The effectiveness of skin care protocols for pressure ulcers

Pressure ulcers (PU) remain a serious healthcare problem in the United States. This study investigated the effectiveness of a prevention and early intervention program in reducing the prevalence of pressure ulcers (i.e., the number or the percentage of persons with pressure ulcers at a given time) in a rehabilitation hospital. The Braden Scale for Predicting Pressure Sore Risk was used to assess subjects' PU risk. Protocols were established for PU stages consistent with the National Pressure Ulcer Advisory Panel consensus statement on pressure ulcers. Staff were educated about PUs and the specific protocols for prevention and treatment. Concurrent quarterly prevalence audits on a total of 116 patients were conducted for 1 year. An audit also was done 16 months after protocols had been established. There was a 60% decrease in pressure ulcer prevalence from the 25% baseline to the 10% found at the audit following implementation of the protocols.     

Liver tumor ablation techniques

Decubitus ulcers are an important problem which must be known by health professionals in general and by nurses in particular. Its prevention is one of the basic care in Nursing. This care becomes especially relevant in patients who are admitted into Intensive Care Units. The objectives of the study are to know the incidence rate of patients who develop decubitus ulcers during their stay in the Unit and the proposal to introduce measures aiming to decrease its incidence. In general, the study proves that 17% of patients develop decubitus ulcers during their hospitalization and that 31.8% of patients who are catalogued as risk patients develop ulcers. The preventive measures introduced are the reassessment and application of prevention and treatment of decubitus ulcers protocols, the creation of improvement groups where these problems are approached, perfecting courses about decubitus ulcers, clinical sessions where strategies are unified, graphic divulging measures (notices, etc.) and antiscaric materials such as heelers, small cushions for head support, pillows, etc.     

Do multiple measurements employing different ultrasonic techniques improve the accuracy of amniotic fluid volume assessment?

BACKGROUND: To determine the results of standardized ulcer treatment regimes and effects of the oral thromboxane A2 antagonist Ifetroban (250 mg daily) on healing of chronic lower-extremity venous stasis ulcers. METHODS: In a prospective, randomized, double blind, placebo-controlled multicenter study, 165 patients were randomized to Ifetroban (n = 83) versus placebo (n = 82) for a period of 12 weeks. Both groups were treated with sustained graduated compression and hydrocolloid. Ulcer size was measured weekly by tracings and computerized planimetry. A total of 150 patients completed the study. RESULTS: Complete ulcer healing was achieved after 12 weeks in 55% of patients receiving Ifetroban and in 54% of those taking a placebo with no significant differences; 84% of ulcers in both groups achieved greater than 50% area reduction in size. CONCLUSIONS: These results are likely to be useful as a benchmark for comparison with other treatment protocols concerning the care of chronic lower-extremity stasis ulcers.     

Skin care strategies in a skilled nursing home

1. Pressure ulcers continue to be a serious problem in nursing home settings. They are significant as a source of discomfort and disability among nursing home residents, as well as a source of financial concern for the institutional agencies responsible for resident care. 2. Prevention and intervention at the earliest stages of pressure ulcer development offer the most effective approaches to mediating the human and economic costs imposed by pressure ulcers. 3. Strategies that are effective in reducing both the development and severity of pressure ulcers can be successfully implemented in long-term care settings. Further studies are needed that will provide additional support for the strategies and protocols used in this study.     

Efficacy of famotidine in the healing of active benign gastric ulceration: comparison of nonsteroidal anti-inflammatory- or aspirin-induced gastric ulcer and idiopathic gastric ulceration. Long Island Jewish Medical Center Acid-Peptic Study Group

Seventy-one of 85 consecutive patients with endoscopically confirmed active benign gastric ulcers completed an 8-week study to evaluate the effects on healing of famotidine 40 mg given as a single dose at night. The healing rate in the 48 patients in whom the ulcers were associated with nonsteroidal anti-inflammatory drug (NSAID) or aspirin (ASA) use was compared with that in the 23 patients with idiopathic ulcers. Endoscopy, symptom assessments, antacid use, hematology, and serum chemistry were performed at weeks 4 and 8 of treatment. Famotidine 40 mg at bedtime healed 63 (89%) of the 71 ulcers at 8 weeks; the healing rate for NSAID/ASA-associated ulcers was 46 (96%) of 48, which was significantly greater than that for idiopathic ulcers (17 of 23; 74%) (P = 0.0119). Of the 54 patients who returned a questionnaire 1 to 2 years after completing the study, 20% were still taking an NSAID/ASA (mainly for cardiovascular prophylaxis). About half of the patients surveyed were taking anti-ulcer medication. None of these patients had experienced any serious ulcer complication. The results of this study suggest that differentiating NSAID/ASA-induced ulcers from idiopathic ulcers may be important with regard to healing rates and duration of therapy.     

Ulcus cruris--vascular etiology and surgical treatment options

Leg ulcers comprise a problem with various contributing factors requiring selective therapy adapted to the underlying cause. The majority can be classified as arterial (approx. 20%) or venous (approx. 80%) ulcers. Arterial ulcers as well as most mixed (arterial-venous) ulcers can be treated by arterial reconstruction and subsequent skin grafting, with additional ligation of perforator veins or (segmental) stripping of the saphenous vein. Leg ulcers due to chronic insufficiency of the deep venous system are most often the result of previous deep venous thrombosis followed by recanalization and development of a postthrombotic syndrome. Compression regimens remain standard therapy with emphasis on preventing ulcer formation. Ulcer healing can be achieved by compression therapy although recurrence rates are high. Surgery is not the treatment of first choice for leg ulcers, however, in selected cases surgical therapy is indicated. To prevent recurrence, continued consistent compression, keeping the patient well-informed and offering supportive guidance are imperative.     

Effect of pressure ulcers on the survival of long-term care residents

BACKGROUND: Past studies have emphasized that patients with pressure ulcers are at high risk of dying. However, it remains unclear whether this increased risk is related to the ulcer or to coexisting conditions. In this study we examined the independent effect of pressure ulcers on the survival of long-term care residents. METHODS: We evaluated all 19,981 long-term care residents institutionalized in Department of Veterans Affairs (VA) long-term care facilities as of April 1, 1993. Baseline resident characteristics and survival status were obtained by merging data from five existing VA data bases. Survival experience over a 6-month period was described using a proportional hazards model. RESULTS: Pressure ulcers were present in 1,539 (7.7%) long-term care residents. Residents with pressure ulcers had a relative risk of 2.37 (95% CI = 2.13, 2.64) for dying as compared to those without ulcers. After adjusting for 16 other measures of clinical and functional status, the relative risk associated with pressure ulcers decreased to 1.45 (95% CI = 1.30, 1.65). No increased risk of death was noted for residents with deeper ulcers. CONCLUSIONS: Pressure ulcers are a significant marker for long-term care residents at risk of dying. After adjusting for clinical and functional status, however, the independent risk associated with pressure ulcers declines considerably. The fact that larger ulcers are not associated with greater risk suggests that other unmeasured clinical conditions may also be contributing to the increased mortality associated with pressure ulcers.     

Rhythmic external compression of the limbs: a method for healing cutaneous ulcers in systemic sclerosis

OBJECTIVE: To evaluate the usefulness of rhythmic external compression (REC) of the limbs on the healing of ischemic cutaneous ulcers in systemic sclerosis (SSc). METHODS: A prospective study analyzing 17 patients with SSc with symptomatic ischemic cutaneous ulcers in the limbs of more than 4 weeks' duration, who submitted to 20 sessions of REC, each session of one hour duration, 3 times a week. Patients were assessed at study entry, at the end of REC sessions, and at 30, 60, and 90 days after treatment. We also conducted a retrospective analysis of the outcome of ischemic vascular ulcers in a group of 20 patients with SSc who did not undergo REC. RESULTS: Twenty-eight ischemic vascular ulcers were submitted to REC. There was complete healing of 20 ulcers (71%) at the end of REC sessions. The healing was statistically more frequent in the distal ulcers (fingers and toes) (p = 0.0289), independent of SSc variant. There was a statistically significant correlation between pain resolution until the 15th session of REC and future ulcer healing (p < 0.0001). At followup, there were relapses in 2 ulcers 30 days after treatment. In the 20 patients with SSc who did not undergo REC, at followup, after 90 days of conventional treatment, there was healing of 7 ulcers (35%). CONCLUSION: REC could represent a therapeutic option in the treatment of ischemic cutaneous ulcers in SSc.     

Ulcer location in the stomach and pylorantral hypertrophy: problem of correlation of the ulcer location and wall hypertrophy in ulcus ventriculi

Relationship between gastric ulcer (n = 100) site and antropyloric wall hypertrophy was examined in a prospective study. Irrespective of ulcer multiplicity most ulcers were found to be located at the lesser curvature and at the posterior wall (p less than 0,001); men had significantly more ulcers at the posterior wall than females (p less than 0, 001). Single ulcers and those connected with pyloric stenosis were more distant to the pylorus than multiple ulcers (p less than 0,001). Ulcer location did not relate to hypertrophy of the pyloric channel wall. Observed differences between single and multiple ulcers were limited to wall parts only: the musculature of high located single ulcers was significantly less hypertrophied 2,5 cm orally of the pylorus (p less than 0,02) and that of high multiple ulcers was more hypertrophied at the pylorus (p less than 0,02) than in the other parts. These findings suggest that ulcer variations do not influence the diffuse antropyloric disease in gastric ulcer patients and suggest that the generalized antral changes are prior to gastric ulcer occurance.     

Pressure ulcer prevalence and incidence in a rehabilitation hospital

Pressure ulcers remain a serious health problem, especially in terms of personal suffering and economics. The study described here, conducted in a rehabilitation setting, investigated the prevalence (number of persons with pressure ulcers at a given time) and the incidence (number of persons developing pressure ulcers over a given time) of pressure ulcers. Skin assessments and risk assessments of the subjects were completed using the Braden Scale for Predicting Pressure Sore Risk. Demographic data were obtained. The prevalence rate was 25%, although there was no incidence during the time of this study. Factors associated with the prevalence of pressure ulcers are discussed.     

Surgery for asymptomatic carotid stenosis: a study of three patient subgroups

Increasing evidence suggests that non-steroidal anti-inflammatory drugs (NSAID) differ in gastrotoxicity. This study aimed to compare the effects of a short-acting NSAID, tiaprofenic acid, with indomethacin on experimental gastric ulcer healing in a rat model. Similar anti-inflammatory and prostaglandin-inhibitory doses of indomethacin (1 mg/kg) and tiaprofenic acid (2 mg/kg) were administered to rats with acetic acid-induced ulcers. After 2 weeks treatment, rats were killed and ulcer size determined. In addition, histological sections of ulcers were assessed for ulcer contraction and mucosal regeneration. The degree of inhibition of prostaglandin E2 (PGE2) synthesis was 72% at 2 h after tiaprofenic acid and 64% at 2 h after indomethacin administration, respectively. Rats treated with indomethacin for 2 weeks had significantly larger ulcers, both macroscopically and microscopically, than controls. Rats treated with tiaprofenic acid for 2 weeks had ulcers of a similar size to those of controls. Indomethacin-treated ulcers showed a failure in mucosal regeneration. Tiaprofenic acid-treated ulcers had significantly more regeneration than indomethacin-treated ulcers. We conclude that tiaprofenic acid inhibits mucosal prostaglandin levels but does not inhibit experimental gastric ulcer healing. These findings suggest that inhibition of PGE2 synthesis is not the only factor in generating gastrotoxicity and that a shift to low gastrotoxic NSAID may be clinically worthwhile.     

Pemphigus vulgaris on an old surgical scar: Koebner''s phenomenon?

BACKGROUND: The relationship between deep and superficial venous reflux and healing of venous ulceration by non-operative compression therapy has not been studied previously. METHODS: A total of 155 patients with chronic venous ulcers underwent duplex ultrasonography before treatment with compression bandaging at a hospital-based venous clinic. RESULTS: At 24 weeks, 104 (67 per cent) of ulcers had healed. There was no significant difference in the pattern of either deep or superficial venous reflux between healed and non-healed ulcers except with respect to the popliteal vein. In healed ulcers, 39 scans (38 per cent) indicated competence of the above-knee popliteal vein compared with five (10 per cent) in the non-healing group (P < 0.001, chi 2 test). Similarly, 43 scans (42 per cent) showed below-knee popliteal vein competence in the healed ulcers compared with only five (10 per cent) performed in legs remaining ulcerated (P < 0.001, chi 2 test). CONCLUSION: Popliteal vein incompetence is an indicator of poor response to compression therapy for venous ulceration.     

Setopress vs Elastocrepe in chronic venous ulceration

Venous ulceration is a major problem, particularly in the elderly population. It causes stress to the patient and treatment can be time-consuming. Compression therapy is considered to be the most appropriate non-invasive treatment of venous ulcers. It is generally accepted that composite bandage systems are most efficacious using a long-stretch or short-stretch bandage system. The study reported has compared a long-stretch bandage (Setopress) with a short-stretch bandage (Elastocrepe) over a 16-week period in the treatment of patients with venous ulceration. The trial was a prospective, randomized, observer-blind, parallel group study. Thirty-two patients (male and female) with a total of 39 ulcers completed the trial. After 15 weeks, 11 of 19 ulcers treated with the long-stretch bandage and 7 of 20 ulcers treated with the short-stretch bandage had healed. The differences were not statistically significant. After 15 weeks, the ulcer healing rate for the long-stretch bandage was 58% compared with 35% for the short-stretch bandage. The combined proportion of ulcers healed or improved was statistically significantly greater in the long-stretch bandage group.     

Isolation and structure elucidation of cirensenosides O and P from the leaves of Oplopanax elatus Nakai

Among 1470 patients over 65-year-old who were treated for various diseases, 50 had gastric ulcer and 10 had duodenal ulcer. About half the gastric ulcers were located in the body and fundus (n = 24, 48.0%). One third of the patients with gastric or duodenal ulcers had as their chief complaints hematemesis and hematochezia (n = 20, 33.3%), and a greater number had atypical gastrointestinal complaints (general malaise, fever etc, n = 25, 41.7%). In 10 patients (16.7%) the ulcers were due to non-steroidal anti-inflammatory drugs, in 5 (8.3%) they were due to steroid hormones, both of which had been given to treat other conditions; in 45 (75.0%) the origin of the ulcers was unknown. Complications of gastric and duodenal ulcers were hematemesis and hematochezia (n = 20, 33.3%), and perforation (n = 2, 3.3%). Duodenal ulcers tended to be severe, and were associated with death due to bleeding and peritonitis.     

Pressure ulcers in community-resident persons with spinal cord injury: prevalence and risk factors

The prevalence and correlates of pressure ulcers in terms of their number, severity, and anatomical location were studied in a community-based sample of 100 men and 40 women with spinal cord injury. Thirty-three percent (n = 46) presented with one or more ulcers of at least one stage I severity when visually examined. Twenty-one individuals had more than one ulcer, the maximum number of ulcers being seven. Of 87 ulcers for which severity ratings were available, 30 (34.5%) were stage I, 33 (37.9%) were stage II, and 24 (27.6%) were either stage III or IV. Individuals with an ulcer exhibited more paralysis and were more dependent on others in activities of daily living. A greater proportion of blacks had more severe ulcers (stages III and IV) than their white counterparts. Persons with more severe ulcers incurred their injury later in life, and had significantly lower mean scores on the Occupation and Mobility dimensions of the Craig Handicap Assessment and Reporting Technique. The findings suggest that factors governing initial development of a pressure ulcer differ in part from those responsible for an ulcer progressing in severity.     

Duodenal bicarbonate secretion: eradication of Helicobacter pylori and duodenal structure and function in humans

BACKGROUND & AIMS: Eradication of Helicobacter pylori expedites duodenal ulcer healing and prevents recurrences. Most patients with duodenal ulcers have impaired proximal duodenal mucosal bicarbonate secretion (DMBS). In patients with inactive, healed duodenal ulcers and normal subjects, the effect of H. pylori infection on DMBS and proximal duodenal secretory function and structure were examined. METHODS: DMBS was quantitated before and after eradication of H. pylori. Mucosal structure (duodenal bulb histopathology) and function (DMBS at rest and stimulated, effect of active vs. healed ulcer and of age) were determined in patients with duodenal ulcers and normal subjects. RESULTS: In patients with duodenal ulcers, H. pylori eradication normalized proximal DMBS. Histological examination of duodenal biopsy samples was comparable in patients with duodenal ulcers and normal subjects without apparent relationship between inflammation and DMBS. Significantly impaired DMBS occurred in response to all agonists tested (luminal acid, prostaglandin E2, and cephalic-vagal stimulation) in patients with duodenal ulcers, suggesting a generalized secretory defect. Neither the presence of active (vs.inactive) ulcer nor age significantly affected bicarbonate secretion. CONCLUSIONS: In patients with duodenal ulcers, eradication of H. pylori normalized proximal DMBS and may thereby reduce ulcer recurrences. Altered DMBS in patients with duodenal ulcers was unrelated to histopathologic abnormalities. Impaired bicarbonate secretion in patients with duodenal ulcers could be caused by a cellular and/or physiological regulatory transport defect possibly related to H. pylori.     

Occupational allergy in saffron workers

Decubital ulcers contribute to morbidity and mortality in elderly patients. Macrophages play a major role in the process of wound healing. We compared the efficacy of local treatment of decubital ulcers in elderly patients using macrophages prepared from a blood unit, vs. conventional treatments. Patients with decubital ulcers (n = 199) hospitalized during one year in a Geriatric Hospital in Israel, were included in the study. The ulcers of 72 patients (average age 82), who provided informed consent, by themselves or by family, were treated by local injection of macrophages prepared from a blood unit in a closed sterile system. The remaining 127 patients (average age 79) were treated conventionally and served as controls. No exclusion criteria were applied. Only a completely healed ulcer was considered a positive outcome of treatment. In the macrophage-treated group 27% (36 out of 131 ulcers) were healed compared to 6% (15 out of 248) in the control group (p < 0.001). There was also a significantly faster healing in the experimental group (p < 0.02). No side effects were noted. We conclude that Macrophages prepared from a blood unit, in cost-effective, closed, sterile system, are significantly more effective than conventional methods for the treatment of ulcers in elderly patients.     

Pinch grafting of leg ulcers in primary care

Treatment of chronic leg ulcers consumes considerable primary care resources. For the patient, it often entails restrictions in everyday life. This study describes the results of 84 skin transplantations on 45 patients with 55 ulcerated limbs, using the pinch graft technique, performed in primary care from 1987-1993. The healing rate after 12 weeks for venous ulcers was 45%, and for neuropathic ulcers 44%. Venous ulcers represented 56% of all the ulcers, while 16% were neuropathic. One year postoperatively, 47% (19/40) of examined ulcers remained healed. The results from our study suggest that venous and neuropathic ulcers may be particularly well suited for skin transplantation, which can easily be performed in primary care.     

Pain in venous leg ulcers

A prospective study was conducted to assess the prevalence, severity and diagnostic utility of pain in patients with venous leg ulcers. A semi-structured questionnaire was completed by 140 consecutive patients in two specialist centres caring for patients with leg ulcers. A high proportion (64%) of the 94 patients with ulcers of purely venous aetiology reported severe pain; 50% of these patients were taking either mild analgesia or none at all. In 10 of 72 cases, leg elevation made the pain worse. Venous ulcers are painful. Pain in three distinct locations was reported by patients-within ulcers, around ulcers and elsewhere in the leg. The presence of severe pain does not necessarily indicate arterial disease or infection. Pain is, in general, inadequately controlled in these patients.