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

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

Background: Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability. Methods: We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367. Findings: Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications. Interpretation: Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management. Funding: The UK National Institute for Health Research Health Technology Assessment Programme

Barriers to Effective Cancer Pain Management: a Survey of Australian Family Caregivers

Cancer pain continues to be an important focus of health research and intervention development. The continuing shift of cancer care to the community increases the family caregiver's role in pain management and highlights the need to understand family experiences and also family barriers to effective pain management. This paper presents the findings of an Australian study exploring attitudinal barriers to effective pain management amongst 75 family caregivers of people with cancer attending an outpatient clinic. Approximately 75% of the caregivers demonstrated concerns or were unsure about addiction, a belief likely to impact on the use of prescribed opioids in the home. Caregivers demonstrated similar levels of concern about side-effects or whether the presence of pain indicated disease progression. These findings support research in other populations and are further evidence of the need to include family caregivers, along with patients, in intervention studies aimed at reducing the impact of these barriers on effective pain management

Pain in Alzheimer's disease: comparison of nursing assistents' assessment with the patient's own evaluation

Aim. This paper reports on a study examining the level of agreement between the pain perceptions of nursing assistants, older people without dementia and patients with Alzheimer's dementia. It was hypothesized that nursing assistants would overestimate the pain experience of patients with Alzheimer's dementia. Background. There is now increasing evidence that, in contrast to other subtypes of dementia, patients with Alzheimer's disease might experience a decrease in pain. It is unfortunate that these latest insights into the complex relationship between subtypes of dementia and pain are not always included in education programmes for nursing assistants. Method. Twenty patients with Alzheimer's disease and 17 older people with arthrosis and/or osteoporosis but no dementia and their personal nursing assistants participated in the study. Pain experience was assessed using the Coloured Analogue Scale for the assessment of Pain Intensity and Pain Affect, the Faces Pain Scale, and the Checklist of Non-verbal Pain Indicators. The data were collected in 2002-2003. Results. Before and after walking, the absolute difference in pain evaluation between nursing assistants and older people without dementia was statistically significantly less than the difference in pain evaluation between nursing assistants and patients with Alzheimer's disease on the Coloured Analogue Scale for Pain Intensity ( P 0 007 and P 0 04, respectively) and on the Coloured Analogue Scale for Pain Affect ( P 0 009 and P 0 01, respectively). Conclusion. Nursing assistants may overestimate the extent of suffering from pain of patients with Alzheimer's disease. They might be very well able to estimate this pain, provided they were educated about new insights into the influence of the various subtypes of dementia on pain

Influence of diet lysine level on performance of finishing barrows and gilts

Swine Industry Day 1973 is known as Swine Day, 1973One hundred eighteen barrows and gilts were used to evaluate adding lysine to a 11.2% crude protein, milo-soybean meal ration. Rate of gain was significantly improved (P<.05) in both barrows and gilts receiving the higher dietary levels of lysine, but not feed efficiency. Loin-eye area of barrows receiving three levels of lysine was not affected, but loin-eye area of gilts was significantly improved by the addition of lysine to the diet. Carcass length, backfat thickness and ham and loin percentage were not improved in either barrows or gilts. Rate of gain, feed efficiency, and carcass parameters did not differ significantly for pigs fed .65 or .80% lysine

Lysine supplemented rations for boars, barrows and gilts

Swine Industry Day 1974 is known as Swine Day, 1974Feeding trials involving each sex (boars, barrows and gilts) of finishing-weight pigs were conducted to determine the value of adding lysine to the rations. Rations containing 0.55% lysine were adequate for performance (rate of gain and feed/gain ratio) and carcass parameters (loin eye area, backfat thickness, length, and percentage of lean cuts) in all sexes