Ulcer Stage Research Articles

A Prospective Study of Histopathological Changes of Lung, Liver, Kidney and Upper GI in Burns

Multiple organs are involved in causing mortality of burn patients. But most commonly lung, liver, kidney, upper GI are involved. Knowing these histopathological changes helps in determining the cause of death depending on the duration of survival. We carried out a study involving 50 autopsy cases of burns. Above organ samples collected, sent for histopathological examination and the reports were compared with the previous studies. It was noted that majority of lung specimens showed diffuse alveolar damage as the major histopathological change. The kidneys showed acute tubular necrosis in majority of specimens which is a common pathology behind acute renal failure in burn patients. The liver showed changes of hepatic necrosis, congestion, portal triaditis, fatty changes, cholestasis, cloudy swelling. The stomach and duodenum showed changes of superficial gastroduodenal ulcerations in the early stages of burns and Curling's ulcers in the later stages depending on the duration of survival. As there are less number of studies done in this regard, our study will throw some light on further research in the field of forensic pathology.

Expression of microRNA-106b and its clinical significance in cutaneous melanoma.

MicroRNA-106b (miR-106b) is overexpressed in various types of cancers and is associated with the regulation of carcinogenic processes. However, its clinical significance in cutaneous melanoma has not been reported. qRT-PCR was performed to examine the expression of miR-106b in 15 cases of dysplastic nevi, 17 cases of melanoma metastases, and 97 cases of primary cutaneous melanoma tissue samples. Survival rate was determined with Kaplan-Meier and statistically analyzed with the log-rank method between groups. Survival data were evaluated through multivariate Cox regression analysis. Significant differences in miR-106b expression were shown between dysplastic nevi and primary cutaneous melanomas (P < 0.01), between primary melanomas and metastatic cutaneous melanomas (P < 0.01), and between primary cutaneous melanomas and metastatic cutaneous melanomas (P < 0.001). We found that high miR-106b expression was correlated with Breslow thickness (P = 0.002), tumor ulceration (P = 0.002), and advanced clinical stage (P < 0.001). The patients with high miR-106b expression showed shorter 5-year overall survival than those with low miR-106b expression (P = 0.02; log-rank test). Multivariate regression analysis showed that the status of miR-106b expression was an independent prognostic factor for overall survival (HR = 2.09, 95%CI: 1.11-10.26, P = 0.02). This study showed that miR-106b may contribute to the progression of cutaneous melanoma and its up-regulation may be independently associated with poor prognosis of cutaneous melanoma. This suggests that miR-106b might serve as a promising biological marker for further risk stratification in the management of cutaneous melanoma.

Endoscopic and Clinical Features of Cytomegalovirus Colitis in Critically Ill Patients: A Retrospective Review

Background Patients with cytomegalovirus (CMV) colitis have increasingly been recognized among critically ill patients, yet few specific clinical and endoscopic features are known. In this study, we investigated the common clinical and endoscopic features of CMV colitis in critically ill patients. Methods From January 1, 2000 to February 28, 2014, patients with a histopathological diagnosis of CMV colitis were retrospectively reviewed. We reviewed and analyzed the clinical presentation, primary diseases, serum CMV antibody, treatment, mortality, and endoscopic features of these patients. Results Eighteen patients were diagnosed as having CMV colitis and 15 CMV colitis patients were included in this study. The mean age was 65.7 years (range 42–92 years). Bloody diarrhea and persistent diarrhea were the most common initial presentations of CMV, and sepsis was the most common comorbidity found. CMV-IgM was positive in three (17%) patients, and CMV-IgG was positive in 14 (93.3%) patients. All patients received ganciclovir and 11 patients clinically improved. Four (26.6%) patients died and two patients had colon perforation. According to the severity of the diseases, endoscopic presentation of CMV colitis ranged from colonic mucosa edema, loss of vasculature, subepithelial hemorrhage, and circular or geographic ulcers to perforation. Ten (66.7%) patients had multiple ulcers and five (33.3%) patients had a single ulcer. Eleven (73.3%) patients had colitis involving distal to splenic flexure, and four (26.6%) patients had colitis involving the whole colon. Conclusion Critically ill patients who present with bloody stool or persistent diarrhea should be considered for the diagnosis of CMV colitis. The endoscopic presentation of CMV colitis is highly variable. We suggest that the endoscopic manifestation of CMV colitis can be divided into three stages: nonulcerative inflammatory stage, simple ulcerative stage, and complicated ulcerative stage.

The Effect of Application Parameter of Pulsed Direct Current on Wound Healing of Patients with Pressure Ulcer

This study investigated the effects of changes to the pulsation factor of pulsed direct currents on wound healing. Patients with a pressure ulcer at a care hospital for the elderly were randomly divided into three groups: Group 1 involved the application of in pulse duration, 10 ms in pulse period, 100 pps in a pulsation factor, 15 mA in pulse amplitude, and polarity red+ by using pulsed direct currents; Group 2 involved a change of pulse period to 8 ms; and Group 3 received general wound management. Although there were no statistically significant differences in the changing stages of pressure ulcers among the groups, all the groups dropped in numerical stages. In the two groups to which pulsed direct currents were applied, there was a statistically significant reduction in the stages of pressure ulcers from the initial assessment to the 12-week assessment (p

A novel model of human skin pressure ulcers in mice.

IntroductionPressure ulcers are a prevalent health problem in today's society. The shortage of suitable animal models limits our understanding and our ability to develop new therapies. This study aims to report on the development of a novel and reproducible human skin pressure ulcer model in mice.Material and MethodsMale non-obese, diabetic, severe combined immunodeficiency mice (n = 22) were engrafted with human skin. A full-thickness skin graft was placed onto 4×3 cm wounds created on the dorsal skin of the mice. Two groups with permanent grafts were studied after 60 days. The control group (n = 6) was focused on the process of engraftment. Evaluations were conducted with photographic assessment, histological analysis and fluorescence in situ hybridization (FISH) techniques. The pressure ulcer group (n = 12) was created using a compression device. A pressure of 150 mmHg for 8 h, with a total of three cycles of compression-release was exerted. Evaluations were conducted with photographic assessment and histological analysis.ResultsSkin grafts in the control group took successfully, as shown by visual assessment, FISH techniques and histological analysis. Pressure ulcers in the second group showed full-thickness skin loss with damage and necrosis of all the epidermal and dermal layers (ulcer stage III) in all cases. Complete repair occurred after 40 days.ConclusionsAn inexpensive, reproducible human skin pressure ulcer model has been developed. This novel model will facilitate the development of new clinically relevant therapeutic strategies that can be tested directly on human skin.

Study of carotid disease in patients with peripheral artery disease.

To study the stenosis of the carotid arteries in patients with symptomatic peripheral arterial disease. we assessed 100 consecutive patients with symptomatic peripheral arterial disease in stages of intermittent claudication, rest pain or ulceration. Carotid stenosis was studied by echo-color-doppler, and considered significant when greater than or equal to 50%. We used univariate analysis to select potential predictors of carotid stenosis, later taken to multivariate analysis. The prevalence of carotid stenosis was 84%, being significant in 40% and severe in 17%. The age range was 43-89 years (mean 69.78). Regarding gender, 61% were male and 39% female. Half of the patients had claudication and half had critical ischemia. Regarding risk factors, 86% of patients had hypertension, 66% exposure to smoke, 47% diabetes, 65% dyslipidemia, 24% coronary artery disease, 16% renal failure and 60% had family history of cardiovascular disease. In seven patients, there was a history of ischemic cerebrovascular symptoms in the carotid territory. The presence of cerebrovascular symptoms was statistically significant in influencing the degree of stenosis in the carotid arteries (p = 0.02 at overall assessment and p = 0.05 in the subgroups of significant and non-significant stenoses). the study of the carotid arteries by duplex scan examination is of paramount importance in the evaluation of patients with symptomatic peripheral arterial disease, and should be systematically conducted in the study of such patients.

A Nationwide Analysis of Postoperative Deep Vein Thrombosis and Pulmonary Embolism in Colon and Rectal Surgery

There are limited data regarding predictive factors of postoperative venous thromboembolism (VTE) in patients undergoing colorectal resection. We sought to identify associations between patient comorbidities and postoperative VTE in colorectal resection. The National Surgical Quality Improvement Program (NSQIP) database was used to examine clinical data of patients experiencing postoperative VTE after colorectal resection from 2005 to 2011. Multivariate analysis using logistic regression was performed to quantify risk factors of VTE. We sampled 116,029 patients undergoing colorectal resection. The rate of VTE was 2 % (2,278) with 0.2 % (182) having deep vein thrombosis (DVT) and pulmonary embolism (PE). The first week after operation was the most common time for postoperative VTE. A significant number of patients suffering DVT and PE were diagnosed after index hospital discharge (PE 34.6 %, DVT 29.3 %). The most important risk factors identified for DVT include (P < 0.05) ASA score >2 (adjusted odds ratio (AOR) 1.77) and hypoalbuminemia (serum albumin level <3.5 mg/dl) (AOR 1.69). The most important factors had associations with PE include (P < 0.05) DVT (AOR 14.60) and disseminated cancer (AOR 1.70). Ulcerative colitis (AOR 1.48, P = 0.01) and stage 4 cancer (AOR 1.29, P = 0.02) have associations with DVT. Open colorectal procedures have higher risk of DVT compared to laparoscopic procedures (AOR 1.33, P < 0.01). Postoperative VTE occurs in 2 % of colorectal resections. Thirty percent of VTE events were diagnosed after discharge. Prophylactic treatment of VTE after discharge may have benefits in high-risk patients. Thirteen and eleven perioperative risk factors have associations with DVT and PE, respectively. Emergent admission, open procedures, ulcerative colitis, and stage 4 cancer patients have increased risk of DVT.

Determinants of mortality among older adults with pressure ulcers

The presence of pressure ulcers imposes a huge burden on the older person's quality of life and significantly increases their risk of dying. The objective of this study was to determine patient characteristics associated with the presence of pressure ulcers and to evaluate the risk factors associated with mortality among older patients with pressure ulcers. A prospective observational study was performed between Oct 2012 and May 2013. Patients with preexisting pressure ulcers on admission and those with hospital acquired pressure ulcers were recruited into the study. Information on patient demographics, functional status, nutritional level, stages of pressure ulcer and their complications were obtained. Cox proportional hazard analysis was used to assess the risk of death in all patients. 76/684 (11.1%) patients had pre-existing pressure ulcers on admission and 30/684 (4.4%) developed pressure ulcers in hospital. There were 68 (66%) deaths by the end of the median follow-up period of 12 (IQR 2.5–14) weeks. Our Cox regression model revealed that nursing home residence (Hazard Ratio, HR=2.33, 95% confidence interval, CI=1.30, 4.17; p=0.005), infected deep pressure ulcers (HR=2.21, 95% CI=1.26, 3.87; p=0.006) and neutrophilia (HR=1.76; 95% CI 1.05, 2.94; p=0.031) were independent predictors of mortality in our elderly patients with pressure ulcers. The prevalence of pressure ulcers in our setting is comparable to previously reported figures in Europe and North America. Mortality in patients with pressure ulcer was high, and was predicted by institutionalization, concurrent infection and high neutrophil counts.

Informatics: International Classification of Diseases-10: Implications for Nursing

One of the biggest events to hit healthcare data in decades is the conversion of coded clinical data to the International Statistical Classification of Diseases and Related Health Problems: Tenth Revision, commonly referred to as ICD-10. The last change of this nature was in 1983 when Medicare implemented ICD-9 as part of the Inpatient Prospective Payment System (IPPS). Since that time, healthcare has advanced significantly and ICD-9 codes no longer represent the advances and complexities in care provided to patients; thus healthcare in the United States is expected to transition to ICD-10 on October 1, 2015.ICD-10 is intended to support the systematic recording, analysis, interpretation, and comparison of morbidity and mortality data from around the world (World Health Organization, 2011). There are two parts to ICD-10: ICD-10Clinical Modification (CM) and ICD-10- Procedure Coding System (PCS). Compared to ICD-9-CM with 14,000 codes, ICD-10-CM has 69,000 available codes to be used for diagnosis codes on all inpatient and outpatient accounts. In ICD-9-PCS there are approximately 3,000 codes; this will change with ICD-10-PCS to 72,000 available codes to be used only for inpatient procedural coding.ICD-10 will touch everything from registration and scheduling, to revenue cycle and payer contracts, information systems, and ultimately will be used to improve patient care and outcomes. The important and widespread uses of ICD-10 data make it critical to understand these new documentation requirements. As healthcare prepares for ICD-10 and the coding of data using an electronic platform, it is important to ask, What are the implications for nursing? Although the answer to this question is not easily found, this informatics column will shed light on the issue by providing a sample case and highlighting the role of nurse informaticists in this historical change in healthcare data. We will conclude that nursing's role in data collection and entry is important in the building of the ICD-10 database, and that the benefits to be achieved from this monumental effort are dependent on accurate documentation and coding.Sample Case: Pressure UlcerPressure ulcer was chosen as a sample case to examine in this column due to the costs incurred in treating pressure ulcers. It was also chosen based on the historical precedent whereby staging of pressure ulcers has been coded in ICD-9-CM from nursing charting/documentation (.Cfin.ters..fQr-MlfidLcare-&jyiadicai,d..S.er.v:ic.es.l[CMS3-& .N,ati.Q.n.aL.Cen.ter for Health ..Statistics LN.CHS.].,. 2.Q.Q.S).MethodThe following steps were used to identify nursing documentation needs for pressure ulcers related to ICD-10.1. Define pressure ulcers.2. Download the ICD-10-CM codes and identify all diagnoses related to pressure ulcers.3. Identify the data elements, i.e., the words used, in the pressure ulcer diagnoses in ICD-10-CM codes.4. Identify related data elements in the current electronic health record (EHR) nursing documentation on pressure ulcers.5. Perform a gap analysis between current EHR documentation by nurses on pressure ulcers and what is needed for nursing documentation in ICD-10-CM.6. Reconcile findings with other databases using nursing documentation on pressure ulcers in short-stay hospitals.7. Collaborate with health information management (HIM) to validate findings.8. Present findings to Chief Nursing Officers, as well as wound care nurses and physical therapists.9. Work with information technology EHR builders to build the data base related to ICD-10-CM that is needed for nurses to document in the EHR.10. Prepare educational materials for staff nurses regarding the changes in pressure ulcer documentation for ICD-10-CM.11. Pilot education materials among staff nurses, making adjustments as needed.12. Disseminate educational materials/offerings regarding nursing documentation of pressure ulcers related to ICD-10-CM. …

Teaching the fruits of pressure ulcer staging.

Accurate pressure ulcer staging is an important skill for nurses, physicians, physical therapists, and certified nursing assistants. Current education is based on the National Pressure Ulcer Advisory Panel's staging system. A review of the literature indicates variability in staging abilities of numerous healthcare providers. With this problem in mind, a new method of teaching pressure ulcer staging by visual analogy was developed. We used the current National Pressure Ulcer Advisory Panel definitions to create a training tool based on a visual analogy between the different pressure ulcer stages and common fruits and vegetables. Initial feedback from a western states wound care conference indicates successful integration of teaching into nursing practice. A poster was also presented at the annual 2011 Wound, Ostomy and Continence Nurse's National Conference. Positive feedback was received from numerous Wound, Ostomy and Continence Nurse's members who requested an electronic copy of the poster. Visual analogies can provide a method of teaching pressure ulcer staging across different disciplines with different levels of training involved in patient care.

A pilot study evaluating protein abundance in pressure ulcer fluid from people with and without spinal cord injury

ObjectiveTo determine whether the biochemistry of chronic pressure ulcers differs between patients with and without chronic spinal cord injury (SCI) through measurement and comparison of the concentration of wound fluid inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases.DesignSurvey.SettingTertiary spinal cord rehabilitation center and skilled nursing facilities.ParticipantsTwenty-nine subjects with SCI and nine subjects without SCI (>18 years) with at least one chronic pressure ulcer Stage II, III, or IV were enrolled.Outcome measuresTotal protein and 22 target analyte concentrations including inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases were quantified in the wound fluid and blood serum samples. Blood samples were tested for complete blood count, albumin, hemoglobin A1c, total iron binding capacity, iron, percent (%) saturation, C-reactive protein, and erythrocyte sedimentation rate.ResultsWound fluid concentrations were significantly different between subjects with SCI and subjects without SCI for total protein concentration and nine analytes, MMP-9, S100A12, S100A8, S100A9, FGF2, IL-1b, TIMP-1, TIMP-2, and TGF-b1. Subjects without SCI had higher values for all significantly different analytes measured in wound fluid except FGF2, TGF-b1, and wound fluid total protein. Subject-matched circulating levels of analytes and the standardized local concentration of the same proteins in the wound fluid were weakly or not correlated.ConclusionsThe biochemical profile of chronic pressure ulcers is different between SCI and non-SCI populations. These differences should be considered when selecting treatment options. Systemic blood serum properties may not represent the local wound environment.

Debridement with conjunctival flap covering for treatment of fungal corneal ulcer

Objective To evaluate the therapeutic outcome of debridement with conjunctival flap covering surgery for different degrees of fungal corneal ulcer.Methods A retrospective analysis was done on 26 eyes of 26 cases of fungal corneal ulcer.They had accepted debridement with conjunctival flap covering surgery.Results 15 eyes in the early stage of corneal ulcer were cured after one surgery.Six eyes recurred in the other 11 eyes with hypopyon recurred.Conclusion Debridement with conjunctival flap covering surgery is effective for early fungal corneal ulcer. Key words: Ulcer, corneal, fungal; Covering, flap, conjunctival; Debridement

Features of matrix metalloproteinase-2 expression in the nuclei of tumor cells of a skin melanoma

Goal of the study. To compare expression of matrix metalloproteinase-2 (MMP-2) in the nuclei and cytoplasm of tumor cells and assess the mutual relation between the localization of MMP-2 expression and different clinical and morphologic criteria in patients with a skin melanoma. Materials and methods. Tumor samples obtained from paraffin blocks taken from patients suffering from a skin melanoma and treated at the Krasnoyarsk Territorial Oncologic Dispensary served as the object of the study. Skin tissue samples taken from patients suffering from a skin melanoma (n = 44) were obtained from the Krasnoyarsk Territorial Pathological Anatomy Bureau. Immunohistochemistry was performed based on a standard technique using primary anti-matrix metalloproteinase-2 antibodies. Results. MMP-2 expression was revealed in the nuclei of tumor cells of a skin melanoma in 43.1% of cases and in the cytoplasm in 56.9% of cases. No significant differences in MMP-2 expression in the nuclei and cytoplasm were revealed (p = 0.33). Patients with nuclear expression in tumor cells are characterized by a more favorable prognosis than patients with cytoplasmic enzyme expression in tumor complexes. No dependence of the intracellular localization of MMP-2 expression on the patient sex or age, tumor localization, Clark level of invasion, Breslow’s thickness, particular features of tumor lymphocyte infiltration, tumor growth phase, histological subtype, pigmentation, tumor ulceration and tumor stage according to AJCC (American Joint Committee on Cancer) was revealed. Conclusion. MMP-2 located in the nuclei can be related to hypoxia in the tumor tissue as well as increased peroxynitrite level, which, in its turn, can have an effect on the function and regulation of matrix metalloproteinases. Moreover, MMP-2 with an atypical localization can be related to tumor cells with different biological characteristics within the same tumor, which characterize the intratumoral heterogeneity of neoplasms. The biological and clinical role of changes in the intracellular localization of the enzyme needs further explanation.

Buruli Ulcer Disease in Republic of the Congo

Buruli Ulcer Disease in Republic of the Congo

An image mining based approach to detect pressure ulcer stage

Treatment of pressure ulcers (PU) is essentially image dependent, because its surface provides relevant visual information for medical procedures. There is an increasing interest to adapt Information Technology advances for a more effective medical image processing. Artificial Intelligence concerned techniques, say Image Mining, can be very helpful to manage large amount of PU images in order to increase productivity of health professionals and patients life quality. This paper proposes an Image Mining based system for automatic interpretation of tissue and color to support the treatment of patients with PU.

Oral Treatment of Pressure Ulcers with Polaprezinc (Zinc L-carnosine Complex): 8-Week Open-Label Trial

Polaprezinc (zinc L-carnosine complex) is a tablet commonly prescribed for gastric ulcers in Japan. Recently, we reported the effects of polaprezinc on pressure ulcer healing at 4-week follow-up. We aimed to further evaluate the efficacy and safety of polaprezinc in 8-week treatment for chronic pressure ulcers. Patients with stage II-IV pressure ulcers for ≥ 8 weeks received 150 mg/day polaprezinc (containing 116 mg L-carnosine and 34 mg zinc) per os for a maximum of 8 weeks. We measured the severity of pressure ulcers weekly using the Pressure Ulcer Scale for Healing (PUSH) score and monitored blood biochemistry. Fourteen patients (nine men; 68.4 ± 11.8 years) were enrolled. Pressure ulcer stages were II (one patient; 7 %), III (nine; 64 %), and IV (four; 29 %). The PUSH score improved significantly from 8.1 [95 % CI, 6.0-10.3] at baseline to -1.4 [-4.0 to 1.1] after 8 weeks (P < 0.001). Differences from baseline were significant after 1 week (P < 0.05). The mean weekly improvement in PUSH score was 2.0. Eleven patients healed within 8 weeks and none dropped out. Serum zinc levels increased significantly (P < 0.001), whereas serum copper levels (P = 0.001) and copper/zinc ratios (P < 0.001) decreased significantly. In one patient, preexisting copper deficiency deteriorated. These preliminary data suggest that polaprezinc may be effective and well-tolerated in 8-week treatment of pressure ulcers and could be a candidate for their oral treatment.

Diagnosis and management of neurotrophic keratitis.

Neurotrophic keratitis (NK) is a degenerative disease characterized by corneal sensitivity reduction, spontaneous epithelium breakdown, and impairment of corneal healing. Several causes of NK, including herpetic keratitis, diabetes, and ophthalmic and neurosurgical procedures, share the common mechanism of trigeminal damage. Diagnosis of NK requires accurate investigation of clinical ocular and systemic history, complete eye examination, and assessment of corneal sensitivity. All diagnostic procedures to achieve correct diagnosis and classification of NK, including additional examinations such as in vivo confocal microscopy, are reviewed. NK can be classified according to severity of corneal damage, ie, epithelial alterations (stage 1), persistent epithelial defect (stage 2), and corneal ulcer (stage 3). Management of NK should be based on clinical severity, and aimed at promoting corneal healing and preventing progression of the disease to stromal melting and perforation. Concomitant ocular diseases, such as exposure keratitis, dry eye, and limbal stem cell deficiency, negatively influence the outcome of NK and should be treated. Currently, no specific medical treatment exists, and surgical approaches, such as amniotic membrane transplantation and conjunctival flap, are effective in preserving eye integrity, without ameliorating corneal sensitivity or visual function. This review describes experimental and clinical reports showing several novel and potential therapies for NK, including growth factors and metalloprotease inhibitors, as well as three ongoing Phase II clinical trials.

Pressure ulcer multidisciplinary teams via telemedicine: a pragmatic cluster randomized stepped wedge trial in long term care

BackgroundThe study was conducted to determine the clinical and cost effectiveness of enhanced multi-disciplinary teams (EMDTs) vs. ‘usual care’ for the treatment of pressure ulcers in long term care (LTC) facilities in Ontario, CanadaMethodsWe conducted a multi-method study: a pragmatic cluster randomized stepped-wedge trial, ethnographic observation and in-depth interviews, and an economic evaluation. Long term care facilities (clusters) were randomly allocated to start dates of the intervention. An advance practice nurse (APN) with expertise in skin and wound care visited intervention facilities to educate staff on pressure ulcer prevention and treatment, supported by an off-site hospital based expert multi-disciplinary wound care team via email, telephone, or video link as needed. The primary outcome was rate of reduction in pressure ulcer surface area (cm2/day) measured on before and after standard photographs by an assessor blinded to facility allocation. Secondary outcomes were time to healing, probability of healing, pressure ulcer incidence, pressure ulcer prevalence, wound pain, hospitalization, emergency department visits, utility, and cost.Results12 of 15 eligible LTC facilities were randomly selected to participate and randomized to start date of the intervention following the stepped wedge design. 137 residents with a total of 259 pressure ulcers (stage 2 or greater) were recruited over the 17 month study period. No statistically significant differences were found between control and intervention periods on any of the primary or secondary outcomes. The economic evaluation demonstrated a mean reduction in direct care costs of $650 per resident compared to ‘usual care’. The qualitative study suggested that onsite support by APN wound specialists was welcomed, and is responsible for reduced costs through discontinuation of expensive non evidence based treatments. Insufficient allocation of nursing home staff time to wound care may explain the lack of impact on healing.ConclusionEnhanced multi-disciplinary wound care teams were cost effective, with most benefit through cost reduction initiated by APNs, but did not improve the treatment of pressure ulcers in nursing homes. Policy makers should consider the potential yield of strengthening evidence based primary care within LTC facilities, through outreach by APNs.Trial registrationClinicalTrials.gov identifier NCT01232764

Effect of a tea tree oil and organic acid footbath solution on digital dermatitis in dairy cows

Copper sulfate is the industry gold standard footbath ingredient for controlling dairy cow digital dermatitis. However, when used footbath solutions are deposited on soil, high levels of copper in the soil may result, which can have toxic and negative effects on plant growth. An alternative to copper sulfate is Provita Hoofsure Endurance (Provita Eurotech Ltd., Omagh, UK), which is a biodegradable solution containing organic acids, tea tree oil, and wetting agents. The objective of this study was to quantify changes in digital dermatitis frequency when using Provita Hoofsure Endurance and copper sulfate in a split footbath in 3 commercial dairy herds. This study was conducted from January 5, 2012, to March 19, 2012, in 3 commercial Kentucky dairies with 120, 170, and 200 milking Holstein cows. None of the herds was using a footbath for digital dermatitis control before the study. Footbath solutions were delivered using a split footbath. During the study, a 3% Hoofsure Endurance solution for the left hooves and a 5% copper sulfate solution for the right hooves was used. Digital dermatitis was scored every 3wk using the M0 to M4 system, where M0=a claw free of signs of digital dermatitis; M1=a lesion <2cm that is not painful; M2=the ulcerative stage, with lesion diameter of >2cm, and painful to the touch; M3=the healing stage and covered by a scab; and M4=the chronic stage and characterized by dyskeratosis or proliferation of the surface that is generally not painful. McNemar’s test statistic suggested that a statistically significant difference existed in the proportions of M1 and M2 lesions between the beginning and end of the study for both treatments. This indicates that each solution was effective in decreasing the proportion of M1 or M2 lesions from baseline to the last time point. A chi-square test calculated using PROC FREQUENCY of SAS (SAS Institute Inc., Cary, NC) indicated that no statistically significant relationship existed between the treatments among changes in digital dermatitis frequency from the baseline to the end of the study. Performance of the 2 footbath solutions was comparable throughout the study. No significant differences were observed between the copper sulfate and Provita Hoofsure Endurance.

Peer-to-peer learning/teaching: An effective strategy for changing practice and preventing pressure ulcers in the surgical patient

Hospitals are increasingly focused on finding cost effective ways to ensure patient safety and enhance quality outcomes. Hospitalized patients are at increased risk for a variety of complications, one of the most common is the development of pressure ulcers. In 2008, the Center for Medicare and Medicaid services, the largest payer source for older adults in the US, began to withhold reimbursement to care facilities for pressure ulcers (Stage 3 or 4) that develop as a result of hospitalization. Staff nurses are ideally positioned to prevent the development of hospital acquired pressure ulcers (HAPUs); however, studies reveal several barriers including a knowledge deficit of causative factors, incorrect identification and staging of wounds, inaccurate use of risk assessment tools and an under utilization of evidence-supported prevention intervention strategies (Ilesanmi et al., 2012; Sievers et al., 2012). This paper examines a cost effective, innovate approach to address these barriers and reduce hospital acquired pressure ulcers using peer-to-peer learning/teaching with staff nurses.