Nurse-led coaching of shared decision-making for wound treatment of pressure injury: A pilot study of a randomized trial.

Objectives: International guidelines for managing pressure injury (PI) and ulcers recommend that family members and caregivers should be involved in making decisions for appropriate wound care. However, the effect of shared decision-making (SDM) in the context of PI remains unknown. This study investigated the efficacy of nurse-led medical SDM for PI treatment. Materials and Methods: We constructed a patient decision aid (PDA) for PI treatment on the basis of nursing evidence. Subsequently, we conducted a pilot randomized controlled trial to evaluate the efficacy of SDM compared with that of usual care (control group, [CG]) for PI treatment. Participants with stage 3, stage 4, or unstageable PI were included and randomized into two groups. In the SDM group (SDMG), 10 participants received the SDM intervention for PI before treatment. All participants were followed up for 4 weeks. Primary outcomes were measured using the nine-item SDM Questionnaire (SDM-Q-9) and Decisional Conflict Scale (DCS). Secondary outcomes included wound size and cost of wound management. Results: The expert validity (medical professors and general population) of the PDA designed for PI was measured, and the content validity index was 0.96-0.97. A total of 20 participants were enrolled (10 received SDM and 10 received usual care). The mean age of the participants was 55.7 ± 8.8 years. No significant difference in baseline characteristics (sex, age, staging, or wound area) was observed between the two groups. The SDMG had higher SDM-Q-9 (P < 0.001) and DCS (P < 0.01) scores than did the CG. For the secondary outcomes, the SDMG had a decreased change of wound size and lower wound management costs than did the CG; nevertheless, the differences were not statistically significant. Conclusion: We constructed a PDA for PI treatment, which can be applied in clinical care. The pilot test results revealed that the participants had a lower cost related wound treatment and decreasing wound size in SDMG than CG after the intervention of SDM-PI for 4 weeks. In the future, clinical studies should conduct large-scale randomized trials based on the results of this pilot study.

Annular Basal Cell Carcinoma Expanding Around Central Hypertrophic Scarring: A Case Report.

A case of annular basal cell carcinoma (BCC) with central atrophic scarring that developed secondary to spontaneous regression has been reported. We present a novel case of a large, expanding nodular and micronodular BCC with annular morphology with central hypertrophic scarring. A 61-year-old woman presented with a two-year history of a mildly itchy lesion on the right breast. Previously diagnosed as an infection, the lesion persisted after treatment with topical antifungal agents and oral antibiotics. Physical examination revealed a 5x6 cm plaque consisting of a pink-red arciform/annular edge with an overlying scale crust and a large, centrally positioned, firm, alabaster-colored portion. A punch biopsy of the pink-red rim revealed nodular and micronodular BCC features. A deep shave biopsy of the central bound-down plaque showed histopathology of scarring fibrosis with no findings of BCC regression. The malignancy was treated with two sessions of radiofrequency destruction, which led to the resolution of the tumor with no recurrence to date. Contrary to the previously reported case, BCC in our case was expanding, associated with hypertrophic scarring, and showed no signs of regression. We discuss several possible etiologies of the scarring centrally. With further awareness of this presentation, more such tumors can be detected at early stages to facilitate prompt treatment and prevent local morbidity.

Incidence rates and predictors of stomal-related complications: a 1-year prospective study.

BACKGROUND: Stomal-related complications (SRCs) increase the health care burden and impair quality of life. PURPOSE: To determine the incidence rates and predictors of stomal and peristomal complications (SCs and PCs, respectively). METHODS: This was a prospective cohort study. In total, 215 patients who had undergone ostomy were enrolled and followed-up at 3, 30, 90, 180, and 360 days after surgery. During the follow-up period, SRCs were assessed by 1 colorectal surgeon and 2 wound, ostomy, and continence nurses. The SRCs were classified into SCs and PCs. RESULTS: SRCs were observed in 105 patients (48.8%). The 105 patients had 145 SRCs (66 [45.5%] SCs and 79 [54.5%] PCs). A logistic regression analysis revealed that emergency surgery (odds ratio [OR]: 2.78; P = .041), laparoscopic surgery (OR: 2.91; P = .023), and inappropriate stomal location (OR: 19.23; P < .001) were significant predictors of SCs. Inappropriate stomal location also was significantly associated with PCs (OR: 7.70; P < .001). The cumulative incidence rate of SRCs was 73% in patients who underwent stomal surgery and were followed for 360 days. CONCLUSIONS: Stomas created through emergency or laparoscopic surgery and those created at inappropriate sites were associated with a higher risk of SCs. Inappropriate stomal site was found to be a significant predictor for SCs and PCs.

Preoperative Stoma Site Marking Decreases Stoma and Peristomal Complications: A Meta-analysis.

PURPOSE: We systematically reviewed the literature in order to determine whether evidence indicated that preoperative stoma site marking reduces the occurrence of postoperative stoma and peristomal complications. DESIGN: Systematic review with meta-analysis of pooled findings. SUBJECTS/SETTING: We systematically reviewed 6 electronic databases including PubMed, MEDLINE, CINAHL, Cochrane Library for English language articles, along with the Airiti Library and Wanfang Data for Chinese articles for evidence related to the effects of stoma site marking on stoma and peristomal complications. We sought articles published from their inception to January 31, 2018. METHODS: Ten studies that included 2109 participants, each comparing 2 groups of patients who did and did not undergo preoperative stoma site marking, were retrieved and analyzed. RESULTS: In patients who underwent stoma site marking, the marking was associated with reduced stoma and peristomal complications in all stoma types (odds ratio [OR] = 0.52; 95% CI, 0.42-0.64; P < .001). Patients who underwent stoma and had fecal ostomies experienced fewer complications (OR = 0.34; 95% CI, 0.25-0.47; P < .001) than patients with unmarked stomas. In contrast, patients with urostomies did not experience fewer complications when compared to those with unmarked ostomies (OR = 0.531; 95% CI, 0.23-1.21; P = .132). Persons with fecal ostomies also had fewer hernias and peristomal skin complications (ORs = 0.25 and 0.30; 95% CIs, 0.09-0.71 and 0.20-0.44, respectively; both Ps < .001). The results revealed that stoma site marking was associated with reduced early and late stoma and peristomal complications (ORs = 0.76 and 0.38; 95% CIs, 0.61-0.94 and 0.32-0.46; P = .010 and P < .001, respectively). CONCLUSIONS: Preoperative stoma site marking is associated with a reduced occurrence of stoma and peristomal complications and should be considered as a standard of preoperative care.

[Medical Device Related Pressure Injury Prevention Strategies].

Medical Device Related Pressure Injury was incorporated into the redefinition of pressure injuries during the National Pressure Ulcer Advisory Panel 2016 Staging Consensus Conference. It is evident that this type of iatrogenic injury is gradually receiving more attention. Unlike pressure injuries over a bony prominence, which may be alleviated by repositioning different body parts, injuries that require non-retractable medical devices to be securely fastened to an injury site carry a higher risk of causing pressure injuries and of requiring subsequent care in a clinical setting. Furthermore, facial skin and mucosal membranes are the most common sites of Medical Device Related Pressure Injuries. Once these injuries occur, they easily result in damage to appearance, loss of function, and even bone exposure and infection, which may lead to medical disputes. Therefore, in recent years, research and exploration in this field has increased in many countries. However, discussions regarding Medical Device Related Pressure Injuries in Taiwan are still lacking. Thus, the aim of this article is to discuss the definition, risk factors, damage classification, and prevention strategies of Medical Device Related Pressure Injuries by combining domestic and international literature reviews and clinical verifications for the purpose of providing knowledge to medical staffs in hopes of reducing the incidence of Medical Device Related Pressure Injuries and degree of damage.

Notch3 signaling-mediated melanoma-endothelial crosstalk regulates melanoma stem-like cell homeostasis and niche morphogenesis.

Melanoma is among the most virulent cancers, owing to its propensity to metastasize and its resistance to current therapies. The treatment failure is largely attributed to tumor heterogeneity, particularly subpopulations possessing stem cell-like properties, ie, melanoma stem-like cells (MSLCs). Evidence indicates that the MSLC phenotype is malleable and may be acquired by non-MSLCs through phenotypic switching upon appropriate stimuli, the so-called 'dynamic stemness'. Since the phenotypic characteristics and functional integrity of MSLCs depend on their vascular niche, using a two-dimensional (2D) melanoma-endothelium co-culture model, where the MSLC niche is recapitulated in vitro, we identified Notch3 signaling pathway as a micro-environmental cue governing MSLC phenotypic plasticity via pathway-specific gene expression arrays. Accordingly, lentiviral shRNA-mediated Notch3 knockdown (KD) in melanoma cell lines exhibiting high levels of endogenous Notch3 led to retarded/abolished tumorigenicity in vivo through both depleting MSLC fractions, evinced by MSLC marker downregulation (eg, CD133 and CD271); and impeding the MSLC niche, corroborated by the attenuated tumor angiogenesis as well as vasculogenic mimicry. In contrast, Notch3 KD affected neither tumor growth nor MSLC subsets in a melanoma cell line with relatively low endogenous Notch3 expression. Thus, Notch3 signaling may facilitate MSLC plasticity and niche morphogenesis in a cell context-dependent manner. Our findings illustrate Notch3 as a molecular switch driving melanoma heterogeneity, and provide the biological rationale for Notch inhibition as a promising therapeutic option.

[Preventing Facial Pressure Injuries in Patients Who Use Noninvasive Positive Pressure Ventilators: The Efficiency of Dressings].

BACKGROUND: Noninvasive positive pressure ventilation (NPPV) provides ventilation without tracheal intubation. Facial pressure injury is a recognized complication of this technique, making the prevention of facial pressure injuries an important issue for NPPV patients. PURPOSE: The present study compared the effects of foam dressing and hydrocolloid dressing in preventing facial pressure injuries in NPPV patients. METHODS: A randomized clinical trial was used to evaluate participants that were referred from the intensive care unit of a medical center in eastern Taiwan. Participants were randomized into two groups: the foam dressing group and the hydrocolloid dressing group. Statistics used in analysis were: analysis mean, standard deviation, chi-square, independent t-test, and the generalized estimating equation. RESULTS: Sixty participants were enrolled as participants. The incidence rate of facial pressure injury was 11.7% (7/60). No significant difference was found between the two groups in terms of duration of NPPV use, incidence of facial pressure injury, and occurrence time of facial pressure injury. However, the hydrocolloid dressing group had a higher usage amount than the foam dressing group (p < .05). CONCLUSIONS: Foam and hydrocolloid dressings are both helpful in preventing facial pressure injury when used in conjunction with regular skin assessments.

[Nursing Experience With a Patient With Gastrostomy Leakage Resulting in Moisture-Associated Skin Damage].

Leakage is a common complication of gastrostomy. Exposure of the skin surrounding the gastrostomy tube to moisture or chemical irritants may cause moisture-associated skin damage (MASD) and seriously affect the patient's quality of life. This case study describes a nursing experience with gastrostomy leakage that resulted in MASD. An assessment conducted from July 29, 2015 to August 20, 2015 revealed that heavy gastronomy leakage had caused extensive skin erosion, ulceration, hyperplasia, and superficial infection. Simultaneously, the patient was required to conduct complex stoma care, which resulted in physical and psychological exhaustion. Changes in traditional tube and wound care were discussed on multiple occasions with an interdisciplinary healthcare team. Based on the evidence-based literature, we provide gastrostomy and MASD management strategies. Through team collaboration, we prevented gastric contents from contacting the patient's skin directly, improved patient comfort, controlled effluent and skin infections, maintained fluid and electrolyte balances, and acce-lerated the healing of the damaged skin. We recommend that healthcare professionals caring for patients with gastrostomy leakage be provided with early skin protection programs to learn the standard methods for identifying and correcting leakage factors, containing effluent, and adequately stabilizing the gastrostomy tube in order to reduce the impact on the patient's quality of life. In addition, patient education on tube and skin care should be provided to prevent the reoccurrence of complications.

[Nursing Experience With Providing Wound Care for a Newborn With Epidermolysis Bullosa].

Epidermolysis bullosa (EB) is a rare hereditary, chromosomal disease of the skin. Life-threatening septicemia may result if appropriate care is not provided to alleviate the extensive skin irritation that is the main symptom of this disease. This case report describes the experience of the author in nursing a wound area on a newborn that was suspected of being caused by EB. This wound area comprised blisters and peeling skin that covered 30% of the entire skin area of the infant. A holistic assessment conducted from December 1st, 2013 to January 7th, 2014 revealed that this large of an area of damage to the skin and mucosa considerably complicated the task of wound care and caused severe pain to the infant. In response to the special needs of this case, our medical team conducted a literature review of wound care for this rare disease. Based on the suggestions of previous empirical studies, nursing measures for the skin, mucosa, and wounds of the newborn were then administered through inter-team cooperation. These actions effectively reduced the pain, controlled the infection, and accelerated wound healing. In addition, progressive contact was used to guide the primary caregivers of the newborn, which alleviated their physical and psychological stresses effectively. The caregivers were educated systematically on wound care and guided to learn techniques for nursing and dressing wounds. Thus, these caregivers were better prepared to continue providing wound care at home. We suggest that healthcare professionals reference empirical studies when providing care to EB newborns during the acute-care period and provide wound care and supportive therapies to control the occurrence of complications using a multidisciplinary team-care model. In addition, social resources should be used effectively in nursing care plans to mitigate the effect of this rare disease on families.

Induction of Vasculogenic Mimicry Overrides VEGF-A Silencing and Enriches Stem-like Cancer Cells in Melanoma.

The basis for resistance to VEGF inhibition is not fully understood despite its clinical importance. In this study, we examined the adaptive response to VEGF-A inhibition by a loss-of-function analysis using plasmid-based shRNA. Tumor xenografts that initially responded to VEGF-A inhibition underwent an adaptation in vivo, leading to acquired resistance. VEGF-A blockade in tumors was associated with HIF1α expression and an increase in CD144(+) vasculogenic mimicry (VM), leading to formation of channels displaying Tie-1 and MMP-2 upregulation. CD133(+) and CD271(+) melanoma stem-like cells (MSLC) accumulated in the perivascular niche. Tumor xenografts of melanoma cell populations that were intrinsically resistant to VEGF-A blockade did not exhibit any of these features, compared with nontarget control counterparts. Thus, melanomas that are initially sensitive to VEGF-A blockade acquire adaptive resistance by adopting VM as an alternate angiogenic strategy, thereby enriching for deposition of MSLC in the perivascular niche through an HIF1α-dependent process. Conversely, melanomas that are intrinsically resistant to VEGF-A blockade do not show any evidence of compensatory survival mechanisms that promote MSLC accumulation. Our work highlights the potential risk of anti-VEGF treatments owing to a selective pressure for an adaptive resistance mechanism that empowers the development of stem-like cancer cells, with implications for how to design combination therapies that can improve outcomes in patients.

CD133-targeted niche-dependent therapy in cancer: a multipronged approach.

Cancer treatment continues to be challenged by the development of therapeutic resistances and relapses in the clinical setting, which are largely attributed to tumor heterogeneity, particularly the existence of cancer stem cells (CSCs). Thus, targeting the CSC subpopulation may represent an effective therapeutic strategy. However, despite advances in identifying and characterizing CD133(+) CSCs in various human cancers, efforts to translate these experimental findings to clinical modalities have been slow in the making, especially in light of the growing awareness of CSC plasticity and the foreseeable pitfall of therapeutically targeting CSC base sorely on a surface marker. We, and others, have demonstrated that the CD133(+) CSCs reside in complex vascular niches, where reciprocal signaling between the CD133(+) CSCs and their microenvironment may govern niche morphogenesis and homeostasis. Herein, we discuss the multifaceted functional role of the CD133(+) cells in the context of their niche, and the potential of targeting CD133 as a niche-dependent approach in effective therapy.

CD133+ melanoma subpopulations contribute to perivascular niche morphogenesis and tumorigenicity through vasculogenic mimicry.

Tumor cell subpopulations that express cancer stem cell markers such as CD133 (prominin1) or ABCB5 are thought to be crucial for tumor initiation and heterogeneity, but their biological significance in melanoma has been controversial. Here, we report that CD133(+) and ABCB5(+) subpopulations are colocalized in melanomas in perivascular niches that contain CD144 (VE-cadherin)(+) melanoma cells forming vessel-like channels, a phenomenon termed vasculogenic mimicry (VM). RNAi-mediated attenuation of CD133 established its critical function in morphogenesis of these perivascular niches as well as in melanoma tumorigenicity. Niche-associated genes CD144 and ABCB5 were downregulated in tumors derived from CD133 knockdown (KD) melanoma cells compared with controls. CD133KD cells also lacked the ability to form CD144(+) VM-like channels in a manner that was associated with a depletion of the ABCB5(+) cell subpopulation. Finally, CD133 KD cells exhibited poorer tumor growth in vivo. Taken together, our findings corroborate models in which CD133(+)/ABCB5(+) melanoma cells reside in a complex anastomosing microvascular niche that encompasses CD144(+) VM channels as well as authentic endothelial cell-lined blood vessels. Further, they indicate that CD133(+) cells act as stem-like cells, which drive tumor growth by promoting VM and the morphogenesis of a specialized perivascular niche in melanoma.

Psychometric testing of the Chinese evidence-based practice scales.

AIM: This article is a report of the psychometric testing of the Chinese version of Evidence-Based Practice Implementation and Beliefs, and Barriers to, and Facilitators of Research Utilization scales. BACKGROUND: Investigations into the effect of evidence-based practice on clinical care could be facilitated by instruments for measuring the levels of evidence-based practice implementation; the strength of beliefs in evidence-based practice; the barriers to, and the facilitators of research utilization. An English version of the scales measuring the above constructs has been tested whereas the Chinese one has not. DESIGN: Instrument development. METHODS: Psychometric analyses of the four evidence-based scales were conducted on a sample of 361 nurses from a medical centre in Taiwan. Both the internal consistency and squared multiple correlation coefficients were used to examine reliability. The validity testing for the four scales was estimated by examining their construct and concurrent validity. Data were collected between December 2008-January 2009. FINDINGS: Internal consistencies exist for the Chinese Evidence-Based Practice Implementation, Beliefs, and Barriers to, and Facilitator of Research Utilization scales (≥0·85); some were greater than 0·9, which may indicate redundancy in items. Construct validity of the four scales was supported by hypotheses testing. Concurrent validity of the four scales was supported by known-group analysis, in which experienced nursing researchers had higher scores compared with clinical nurses. CONCLUSION: These scales may have value in discrimination between implementation of EBP and perception of barriers to, and facilitators of research utilization among nurses with different education levels, research experiences or working years in clinical setting.

Targeting CD20 in melanoma patients at high risk of disease recurrence.

Melanomas contain distinct cell subpopulations. Several of these subpopulations, including one expressing CD20, may harbor stem cell-like or tumor-initiating characteristics. We hypothesized that patients at high risk of disease recurrence could benefit from an adjuvant anti-CD20 therapy. Therefore, we initiated a small pilot trial to study the effect of the anti-CD20 antibody rituximab in a group of melanoma patients with stage IV metastatic disease who had been rendered without evident disease by way of surgery, chemotherapy and/or radiation therapy. The major objective was safety, while secondary objectives were description of recurrence-free intervals (RFI) and overall survival (OS). Nine patients received rituximab at 375 mg/m(2) qw for 4 weeks followed by a maintenance therapy every 8 weeks. Treatment was discontinued after 2 years or with disease recurrence. Treatment was well tolerated. After a median observation of 42 months, the median neither of RFI nor of OS has been reached. Despite therapy that ended after 2 years, six out of nine patients are still alive and five of them are recurrence-free. Though the patient number is too small for definitive conclusions, our data may represent a first example of the potential therapeutic value of targeting CD20(+) cell populations-at least for a subset of patients.

Symptom burden and quality of life in patients with malignant fungating wounds.

AIM: This study describes the relationship between symptoms and quality of life in patients with malignant fungating wounds. BACKGROUND: Malignant fungating wounds are complex wounds that can bleed, become malodorous due to infection and are painful causing physical and psychological distress. However, there is a lack of literature on the impact that such wounds can have on quality of life. METHODS: This was a descriptive, cross-sectional multi-centre study of patients with malignant fungating wounds. Participants were recruited from the palliative care, hospice, outpatient clinic and oncology units of three medical centres in Taiwan. Data were collected from February 2008 to August 2009. A structured questionnaire obtained socio-demographic information, medical details, wound assessment information and the Taiwanese version of the McGill quality of life questionnaire was administered by interview. RESULTS: McGill quality of life scores indicated that the participants had the lowest quality of life. The participant's age, dressing change frequency, pain, wound dressing comfort, wound symptom, bleeding and malodour had statistically significant negative correlations with quality of life. Multiple regression analysis showed that age, malodour, pain issues and psychological issues explained 87% of the total variance in quality of life. CONCLUSION: This study contributes to our understanding of the impact of malignant fungating wounds and how correct assessment and management is necessary to improve quality of life. Educational intervention research is needed for patients and caregivers in countries where this has not yet been performed. Further research should also identify whether nursing competence has a direct impact on quality of life.

Multimedia education programme for patients with a stoma: effectiveness evaluation.

AIM: This paper is a report of an evaluation of the effectiveness of a multimedia education program in relation to stoma knowledge, self-care attitudes and behaviour with patients with a stoma in the postoperative period. BACKGROUND: Multimedia education programmes not only give patients with useful information in the absence of health professionals, but can also augment information given in traditional clinical practice. However, the literature on the effectiveness of different approaches to stoma education is limited. METHOD: A randomized experimental study design was used. Participants were recruited from a surgical unit in a large hospital in Taiwan. A total of 102 patients with a stoma were randomly assigned to either the multimedia education programme (n=46) or a conventional stoma education programme (n=56) with a follow-up of 1 week. Outcome variables measured were levels of self-care knowledge, attitudes towards self-care and self-care behaviour. FINDINGS: Patients who received the multimedia education programme improved their overall self-care knowledge, attitudes and behaviour statistically significantly when compared with those who received the conventional stoma education programme. CONCLUSION: Although further, longer-term follow-up will be useful, this study demonstrates that multimedia packages can enhance patient involvement in their stoma care and can augment stoma education - particularly in resource challenged healthcare environments.

Urticarial hypersensitivity reaction caused by temozolomide.

Temozolomide is an oral alkylating agent approved for the treatment of glioblastoma and anaplastic astrocytoma, and is currently under clinical investigation for the treatment of brain metastases from a variety of cancers. Temozolomide is well tolerated, and the reported dermatologic side effects of this medication are limited. Here, the authors report the first case of an urticarial hypersensitivity reaction induced by temozolomide. As this drug will likely be increasingly utilized in the near future, it is important to be aware of its potential to cause adverse cutaneous manifestations.

Differentiation of zebrafish melanophores depends on transcription factors AP2 alpha and AP2 epsilon.

A model of the gene-regulatory-network (GRN), governing growth, survival, and differentiation of melanocytes, has emerged from studies of mouse coat color mutants and melanoma cell lines. In this model, Transcription Factor Activator Protein 2 alpha (TFAP2A) contributes to melanocyte development by activating expression of the gene encoding the receptor tyrosine kinase Kit. Next, ligand-bound Kit stimulates a pathway activating transcription factor Microphthalmia (Mitf), which promotes differentiation and survival of melanocytes by activating expression of Tyrosinase family members, Bcl2, and other genes. The model predicts that in both Tfap2a and Kit null mutants there will be a phenotype of reduced melanocytes and that, because Tfap2a acts upstream of Kit, this phenotype will be more severe, or at least as severe as, in Tfap2a null mutants in comparison to Kit null mutants. Unexpectedly, this is not the case in zebrafish or mouse. Because many Tfap2 family members have identical DNA-binding specificity, we reasoned that another Tfap2 family member may work redundantly with Tfap2a in promoting Kit expression. We report that tfap2e is expressed in melanoblasts and melanophores in zebrafish embryos and that its orthologue, TFAP2E, is expressed in human melanocytes. We provide evidence that Tfap2e functions redundantly with Tfap2a to maintain kita expression in zebrafish embryonic melanophores. Further, we show that, in contrast to in kita mutants where embryonic melanophores appear to differentiate normally, in tfap2a/e doubly-deficient embryonic melanophores are small and under-melanized, although they retain expression of mitfa. Interestingly, forcing expression of mitfa in tfap2a/e doubly-deficient embryos partially restores melanophore differentiation. These findings reveal that Tfap2 activity, mediated redundantly by Tfap2a and Tfap2e, promotes melanophore differentiation in parallel with Mitf by an effector other than Kit. This work illustrates how analysis of single-gene mutants may fail to identify steps in a GRN that are affected by the redundant activity of related proteins.