Prevention and treatment of pressure ulcers

The prevention and treatment of pressure ulcers continues topresent a challenge across acute and long-term care settings, and costs the NHS up to £2.64 billion annually. As well as causing a reduced quality of life for sufferers, they can prove to be fatal. The complexity of the exact causes of skin breakdown and accurate risk assessment has proved problematic to fully understanding this common nursing problem, yet despite limited evidence clear guidelines on best practice exist, suggesting that prevention strategies should encompass interventions in three areas: risk assessment; relief of pressure, and education. Evidence exists that where these strategies are adopted at an organizational level, and strong leadership provided, the outcomes can be remarkable. This article outlines effective prevention and risk-reduction strategies, together with interventions that can promote healing.<br/

Ultrasound modulates pro-inflammatory cytokine release in soft tissue

Introduction: ultrasound therapy promotes cytokine release in vitro1 and has been suggested to improve the healing rates of pressure ulcers2. Unfortunately much of the evidence is conflicting, and it is difficult to draw firm conclusions on effectiveness3. Traditionally US is thought to promote the release of proinflammatory cytokines and speed up the inflammatory phase of tissue repair5. Thus the aim of this study was to investigate the effect of US on proinflammatory cytokine release in vivo.Methods: fifteen healthy volunteers were recruited following ethics approval. Microdialysis fibres were implanted at a depth of 1mm at two separate sites on the volar aspect of the non-dominant forearm. The fibres were perfused with PBS (3µl/min) and each site randomly allocated to receive either non thermal low intensity US at a pulse ratio of 1:4 and an intensity of 0.5 W/cm2 and sham ultrasound (SUS) for 10 minutes. Dialysate was collected for 30 minutes prior to intervention and every 30 minutes following intervention and pro-inflammatory cytokines (IL-1ß, IL-6, IL-8, TNF?) quantified via immunoassay. Results: the mean (± SEM) baseline concentrations of IL-1ß, IL-6, IL-8 and TNF? were 0.9 (0.2), 3.5 (0.8), 14.3 (4.1) and 0.3 (0.08) pg/ml. There was no significant difference in baseline values between the two sites. A significant (p&lt;0.05) increase in all cytokines from baseline was observed following the application of sham US, with the mean (± SEM) concentrations of IL-1ß, IL-6, IL-8 and rising to 2.8 (0.5), 11.4 (1.6), 31.6 (3.6) and 0.8 (0.2) pg/ml. In contrast the increase seen in all cytokines, except TNF?, following HFUS was significantly (p&lt;0.01) reduced, the mean (± SEM) IL-1ß, IL-6, IL-8 and TNF? concentrations being 0.8 (0.1), 5.6 (0.7), 20.1 (2.3), and 0.4 (0.05) pg/ml (Figure 1).Discussions: this study demonstrates that US is able to modulate cytokine release in the superficial soft tissue and significantly reduces the release of proinflammatory cytokines compared to sham US. Clinical relevance: This suggests that current thinking concerning the mechanism of action of therapeutic US may need to be re-evaluated, and further studies are needed to explore the mechanisms involved and the potential benefits to the management of pressure ulcers<br/

An exploratory study of the effects of the pH of synthetic urine on skin integrity in healthy participants.

BACKGROUND: Incontinence-associated dermatitis (IAD) develops from prolonged exposure of skin to urine and/or stool and represents a common complication in older adults, reducing the quality of life. Increased pH is an important etiologic factor of IAD; however, the relationship between urinary pH and skin barrier disruption remains unclear. OBJECTIVE: The aim of this study is to examine the effects of synthetic urine (s-urine) at various pHs on transepidermal water loss (TEWL), stratum corneum hydration (SCH), and skin surface pH. METHODS: S-urine solutions (pH 5.0–9.0) were applied to the volar forearms of 15 healthy participants for 2 h, with another site serving as the untreated control. Measurements of TEWL, SCH, and skin surface pH were obtained at baseline (BL) and after each challenge. Skin buffering capacity was also examined in 5 volunteers by recording skin pH at BL, after 2 h exposure and every 5 min for 40 min. RESULTS: TEWL and SCH were increased following exposure to s-urine compared to BL values. Although there was a tendency for pH to increase after exposure, further investigation showed that changes are only temporal as pH value is restored to BL within 5 mins. There were no significant differences between solutions. CONCLUSIONS: This study revealed that urine disrupts healthy skin integrity; however, its effects are not pH dependent. Transient changes were observed on the acid mantle of the skin due to its innate buffering capacity. Future studies need to examine the effects of urine combined with bacteria responsible for pH elevation in patients with urinary incontinence

Monitoring contractile dermal lymphatic activity following uniaxial mechanical loading

It is proposed that direct mechanical loading can impair dermal lymphatic function, contributing to the causal pathway of pressure ulcers. The present study aims to investigate the effects of loading on human dermal lymphatic vessels. Ten participants were recruited with ages ranging from 24-61 years. Participants had intradermal indocyanine green injections administrated between left finger digits. Fluorescence was imaged for 5 minute sequences with an Infra-Red camera prior to lymph vessel loading, immediately after axial loading (60mmHg) and following a recovery period. Image processing was employed to defined transient lymph packets and compare lymph function between each test phase. The results revealed that between 1-8 transient events (median =4) occurred at baseline, with a median velocity of 8.1mm/sec (range 4.1-20.1mm/sec). Immediately post-loading, there was a significant (p&lt;0.05) reduction in velocity (median = 6.4, range 2.2-13.5mm/sec), although the number of transient lymph packages varied between participants. During the recovery period the number (range 1-7) and velocity (recovery median =9.6mm/sec) of transient packets were largely restored to basal values. The present study revealed that some individuals present with impaired dermal lymphatic function immediately after uniaxial mechanical loading. More research is needed to investigate the effects of pressure and shear on lymphatic vessel patency. <br/

Using the theory of planned behaviour to explore the multicultural nursing workforces' behavioural intentions to comply with nursing policies and procedures in Prince Military Medical City (PSMMC) in Kingdom of Saudi Arabia

Background &amp; aims: mBarrett's esophagus (BE) increases risk for esophageal adenocarcinoma (EAC). Increased risk for BE has been associated with single nucleotide polymorphisms (SNPs) on chromosome 6p21 (within the HLA region) and on 16q23, where the closest protein-coding gene is FOXF1. The Barrett's and Esophageal Adenocarcinoma Consortium (BEACON) identified risk loci for BE and esophageal adenocarcinoma in CRTC1 and BARX1, and within 100 kb FOXP1. We aimed to identify SNPs that increased risk for BE in a genome-wide association study (GWAS) and to validate previously reported associations.Methods: we performed a GWAS to identify variants associated with BE and further analyzed promising variants identified by the BEACON. We performed genotype analysis of 10,158 patients with BE and 21,062 controls.Results: we identified 2 SNPs not previously associated with BE: rs3072 (2p24.1; odds ratio [OR] = 1.14; 95% CI: 1.09–1.18; P = 1.8 × 10?11) and rs2701108 (12q24.21; OR = 0.90; 95% CI: 0.86–0.93; P = 7.5 × 10?9). The closest protein-coding genes were GDF7 (rs3072), which encodes a ligand in the bone morphogenetic protein pathway, and TBX5 (rs2701108), which encodes a transcription factor that regulates esophageal and cardiac development. We also identified 3 SNPS already identified by the BEACON (rs2687201, rs11789015, and rs10423674). Meta-analysis of all data identified another SNP associated with BE and esophageal adenocarcinoma: rs3784262, near ALDH1A2 (OR = 0.90; 95% CI: 0.87–0.93; P = 3.72 × 10?9).Conclusions: we identified 2 loci associated with risk for BE and provide data to support a locus previously associated with risk in the BEACON. The genes we found to be associated with risk for BE encode transcription factors involved in thoracic, diaphragmatic, and esophageal development or proteins involved in the inflammatory respons

The strength of the association between heterozygosity and probability of interannual local recruitment increases with environmental harshness in blue tits

The extent of inbreeding depression and the magnitude of heterozygosity–fitness correlations (HFC) have been suggested to depend on the environmental context in which they are assayed, but little evidence is available for wild populations. We combine extensive molecular and capture–mark–recapture data from a blue tit (Cyanistes caeruleus) population to (1) analyze the relationship between heterozygosity and probability of interannual adult local recruitment and (2) test whether environmental stress imposed by physiologically suboptimal temperatures and rainfall influence the magnitude of HFC. To address these questions, we used two different arrays of microsatellite markers: 14 loci classified as neutral and 12 loci classified as putatively functional. We found significant relationships between heterozygosity and probability of interannual local recruitment that were most likely explained by variation in genomewide heterozygosity. The strength of the association between heterozygosity and probability of interannual local recruitment was positively associated with annual accumulated precipitation. Annual mean heterozygosity increased over time, which may have resulted from an overall positive selection on heterozygosity over the course of the study period. Finally, neutral and putatively functional loci showed similar trends, but the former had stronger effect sizes and seemed to better reflect genomewide heterozygosity. Overall, our results show that HFC can be context dependent, emphasizing the need to consider the role of environmental heterogeneity as a key factor when exploring the consequences of individual genetic diversity on fitness in natural populations.Peer reviewe

Survival of Migrating Salmon Smolts in Large Rivers With and Without Dams

The mortality of salmon smolts during their migration out of freshwater and into the ocean has been difficult to measure. In the Columbia River, which has an extensive network of hydroelectric dams, the decline in abundance of adult salmon returning from the ocean since the late 1970s has been ascribed in large measure to the presence of the dams, although the completion of the hydropower system occurred at the same time as large-scale shifts in ocean climate, as measured by climate indices such as the Pacific Decadal Oscillation. We measured the survival of salmon smolts during their migration to sea using elements of the large-scale acoustic telemetry system, the Pacific Ocean Shelf Tracking (POST) array. Survival measurements using acoustic tags were comparable to those obtained independently using the Passive Integrated Transponder (PIT) tag system, which is operational at Columbia and Snake River dams. Because the technology underlying the POST array works in both freshwater and the ocean, it is therefore possible to extend the measurement of survival to large rivers lacking dams, such as the Fraser, and to also extend the measurement of survival to the lower Columbia River and estuary, where there are no dams. Of particular note, survival during the downstream migration of at least some endangered Columbia and Snake River Chinook and steelhead stocks appears to be as high or higher than that of the same species migrating out of the Fraser River in Canada, which lacks dams. Equally surprising, smolt survival during migration through the hydrosystem, when scaled by either the time or distance migrated, is higher than in the lower Columbia River and estuary where dams are absent. Our results raise important questions regarding the factors that are preventing the recovery of salmon stocks in the Columbia and the future health of stocks in the Fraser River