Pressure Ulcers Research Articles

Implementing the PURPOSE T pressure ulcer risk assessment tool into clinical practice.

The first intervention in pressure ulcer prevention is often the completion of a pressure ulcer risk assessment, which aims to identify a patient's level of risk of developing a pressure ulcer. Appropriate care planning should then follow. There are several pressure ulcer risk assessment tools that nurses can use in their clinical practice, but it has not always been clear which is the most effective. One of these tools - the PURPOSE T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) - has recently been recommended in national guidelines and is now considered to be the only tool with an up-to-date evidence base. This article examines some of the risk assessment tools used to assess pressure ulcer risk, as well as providing an overview of the PURPOSE T and explaining its significance in pressure ulcer prevention.

Resting energy expenditure during spinal cord injury rehabilitation and utility of fat-free mass-based energy prediction equations: a pilot study

Study designLongitudinal observational study. Measurements were undertaken between weeks 4–6 post-spinal cord injury (SCI), repeated at week 8 and every 4 weeks thereafter until week 20 or rehabilitation discharge, whichever occurred first.ObjectivesObserve variation in measured resting energy expenditure (REE) and body composition in males undergoing SCI rehabilitation, compare REE with SCI-specific prediction equations incorporating fat-free mass (FFM), and explore the prevalence of clinical factors that may influence individual REE.SettingSpinal Injuries Unit, Brisbane, Queensland, Australia.MethodsIndirect calorimetry was used to measure REE and bioimpedance spectroscopy to assess body composition. Four SCI-specific FFM-based REE and basal metabolic rate (BMR) prediction equations were compared to measured REE. A clinically significant change in REE was defined as +/− 10% difference from the week 4–6 measurement. Clinical factors that may affect REE variations were collected including infection, pressure injuries, autonomic dysreflexia, spasticity, and medications.ResultsFifteen people participated (mean age 35 ± 13 years, 67% paraplegic). There was no statistically significant change in mean REE, weight, or body composition, and the Chun and Nightingale BMR prediction equations performed best (rc > 0.8 at all time points). One-third of participants had >10% change in REE on 11 occasions, with clinical factors not consistently associated with the observed changes.ConclusionDuring SCI rehabilitation, mean REE, weight, and body composition remain unchanged, and FFM-based BMR prediction equations may be an acceptable alternative to indirect calorimetry. Future research designs should avoid single indirect calorimetry measures as snapshot data may not represent typical REE in this population.

The pressure injury prevalence and practice improvements (PIPPI) study: A multiple methods evaluation of pressure injury prevention practices in an acute-care hospital.

Pressure injuries are a significant problem for immobile patients in acute care and can have a profound impact on patients' health and well-being, putting pressure on healthcare systems and strain on the healthcare economy. Nurses play a pivotal role in preventing pressure injuries. A study using multiple methods was conducted to explore pressure injury prevention practices in four inpatient units within a tertiary-level Australian Hospital. Quantitative and qualitative methods were used to gather data across a 9-month period. Observations, audits, surveys and interviews were used to collect data across five time points. Statistical analysis of the quantitative data was undertaken, and thematic analysis was used to analyse qualitative data. Data were integrated using a realist evaluation framework. Ethical approval for the study was granted. The quantitative results demonstrated significant reductions in pressure injury prevalence from 11.5% at commencement to 4.8% at completion of the study. Hospital-acquired pressure injuries also reduced from 4.6% to 1.9%. These results were achieved even though nursing knowledge and attitudes did not increase during the study period. Three qualitative themes were identified: Making Nursing Care Visible, Understanding the 'Why' and Engagement is Key. This study demonstrates that pressure injuries can be prevented with improvements in nursing care processes. Nurses' knowledge and attitudes towards pressure injury prevention did not change throughout this study and further research is required on how nurses' knowledge and attitudes contribute towards pressure injury prevention practices.

Topical hADSCs-HA Gel Promotes Skin Regeneration and Angiogenesis in Pressure Ulcers by Paracrine Activating PPARβ/δ Pathway.

Pressure ulcer is common in the bedridden elderly with high mortality and lack of effective treatment. In this study, human-adipose-derived-stem-cells-hyaluronic acid gel (hADSCs-HA gel) was developed and applied topically to treat pressure ulcers, of which efficacy and paracrine mechanisms were investigated through in vivo and in vitro experiments. Pressure ulcers were established on the backs of C57BL/6 mice and treated topically with hADSCs-HA gel, hADSCs, hyaluronic acid, and normal saline respectively. The rate of wound closure was observed continuously during the following 14 days and the wound samples were obtained for Western blot, histopathology, immunohistochemistry, and proteomic analysis. Human dermal fibroblasts (HDFs) and human venous endothelial cells (HUVECs) under normal or hypoxic conditions were treated with conditioned medium of human ADSCs (ADSC-CM), then CCK-8, scratch test, tube formation, and Western blot were conducted to evaluate the paracrine effects of hADSCs and to explore the underlying mechanism. The in vivo data demonstrated that hADSCs-HA gel significantly accelerated the healing of pressure ulcers by enhancing collagen expression, angiogenesis, and skin proliferation. The in vitro data revealed that hADSCs strengthened the proliferation and wound healing capabilities of HDFs and HUVECs, meanwhile promoted collagen secretion and tube formation through paracrine mode. ADSC-CM was also proved to exert protective effects on hypoxic HDFs and HUVECs. Besides, the results of proteomic analysis and Western blot elucidated that lipid metabolism and PPARβ/δ pathway mediated the healing effect of hADSCs-HA gel on pressure ulcers. Our research showed that topical application of hADSCs-HA gel played an important role in dermal regeneration and angiogenesis. Therefore, hADSCs-HA gel exhibited the potential as a novel stem-cell-based therapeutic strategy of treating pressure ulcers in clinical practices.

Risk factors and characteristics of intraoperative pressure injuries caused by medical devices and adhesives: A case-control retrospective study

Background: Undesirable injuries during the intraoperative period, such as pressure injuries caused by improper positioning, medical devices, or adhesive tapes, can lead to patient harm and decreased satisfaction. This study aims to identify the risk factors of pressure injuries during the intraoperative period and the characteristics of these injuries. Methods: A retrospective case-control study was conducted at King Khaled University Hospital in Riyadh, Saudi Arabia. Data were collected from the hospital incident reporting system and electronic medical records for incidents reported from January 1, 2022 to December 31, 2022. Inclusion criteria consisted of all patients with a reported pressure injury, including pressure ulcers, medical adhesive-related skin injuries, or medical device-related pressure injuries, occurring at least once during surgery. Results: Among the 113 patients, 57 (50.44%) had intraoperative pressure injuries (cases), while 56 (49.56%) did not (controls). The most common locations for pressure injuries were the lips (33.33%). Most of these injuries were classified as Medical Adhesive-Related Skin Injury (61.40%). Stage 1 injuries were observed in 47 cases (82.46%), while Stage 2 injuries were observed in 10 cases (17.54%). Duration of surgery and device tightness were identified as significant risk factors (P < 0.001). Conclusion: This case-control study identified the duration of surgery and device tightness as significant risk factors for intraoperative pressure injuries. The findings emphasize the importance of implementing evidence-based prevention strategies. Healthcare professionals should prioritize staff education and training, while future research should focus on conducting prospective, multicenter studies and developing risk assessment tools and innovative medical devices.

How does the training given to intensive care nurses affect their attitudes toward preventing pressure ulcers?

ObjectiveThe study aimed to determine the effect of training in the prevention/treatment of pressure ulcers on nurses' attitudes. Material methodThe study was conducted experimentally in a pretest-posttest design. Training was given to nurses participating in the study with content prepared by "Wound and Ostomy Incontinence Nurses Association" guide. The study was conducted between August and October with nurses working in Level 3 intensive care units. The study was completed with 79 nurses. Before the training was given, the "Nurse Introduction Form" and " Attitude Towards Pressure Ulcer Prevention Instrument (ATPUPI)" form were applied to those. All nurses were re-administered the ATPUPI scale three months after the training to evaluate their attitudes. Frequency analysis, descriptive statistics, one-way ANOVA, and independent sample tests were used in statistical analyses. ResultsThe mean age of the nurses was 29.62 ± 5.74 years, the mean length of service was 71.77 ± 77.19 months, 94.9 % were graduates, and 82.3 % worked in shifts. The mean scores before the training were 44.53 ± 4.13 and 45.12 ± 2.53 after the training. It was determined that there was a significant difference between the nurses who did not receive training on pressure ulcers other than undergraduate education and those who obtained training in terms of the mean score of ATPUPI. Still, after the training, the mean scores reached a similar level, and this difference disappeared. The increase in the mean scores of those who did not receive any education other than undergraduate education was found to be statistically significant. ConclusionAs a result of our study, intensive care nurses' attitudes toward preventing pressure ulcers were found to be at a high level. It was found that the training given to nurses who had not received training on pressure ulcers other than undergraduate education had a significant positive effect on their attitudes. According to this result, it is recommended that in-service training should be given from the moment they start intensive care and repeated at regular intervals to ensure continuity in knowledge, attitude, and care behavior.

A randomised controlled phase II trial to examine the feasibility of using hyper-oxygenated fatty acids (HOFA) to prevent facial pressure injuries from medical devices among adults admitted to intensive care-A research protocol.

One in three patients admitted to intensive care will sustain a pressure injury (PI) from a medical device. These injuries are painful and when on the face, head or neck they can result in permanent disfigurement. Preliminary evidence of the efficacy of hyper-oxygenated fatty acids (HOFAs) to prevent facial pressure injuries from medical devices is promising; however, the feasibility of incorporating HOFAs into current standard care to prevent PI from a medical device of the face, head and neck has not been extensively explored. It is intended that the findings from this phase II feasibility study will inform the design of a larger phase III trial, by addressing two primary aims: (1) to assess the feasibility of incorporating HOFAs into standard care to prevent device-related pressure ulcers of the skin associated with the face, head and neck assess the feasibility and (2) efficacy preliminary effectiveness of HOFA. This feasibility study is an investigator-initiated mixed method study incorporating a multi-centre randomised controlled trial of using HOFAs as an adjunct to standard pressure injury prevention and care, compared with standard care alone to prevent facial, head or neck from medical devices among adults admitted to intensive care. The primary outcome of interest is the incidence of facial, head or neck pressure injuries during the first 14 days in intensive care. Secondary outcomes include PI staging, medical device exposure and intensive care and hospital outcomes. The primary analysis will be undertaken using Cox's Proportional Hazards model, and due to the exploratory nature of this phase II trial, efficacy will be based on a one-sided p-value for superiority set at 0.10. Type I and Type II error rates are set at 20%; therefore, a total sample size of 196 study participants is planned. To explore the feasibility of incorporating HOFA into usual care and to design a larger phase III trial, we will aim to interview between 10 and 20 nurses across participating intensive care unit sites. Pressure injuries of the face, head or neck from medical devices, among adults admitted to intensive care, are considered preventable. This phase II study will investigate the feasibility and efficacy of HOFAs as an adjunct to standard care. Importantly, we aim to inform the development of a larger phase III trial.

Effects of sound on bluff body aerodynamic characteristics in separated and reattaching flows

The coupling effects between sound and flow on the aerodynamic characteristics of bluff bodies are commonly encountered in engineering practices, such as wind turbine blades and heat exchanger compressors. This study experimentally investigates the effects of sound over a broad range of frequencies (0–400 Hz) and sound pressure levels (80–105 dB) on the streamwise wind pressures on a flat plate in both smooth and turbulent flows. Spectral analysis and proper orthogonal decomposition (POD) are employed to explore the effects of sound on the aerodynamic forces acting on the flat plate. The results show that the effects of sound on wind pressure distributions and separation bubble behaviors over the flat plate depend on both sound frequency and sound pressure level. Furthermore, the findings highlight the role of acoustic resonance, which can increase the fluctuating wind pressure on the plate surface by over 400%. These effects can also be influenced by sound pressure levels. Additionally, the results demonstrate varying degrees and forms of attenuation of sound effects in turbulent flows, depending on the wind flow characteristics.

Antimicrobial resistance profiles of and associated risk factors for Pseudomonas aeruginosa nosocomial infection among patients at two tertiary healthcare facilities in Lusaka and Copperbelt Provinces, Zambia.

Antimicrobial resistance (AMR) of pathogens such as Pseudomonas aeruginosa is among the top 10 threats to global health. However, clinical and molecular data are scarce in Zambia. We, therefore, evaluated the AMR profiles of P. aeruginosa nosocomial infections (NIs). A year-long hospital-based cross-sectional study was conducted at two large tertiary-level hospitals in Zambia. Patients with current or previous hospital contact were screened for NIs. The current study focused on patients diagnosed with P. aeruginosa NIs. Clinical specimens were collected for bacteriological culture, and PCR amplification of 16S rRNA gene fragments was performed on pure isolates. Hospital or NIs were defined as infections that arise during hospitalization, occurring at least 48 h after admission. The Kirby-Bauer's disk diffusion method was used to evaluate antibiotic resistance patterns. The association between AMR and risk factors was analysed using the χ2 test. Eight hundred and forty-one patients were screened, and clinical specimens were collected and analysed. Of them, 116 (13.7%) were diagnosed with P. aeruginosa NIs. The participants' ages ranged from 15 to 98 years, with a mean of 51 (SD ± 18). Catheter-associated urinary tract infections (57%) were the most common, followed by pressure sores (38.7%). P. aeruginosa isolates were primarily susceptible to amikacin, which had the highest resistance to FEP. We observed a high prevalence of multidrug resistance (73.6%). The AMR was associated with carbapenem-hydrolysing β-lactamase gene blaOXA-51 and surgical care. This study has demonstrated that multidrug-resistant P. aeruginosa is prevalent in hospitals in Zambia's Lusaka and Ndola districts and possibly countrywide.

A preventive care approach for oral health in nursing homes: a qualitative study of healthcare workers’ experiences

BackgroundOral health problems are common among care-dependent older adults living in nursing homes. Developing strategies to prevent the deterioration of oral health is therefore crucial to avoid pain and tooth loss. A standardized work widely used in nursing homes in Sweden is the quality register Senior Alert (SA), which assesses age-related risks concerning e.g. pressure sores, falls, malnutrition and oral health. The oral health assessment is performed with the Revised Oral Assessment Guide-Jönköping (ROAG-J), which also includes planning and implementation of preventive oral care interventions with the goal of achieving good quality care. However, what facilitates and hinders healthcare workers in working with oral health in SA remains unexplored. The aim of this study was to describe healthcare workers’ experiences of assessing oral health with the ROAG-J, planning and performing preventive oral health care actions in accordance with SA in nursing homes.MethodsHealthcare workers (n = 28) in nursing homes in two Swedish municipalities participated and data was collected through six focus group interviews. Reflexive thematic analysis was used to identify patterns of meaning in the data.ResultsThemes generated in the analysis were:A structured process promotes communication and awareness and stresses the importance of oral health;Oral care for frail older adults is challenging and triggers ethical dilemmas;Unclear responsibilities, roles and routines in the organization put oral health at risk;Differences in experience and competence among healthcare staff call for educational efforts.ConclusionsThe structured way of working increases staff awareness and prioritization of oral health in nursing homes. The main challenges for the healthcare workers were residents’ reluctance to participate in oral care activities and oral care being more complicated since most older adults today are dentate. Organizational challenges lay in creating good routines and clarifying staff roles and responsibilities, which will require continuous staff training and increased management involvement.

Pressure ulcers and frailty: A inseparable couple

Pressure ulcers and frailty: A inseparable couple

Introduction of a Novel Patient Safety Advisory: Evaluation of Perceived Information With a Modified QPP Questionnaire-A Case-Control Study.

Adverse events (AEs) may result in serious injuries or death. AEs occur in approximately 9.2% of hospitalizations, with a potential preventability of 43.5%. The aim of this study was to examine whether use of an illustrated patient safety advisory affected information transfer to inpatients regarding how they can participate in their own care to decrease the risk of AEs. All patients in the control (n = 129) and case/intervention (n = 511) groups received verbal information from healthcare personnel. The intervention group also received the illustrated patient safety advisory, "Your safety at the hospital." Before discharge, patients completed the Quality from the Patient's Perspective questionnaire. Mean patient age was 64.6/62.4 years in the intervention/control group, respectively, and 50% were men. Significant differences between groups were observed for most questions presented from the perceived reality of care perspective, in favor to the intervention group. Patients at surgical wards indicated higher scores on 9 of 12 Quality from the Patient's Perspective questions. Patients with hospital stays ≥4 days, at surgical wards, and living with someone else, placed higher subjective importance to questions concerning, e.g., protection/infection, nutrition, risk of falls and pressure ulcers, and discharge information. Using an illustrated patient safety advisory to complement oral information about patient safety risks resulted in positive responses and a significant difference was demonstrated in how information is perceived. The safety advisory could be used as a tool to decrease AEs. Patients who live alone may need more focused patient safety information to encourage involvement in their own care.

Association between pressure ulcer and lenght of stay in acute and transition care centers

Association between pressure ulcer and lenght of stay in acute and transition care centers

Hospital-acquired pressure ulcers among adult ICU patients in tertiary hospitals in Oman: a one-year prevalence study.

Hospital-acquired pressure ulcer (HAPU) is a significant problem in healthcare settings and is associated with negative impacts on patient health. Although monitoring of pressure ulcers (PUs) among hospitalised patients was started more than a decade ago in Oman, no previous studies have been completed to estimate the prevalence and risk factors of HAPUs among patients in the intensive care unit (ICU). The aim of this study was to estimate the prevalence and identify risk factors for HAPUs among adult ICU patients in selected tertiary hospitals in Oman. A retrospective, cross-sectional, nested, case-control design was used to identify the prevalence rate of HAPUs and risk factors for a cohort of adult ICU patients over one calendar year (1 January-31 December 2019) in two tertiary hospitals in Oman. The prevalence rate for HAPU among ICU patients in Oman was 36.4%. However, when excluding cases of stage 1 ulcer, the rate was 30.37%. The most prevalent location was the sacrum (64.1%), and the most common stage was stage 2 (73.1%). The risk factors for HAPU included male sex (odds ratio (OR): 0.37; p=0.023), organ failure (OR: 3.2; p=0.033), cancer (OR: 3.41; p=0.049), cerebrovascular accident (OR: 12.33; p=0.001), mechanical ventilator (OR: 9.64; p=0.025) and ICU length of stay (OR: 1.24; p<0.001). HAPUs among ICU patients constitute a significant problem associated with severe clinical consequences and result in substantial adverse healthcare outcomes worldwide, including in Oman. Identifying the risk factors and the impact on the healthcare system is the foundation for preventing and managing HAPUs.

Experimental study on vortex-induced vibrations of double-hanger cable: Upstream wake flow induces downstream vibrations

This study is inspired by an experimental observation for vortex-induced vibrations (VIVs) of a double-hanger cable system, in which a smaller vibration of the downwind hanger cable is re-excited over a narrow range of wind speeds beyond the “lock-in” range. This phenomenon is known as the wake vortex-induced vibrations (WVIVs), where the upstream wake flow induces downstream vibrations. To further investigate the characteristics and reasons for WVIVs, a refined wind tunnel test of double-hanger cable was conducted to consider the influence of aerodynamic interaction. The double-hanger cable was modeled by the tandem-arranged spring-mounted cylinders vibrating in two dimensions. The vibration responses of hanger cables were obtained under various wind speeds to reproduce the lock-in phenomenon. In addition, the vibration trajectory, phase relationship, damping ratio, inter-cable correlation, and the wind pressure on the surface of cables were analyzed. Finally, the Stockbridge dampers were designed to suppress the vibrations. The results show that under the aerodynamic interaction of the cables, the onset wind speed of VIVs in the double cables increases, and the downstream cable WVIVs closely follow the VIVs. During the WVIV phase, the downstream cable behavior is characterized by increased negative aerodynamic damping and an inverse displacement correlation between the cables. The phase relationships between the cables are time-varying due to the aerodynamic interaction. The first proper orthogonal decomposition mode of wind pressure dominates the cross-wind of motions and is crucial in vibrations. Stockbridge dampers can effectively reduce the amplitude of VIVs and eliminate WVIVs in cables.

Intensive care nurses' knowledge and practices regarding medical device-related pressure injuries: A descriptive cross-sectional study.

This study aims to determine the levels of knowledge and practices of intensive care nurses regarding medical device-related pressure injuries (MDRPIs). This descriptive cross-sectional study was carried out between September 2023 and February 2024, involving 143 nurses working in intensive care units across three hospitals in Türkiye. The data were collected using the demographic form and the Medical Device-related Pressure Injuries Knowledge and Practice Assessment Tool (MDPI-ASSET). Of the nurses, 74.1% have encountered MDRPIs in their unit, 63.6% feel that their knowledge about MDRPIs is insufficient and 90.2% express a desire to receive training about MDRPIs. The participants' total mean MDPI-ASSET score was 11.12 (out of 21). The nurses achieved the highest mean score on the Aetiology/risk factors sub-scale and the lowest mean score on the Staging sub-scale. The analysis revealed significant differences in the mean MDPI-ASSET total scores among nurses based on the status of previous encounters with MDRPIs (t = 2.342; p = 0.021) and their feelings of responsibility for the development of MDRPIs (t = -2.746; p = 0.007). In this study, the knowledge and practices of intensive care nurses regarding medical device-induced pressure injuries were found to be inadequate. Given the frequent occurrence of MDRPIs in intensive care units, it is necessary to support nurses with continuous organizational-level training to improve the quality of care for critically ill patients.

Defects in Value Associated With Hospital-Acquired Conditions: How Improving Quality Could Save U.S. Healthcare $50 Billion.

Hospital-acquired conditions in the United States are considered avoidable complications but remain common statistics reflecting on health system performance and are a leading cause of patient fatality. Currently, over 3.7 million patients experience a hospital-acquired condition in the United States each year, which costs the U.S. healthcare delivery system an excess of $48 billion. Evidence-based clinical practice guidelines for common hospital-acquired conditions (e.g., infections, falls, pressure injuries) to reduce risk to the patient. In each of these instances, preventing the outcome with these guidelines costs less than treating the outcome, in addition to keeping the patient safe from harm. By applying the framework of defects in value to hospital-acquired conditions, we estimate that U.S. health systems could avert this $48 billion in spending on treating harmful hospital-acquired conditions; more so, these systems of care could recuperate over $35 billion after investing proportionally in a system that delivers greater quality by preventing hospital-acquired conditions over treating them. Currently, the Centers for Medicare and Medicaid Services only withholds reimbursements for hospital-acquired conditions and penalizes health systems with high rates of these outcomes. However, payers do not offer any reward-based incentives for hospital-acquired condition prevention. A series of policy and health system solutions, including tracking of hospital-acquired condition rates in electronic health records, identifying centers of excellence at reducing rates of harm with the use of clinical practice guidelines, and rewarding them monetarily for reduced rates could create equal-sided risk and opportunity to engage health systems in improved performance.

A multifunctional electronic dressing with textile-like structure for wound pressure monitoring and treatment

In the treatment of infected wounds in bedridden or lying chair patients with mobility problems, improper wound care can lead to wound deterioration, prolong disease pain, increase treatment and care costs, and bring heavier psychological, physical, and economic burdens to patients. In the process of wound recovery, patients with mobility problems mainly face the comprehensive problems of poor air permeability, wound pressure could not be monitored, wound infection and slow healing. Therefore, in the process of wound care for such patients, it is imperative to develop a gas permeable dressing that can monitor the patient’s wound compression status in real time and promote wound healing. Here, we developed a textile-shaped gel dressing with pressure-responsive properties. Polydopamine (PDA)-silver coated calcium phosphate nanoparticles (CPNPs）and vascular endothelial growth factor (VEGF) were introduced into the gel to give the gel good antibacterial and therapeutic effects, while enhancing the pressure resistance of the gel to meet the needs of wound pressure monitoring. The textured gel morphology greatly improves the gas permeability of the gel and further improves the pressure sensitivity of the gel. This multifunctional textile-like gel dressing provides a new strategy for the development of treatment monitoring integrated dressing and has broad application prospects.

Decubital Candidiasis Mimicking Molluscum Contagiosum in an Unconscious Patient

ABSTRACT Decubital candidiasis is a rare type of candidiasis often found in bedridden patients. Unlike decubital ulcer, it is also characterized with pustules and papules along with erythema, erosions, and scales. This lesion usually develops in the posterior thorax, lumbosacral, and gluteal region. In this case report, a patient was referred to us with generalized papules that was initially thought to be molluscum contagiosum after being admitted to intensive care unit (ICU). Keywords: Decubital Candidiasis, Candidiasis Miliaria, Candidiasis, Bedridden, Molluscum Contagiosum

Geriatric Cases with Flexural Psoriasis Over the Natal Cleft May Need Special Precaution for Decubitus Ulcer Prevention

Geriatric Cases with Flexural Psoriasis Over the Natal Cleft May Need Special Precaution for Decubitus Ulcer Prevention