaluated using the interclass correlation coefficient (ICC). ICCs of color indicators for intact skin were >0.7 between baseline and the end of follow-up for the 16 participants with two or more clinic visits. Differences in these indices between peristomal and intact regions were evaluated using a linear mixed model. The EI and MI of peristomal skin were significantly higher than those of intact skin (n=42, P<0.001). All color indicators in adjacent regions and areas where adhesive was applied were associated with the discoloration severity score and visual analogue pain score (all P<0.05). This objective and simple method had adequate reproducibility and criterion-related validity and may be useful for peristomal skin assessment. Further research is warranted.

Predictive validity of granulation tissue color measured by digital image analysis for deep pressure ulcer healing: a multicenter prospective cohort study.

This multicenter prospective cohort study examined the predictive validity of granulation tissue color evaluated by digital image analysis for deep pressure ulcer healing. Ninety-one patients with deep pressure ulcers were followed for 3 weeks. From a wound photograph taken at baseline, an image representing the granulation red index (GRI) was processed in which a redder color represented higher values. We calculated the average GRI over granulation tissue and the proportion of pixels exceeding the threshold intensity of 80 for the granulation tissue surface (%GRI80) and wound surface (%wound red index 80). In the receiver operating characteristics curve analysis, most GRI parameters had adequate discriminative values for both improvement of the DESIGN-R total score and wound closure. Ulcers were categorized by the obtained cutoff points of the average GRI (≤80, >80), %GRI80 (≤55, >55-80, >80%), and %wound red index 80 (≤25, >25-50, >50%). In the linear mixed model, higher classes for all GRI parameters showed significantly greater relative improvement in overall wound severity during the 3 weeks after adjustment for patient characteristics and wound locations. Assessment of granulation tissue color by digital image analysis will be useful as an objective monitoring tool for granulation tissue quality or surrogate outcomes of pressure ulcer healing.

Estimation of protein requirements according to nitrogen balance for older hospitalized adults with pressure ulcers according to wound severity in Japan.

OBJECTIVES: To estimate protein requirements in older hospitalized adults with pressure ulcers (PrU) according to systemic conditions and wound severity. DESIGN: Secondary nitrogen balance study over 3 days. SETTING: Long-term care facility. PARTICIPANTS: Twenty-eight older adults with PrU using a urinary catheter. MEASUREMENTS: Nitrogen balance over 3 days was evaluated from habitual nitrogen intake measured using a food weighing record and nitrogen excretion from urine, feces and wound exudate. Nitrogen intake required to maintain nitrogen equilibrium was estimated as an average protein requirement using a linear mixed model. RESULTS: Nitrogen intake at nitrogen equilibrium was 0.151 gN/kg per day (95% confidence interval = 0.127-0.175 gN/kg per day) for all participants. The amount of protein loss from wound exudate contributed little to total nitrogen excretion. A Charlson comorbidity index of 4 or greater (the median value) was related to lower nitrogen intake at nitrogen equilibrium (P = .005). Severe PrU with heavy exudate amounts and measured wound areas of 7.9 cm(2) or greater (the median value) were related to higher nitrogen intake at nitrogen equilibrium in individuals with a Charlson comorbidity index of 3 or less (both P = .04). Larger wound area (correlation coefficient (r) = 0.55, P = .003) and heavier exudate volume (r = 0.53, P = .004) were associated with muscle protein hypercatabolism measured according to 3-methylhistidine/creatinine ratio. CONCLUSION: The average protein requirement is 0.95 g/kg per day for older hospitalized Japanese adults with PrU, but protein requirements depend on an individual's condition and wound severity and range from 0.75 to 1.30 g/kg per day. Severe PrU can require higher protein intakes because of muscle protein hypercatabolism rather than direct loss of protein from wound exudate.

Efficacy of an improved absorbent pad on incontinence-associated dermatitis in older women: cluster randomized controlled trial.

BACKGROUND: Most older adults with urinary incontinence use absorbent pads. Because of exposure to moisture and chemical irritating substances in urine, the perineal skin region is always at risk for development of incontinence-associated dermatitis (IAD). The aim of this study was to examine the efficacy of an improved absorbent pad against IAD. METHODS: A cluster randomized controlled design was used to compare the efficacy of two absorbent pads. Female inpatients aged ≥65 years who had IAD and used an absorbent pad or diaper all day were enrolled. Healing rate of IAD and variables of skin barrier function such as skin pH and skin moisture were compared between the usual absorbent pad group (n = 30) and the test absorbent pad group (n = 30). RESULTS: Thirteen patients (43.3%) from the test absorbent pad group and 4 patients (13.3%) from the usual absorbent pad group recovered completely from IAD. Moreover, the test absorbent pad group healed significantly faster than the usual absorbent pad group (p = 0.009). On the other hand, there were no significant differences between the two groups in skin barrier function. CONCLUSION: The test absorbent pad for older adults with urinary incontinence might be more efficacious against IAD than usual absorbent pad. TRIAL REGISTRATION: UMIN-CTR: UMIN000006188.

Concurrent validation and reliability of digital image analysis of granulation tissue color for clinical pressure ulcers.

Granulation tissue color is one indicator for pressure ulcer (PU) assessment. However, it entails a subjective evaluation only, and quantitative methods have not been established. We developed color indicators from digital image analysis and investigated their concurrent validity and reliability for clinical PUs. A cross-sectional study was conducted on 47 patients with 55 full-thickness PUs. After color calibration, a wound photograph was converted into three images representing red color: erythema index (EI), modified erythema index with additional color calibration (granulation red index [GRI]), and , which represents the artificially created red-green axis of L(*) a(*) b(*) color space. The mean intensity of the granulation tissue region and the percentage of pixels exceeding the optimal cutoff intensity (% intensity) were calculated. Mean GRI (ρ=0.39, p=0.007) and (ρ=0.55, p<0.001), as well as their % intensity indicators, showed positive correlations with a(*) measured by tristimulus colorimeter, but erythema index did not. They were correlated with hydroxyproline concentration in wound fluid, healthy granulation tissue area, and blood hemoglobin level. Intra- and interrater reliability of the indicator calculation using both GRI and had an intraclass correlation coefficient >0.9. GRI and from digital image analysis can quantitatively evaluate granulation tissue color of clinical PUs.

Development and validity of a new model for assessing pressure redistribution properties of support surfaces.

Pressure ulcers are a common problem, especially in older patients. In Japan, most institutionalized older people are malnourished and show extreme bony prominence (EBP). EBP is a significant factor in the development of pressure ulcers due to increased interface pressure concentrated at the skin surface over the EBP. The use of support surfaces is recommended for the prophylaxis of pressure ulcers. However, the present equivocal criteria for evaluating the pressure redistribution of support surfaces are inadequate. Since pressure redistribution is influenced by physique and posture, evaluations using human subjects are limited. For this reason, models that can substitute for humans are necessary. We developed a new EBP model based on the anthropometric measurements, including pelvic inclination, of 100 bedridden elderly people. A comparison between the pressure distribution charts of our model and bedridden elderly subjects demonstrated that maximum contact pressure values, buttock contact pressure values, and bone prominence rates corresponded closely. This indicates that the model provides a good approximation of the features of elderly people with EBP. We subsequently examined the validity of the model through quantitative assessment of pressure redistribution functions consisting of immersion, envelopment, and contact area change. The model was able to detect differences in the hardness of urethane foam, differences in the internal pressure of an air mattress, and sequential changes during the pressure switching mode. These results demonstrate the validity of our new buttock model in evaluating pressure redistribution for a variety of surfaces.

Vibration therapy accelerates healing of Stage I pressure ulcers in older adult patients.

OBJECTIVE: The present study investigated whether vibration therapy using a vibrator could facilitate the healing of Stage I pressure ulcers (PrUs) in older adults. METHODS: The study had a nonrandomized, blinded, controlled design. The subjects were hospital patients in long-term-care facilities with Stage I PrUs. In the experimental group, a vibrator (RelaWave; Matsuda Micronics Corp, Chiba, Japan) was used to apply vibration (frequency: 47 Hz; time: 10 seconds; amplitude modulation cycle: 15 seconds) for 15 minutes 3 times a day for up to 7 days, until Stage I PrUs healed. Apart from the vibration therapy, the experimental and control groups received the same care, which was provided according to PrU care guidelines. The number of healed ulcers was compared between 2 groups. RESULTS: The experimental group consisted of 16 patients with 20 Stage I PrUs; the control group consisted of 15 patients with 21 Stage I PrUs. In the experimental group, 8 (40.0%) PrUs healed; in the control group, 2 (9.5%) PrUs healed. The number of healed ulcers was significantly higher in the experimental group than in the control group (P = .033). The healing rate during the study period was significantly higher in the experimental group than in the control group (P = .018, logrank test). The hazard ratio adjusted for baseline risk factors was 0.031 (95% confidence intervals: 0.002-0.594, P = .021). The mean relative changes per day in wound area and intensity of redness were significantly greater in the experimental group than in the control group (P = .007, and P = .023, respectively). CONCLUSION: Based on these results, the use of the vibrator may facilitate the healing of Stage I PrUs.

Skin injuries caused by medical adhesive tape in older people and associated factors.

AIM AND OBJECTIVES: This study was designed to investigate the status of skin injuries in older individuals caused by adhesive tape and the associated factors for skin injury. BACKGROUND: Older individuals are susceptible to skin injuries caused by medical adhesive tape. However, the current status of such skin injuries and the associated factors involved has not been clearly elucidated. DESIGN: Prospective cohort design, using comparative and descriptive statistical tests. METHODS: The subjects were 155 patients aged 65 or older who were admitted to a long-term care facility and required the use of medical adhesive tape. Patients who showed no skin injuries were selected and the incidence rate and status of skin injuries that occurred during the eight-week study period were investigated. The skin injuries observed were classified by a dermatologist. The associated factors were examined statistically. Informed consent was obtained from all patients. RESULTS: Skin injuries developed at 34 sites in 24 subjects. The cumulative incidence rate was 15.5%, and the incidence density was 38.0/1000 person-days. Many of the skin injuries occurred around pressure ulcers and intravenous hyperalimentation sites. Other prevalent areas included the buttocks and back, where tape is commonly used. The skin injuries were classified as contact dermatitis (70.6%), trauma (20.6%) and infection (8.8%). The ratio of skin contamination and skin mobility in patients with contact dermatitis was significantly higher than in patients without skin injury. CONCLUSION: The highest incidence rate was observed in the buttock area of patients with pressure ulcers. The incidence rate of contact dermatitis was the highest. RELEVANCE TO CLINICAL PRACTICE: Skin care to minimise contamination and more effective ways of applying medical adhesive tape may be needed to prevent contact dermatitis.

Do nutritional markers in wound fluid reflect pressure ulcer status?

Evaluation of wound fluid characteristics for pressure ulcer (PU) assessment in clinical settings remains subjective, requiring considerable expertise. This cross-sectional study focused on nutritional markers in wound fluid as possible objective tools and investigated whether they reflect the PU status according to the healing phase, infection, and granulation, especially after adjusting for serum values. Twenty-eight patients with 32 full-thickness PUs were studied. The concentration of albumin, total protein, glucose, and zinc in wound fluid were measured. For PU status, the healing phases and infection were evaluated by clinical signs, and the degree of granulation tissue formation was determined as the hydroxyproline concentration. The wound fluid/serum ratio for albumin was significantly lower during the inflammatory phase than during the proliferative phase (p=0.020). Infected wound fluid contained less glucose (0.3-1.0 mmol/L) than noninfected ones did (5.0-7.6 mmol/L) in an intraindividual comparison of three cases. The wound fluid/serum ratio for glucose was negatively correlated with hydroxyproline level in the proliferative phase (rho=-0.73, p=0.007), while zinc level in wound fluid showed a positive correlation (rho=0.61, p=0.028). Our results suggest that these traditional nutritional markers in wound fluid, especially wound fluid/serum ratio may be useful to evaluate local PU status.

Factors influencing intact skin in women with incontinence using absorbent products: results of a cross-sectional, comparative study.

Incontinence-associated dermatitis (IAD) is a common problem in elderly incontinent people. A comparative cross-sectional study was conducted to examine and compare properties of intact skin on the buttocks and subumbilicus area in elderly people wearing absorbent products and to identify pad environment factors that affect skin properties. Study participants included 45 elderly (age range: 68 to 103 years) female residents of one nursing home who were incontinent of feces and urine (dual incontinence group--DIG, n = 35) or feces only (fecal incontinence group--FIG, n= 10). Skin pH and hydration were measured and factors believed to affect the perineal environment and contribute to the development of IAD were assessed. In both DIG and FIG, skin hydration levels and pH were higher in the coccygeal than in the subumbilical area. Skin hydration of the sacral region in the DIG was significantly higher than in the FIG (P = 0.019) and skin pH on the coccygeal region and sacral region in the DIG was significantly higher than in the FIG (coccygeal region, P = 0.013; sacral region, P = 0.023). Absorbent pad surface pH (P &0.01) and excessive sweating (P = 0.006) were significantly related to skin pH. Results show that properties of perineal skin in elderly women with incontinence are affected by occlusion with pads, increasing the risk of IAD. Studies comparing the effect of various types of pads and pad-change frequencies on skin properties are needed.

Estimation of protein loss from wound fluid in older patients with severe pressure ulcers.

OBJECTIVE: Protein loss from wound fluid is usually recognized as one of the factors contributing to the deterioration of the nutritional status in older patients with severe pressure ulcers. We quantified the protein loss owing to pressure ulcers and investigated associations with wound-related factors and nutritional status. METHODS: This cross-sectional study included 25 patients (>or=60 y) from 10 institutions, with full-thickness pressure ulcers. Wound fluid was collected once after accumulating beneath a film dressing. The amount of protein loss per day was estimated by the volume of wound fluid per hour and the total protein concentration in the wound fluid. Wound evaluations and nutritional assessments were performed. Correlations between variables were obtained using Spearman's rank correlation. RESULTS: The median age of the patients was 79 y (range 61-100), and median body mass index was 19.6 kg/m(2) (12.2-24.9). The median amount of protein loss was 0.2g/d (0.04-2.1), which corresponded to 0.01 g x kg(-1) x d(-1) (<0.01-0.04) and 0.6% (0.1-13.8) of protein intake. Four wounds characterized as infected or surgically debrided lost 1.5-2.1g of protein per day, which was substantially higher than other wounds lost. Protein loss was correlated with wound severity including area, depth, the wound severity score, and infectious markers (all Ps<0.05), but not with body mass index or arm muscle circumference (P>0.05). CONCLUSION: The amount of protein loss could be small and thus may not be related directly to nutritional status, although it increased as the wound became more severe.