Inter-rater reliability of the EPUAP pressure ulcer classification system using photographs

Background. Many classification systems for grading pressure ulcers are discussed in the literature. Correct identification and classification of a pressure ulcer is important for accurate reporting of the magnitude of the problem, and for timely prevention. The reliability of pressure ulcer classification systems has rarely been tested. Aims and objectives. The purpose of this paper is to examine the inter-rater reliability of classifying pressure ulcers according to the European Pressure Ulcer Advisory Panel classification system when using pressure ulcer photographs.Design. Survey was among pressure ulcer experts.Methods. Fifty-six photographs were presented to 44 pressure ulcer experts. The experts classified the lesions as normal skin, blanchable erythema, pressure ulcer (four grades) or incontinence lesion. Inter-rater reliability was calculated.Results. The multirater-Kappa for the entire group of experts was 0.80 (P < 0.001).Various groups of experts obtained comparable results. Differences in classifications are mainly limited to 1 degree of difference. Incontinence lesions are most often confused with grade 2 (blisters) and grade 3 pressure ulcers (superficial pressure ulcers).Conclusions. The inter-rater reliability of the European Pressure Ulcer Advisory Panel classification appears to be good for the assessment of photographs by experts. The difference between an incontinence lesion and a blister or a superficial pressure ulcer does not always seem clear.Relevance to clinical practice. The ability to determine correctly whether a lesion is a pressure ulcer lesion is important to assess the effectiveness of preventive measures. In addition, the ability to make a correct distinction between pressure ulcers and incontinence lesions is important as they require different preventive measures. A faulty classification leads to mistaken measures and negative results. Photographs can be used as a practice instrument to learn to discern pressure ulcers from incontinence lesions and to get to know the different grades of pressure ulcers. The Pressure Ulcer Classification software package has been developed to facilitate learning

Living with persistent pain: experiences of older people receiving home care.

Background. Although the topic of pain among older people has received increasing interest, little is still known about how pain is experienced or handled by those who no longer manage independently but depend on professionals for help with daily living. Developing pain management for older people requires such knowledge. Aim. To explore sense of self, sense of pain, daily living with pain, sense of others and ways of handling pain in older people with persistent pain. Methods. Interviews with 90 older people receiving home care from nursing auxiliaries in their own homes or in sheltered accommodation were collected from January to June 2000. A typology of older people in persistent pain was developed. Activities for handling pain were examined using content analysis. Findings. Respondents' experiences of themselves and their pain varied. Two groups of older people, considered as 'competent and proud' and 'confident and serene', expressed satisfaction in spite of pain, while the groups 'misunderstood and disappointed' and 'resigned and sad' expressed dissatisfaction. The most common strategies used were medication, rest, mobility, distracting activities and talking about pain. Respondents chose strategies by balancing the advantages of the activities against the disadvantages these brought for their daily living. Conclusion. This study indicates that characteristics of the older people, such as their way of experiencing themselves, how pain affects their daily life and how they perceive effects and side-effects of pain management are areas that need to be identified when staff assess pain and plan pain management. Caring for older people in pain could be improved by listening to and believing their complaints, evaluating effects and side-effects from medications and nonpharmacological pain management and by emphasising the importance of common everyday activities such as mobility and distraction to relieve pain

Uso do abate comparativo na determinação da exigência de energia de mantença de gado de corte pastejando capim-elefante: descrição da metodologia e dos resultados Use of comparative slaughter to set maintenance energy requirements of beef cattle grazing elephantgrass: description of methodology and results

Determinou-se o requerimento líquido de energia de mantença de novilhos mantidos em regime exclusivo de pastejo, em capim-elefante (Pennisetum purpureum, Schum) cv. Napier. O experimento teve duração de 175 dias, utilizando-se nove piquetes, estabelecidos em terreno plano, com área individual de 0,5 ha, sob pastejo rotacionado. Foram utilizados 36 novilhos &frac34;Gir-Holandês com 332 &plusmn; 37 kg e média de 20 meses de idade inicial. Metade dos animais teve o tempo de pastejo restrito a quatro horas por dia, de forma a se limitar o consumo de energia a pouco acima do nível de mantença, e metade teve acesso irrestrito à pastagem. Seis novilhos foram abatidos no início do experimento, para se determinar a composição corporal inicial (grupo referência) e seis (três de cada tratamento) a intervalos sucessivos de 35 dias. A composição corporal dos animais abatidos foi determinada por análise química de amostras representativas de todo o corpo. As exigências líquidas de energia para mantença foram estimadas como o calor produzido em nível zero de ingestão de energia metabolizável, ajustando-se equações do logaritmo da produção de calor em função do consumo de energia metabolizável, por dia e por unidade de tamanho metabólico (kg0,75). Foi ajustada uma equação, calculando-se o tamanho metabólico em função do peso vivo (PV) e outra em função do peso de corpo vazio (PCVZ). O consumo e a digestibilidade da forragem ingerida (extrusa) foram determinados mensalmente. O tempo de pastejo limitado a quatro horas diárias assegurou ingestão de energia em nível pouco acima da mantença, conforme indicaram os ganhos de peso individuais, evidenciando que este procedimento pode ser recomendado para trabalhos futuros. A exigência de energia de mantença encontrada foi de 57 kcal/kg PV0,75 ou 63,27 kcal/kg PCVZ0,75. Os valores obtidos estão dentro da faixa de resultados obtidos no Brasil, sendo mais baixos que os valores recomendados no exterior, para gado europeu.<br>The maintenance net energy requirement of steers grazing elephangrass (Pennisetum purpureum, Schum) cv. Napier, as unique food, was determined. The trial lasted 175 days. Nine 0.5 ha paddocks were implanted in flat-land, in rotational grazing, were used. Thirty-six &frac34; Gyr-Holstein steers averaging initial age of 20 months and 332 &plusmn; 37 kg body weight (BW) were used. Half of animals had grazing time restricted to four hours daily, to limit energy intake at a level close to maintenance, and half had free access to pasture. Six steers were slaughtered at the beginning of trial to determine initial body composition (reference group), and six were slaughtered each 35 days. Body composition was determined by chemical analysis of representative samples of all animal body. The net energy maintenance requirements were estimated as heat production at zero level of metabolizable energy intake, regressing log heat production on metabolizable energy intake, per day and per unit metabolic size. Two equations were fitted: for the first, metabolic size was calculated as a function of body weight (BW0.75) and for the second as function of empty body weight (EBW0.75). Forage intake and digestibility of forage consumed (extrusa) were determined monthly. The grazing time restricted to four hours a day allowed intake of energy at level close to maintenance as indicated the individual weight gains, showing that the procedure used in this research might be used in future trials. The net energy maintenance requirement observed was 57 kcal/kg LW0.75 or 63,27 kcal/kg EBW0.75. The values obtained fall into the range of values observed in Brazil and were lower than those recommended abroad for European type cattle

Characterization of biological types of cattle: indicator traits offertility in beef cows

Genetic diversity among breeds of cattle allows producers to select animals for specific environments or market conditions. Reproductive efficiency is a multi-component trait that is largely influenced by environmental influences such as health and nutritional status; however, there are clearly genetic components to reproductive efficiency, and breed differences in a number of indicator traits associated with fertility and cow productivity have been identified. Historical indicators of fertility include scrotal circumference, age at puberty, and postpartum interval. Both age at puberty and postpartum interval are laborious traits to collect in heifers and cows because they require many days of detection of behavioral estrus. In recent years, the addition of ultrasonography to management practices has allowed for the collection of female traits such as follicle diameter, antral follicle counts, and fetal age that are not as labor intensive. These additional diagnostic traits provide novel phenotypes for the identification of genetic markers of fertility and cow productivity, which would be the ultimate goal. Genetic markers of the number of follicles in the bovine ovary have the potential to identify heifers that will be highly productive cows. Furthermore, identifying and understanding the genes that control various reproductive traits and the response to stressors, such as temperature and nutrient availability, could improve production efficiency by improving management and breeding decisions in a wide range of production environments

Toward Spinozist robotics: Exploring the minimal dynamics of behavioural preference

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