Sacral interface pressure can be alleviated by repositioning with a small-angle change using an automated bed in patients with spinal cord injury

Aim of the studyThis study aimed to compare interface pressure and total contact area of the sacral region in different positions, including small-angle changes, in patients with spinal cord injury (SCI). Furthermore, we analyzed the clinical factors influencing pressure to identify the pressure injury (PI) high-risk group.Materials and methodsAn intervention was conducted for patients with paraplegia (n = 30) with SCI. In the first and second trials, interface pressure and total contact area of the sacral region were recorded from large- and small-angled positions using the automatic repositioning bed, which can change the angle of the back, lateral tilt, and knee.ResultsPositions with back raised ≥45° showed significantly higher pressure on the sacrum than most other positions. The pressure and contact area differences were statistically insignificant for combinations of small-angled changes <30°.Additionally, the duration of injury (β = 0.51, p = 0.010) and neurological level of injury (NLI) (β = −0.47, p = 0.020) were significant independent predictors of average pressure. Similarly, the duration of injury (β = 0.64, p = 0.001), the Korean version of the spinal cord independence measure-III (β = −0.52, p = 0.017), and body mass index (BMI; β = −0.34, p = 0.041) were significant independent predictors of peak pressure.ConclusionsFor repositioning, combinations of small-angle changes <30° effectively reduce pressure on the sacral region in patients with SCI. Lower BMI, longer duration of injury, lower functioning score, and NLI ≥ T7 are predictors of high sacral pressures, which increase the risk for PI. Therefore, patients with these predictors require strict management.     

The effect of head of bed elevation on sacral and heel subepidermal moisture in healthy adults: A randomised crossover study

BackgroundSubepidermal moisture (SEM) changes may detect early tissue injury and enhance pressure injury risk assessments. However, little is known how modifiable factors, like head of bed elevation (HOBE), affect SEM.AimThis study investigated the influence of HOBE on sacral and heel SEM, using the Provizio ® SEM Scanner.MethodA 2 × 2 randomised crossover study compared the effects of 30-min of 30? versus 60? HOBE on sacral and heel SEM in healthy adults.Results48 participants were randomly allocated to 30? or 60? HOBE and crossed over after a 60-min washout period. The mean age was 40.6 years (SD = 18.3). The study found the sacral and heel SEM values were not statistically different at 30? versus 60? HOBE. No clinically relevant association between SEM and characteristics of age, sex, body mass index and skin type were found. Baseline sacral and heel SEM values recovered after a 60-min washout period. Notably, half of the initial baseline measures suggested pressure injury risk.ConclusionThe HOBE may not influence SEM at the sacrum and heels, in healthy adults after 30 min of loading. Standard operating procedures for measuring SEM for pressure injury risk assessment require a stronger body of evidence in varied populations and timeframes before this technology is widely adopted.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12622001456741.     

Variations in sacral oedema levels over continuous 60-degree head of bed elevation positioning in healthy adults: An observational study

BackgroundSubepidermal moisture (SEM) scanning is a novel technology that measures changes in localised oedema. Accumulation of subepidermal oedema is associated with early tissue damage that may lead to a pressure injury.AimThe primary study objective was to observe the variations in sacral subepidermal oedema levels over a continuous period of 60-degree head of bed elevation positioning.MethodsHealthy adult participants were recruited in this prospective observational study. Participants were positioned at 60-degree head of bed elevation for 120 min and sacral SEM measurements were collected at baseline and in 20 min increments.ResultsA total of 20 participants with a mean age of 39.3 years (SD = 14.7) were recruited. The mean SEM delta value increased 6.3% from 0.46 SEM delta at baseline to 0.49 SEM delta after 120 min, however these differences are not statistically significant (p = .21). There were also no significant findings between SEM delta variations and demographic factors.ConclusionIn a sample of healthy individuals, 120 min of continuous loading with a 60-degree head of bed elevation did not lead to a significant change in sacral subepidermal oedema levels. Further research on the response of healthy adult tissue under external forces associated with different angles of head of bed positioning may further contribute to our understanding pressure injury prevention.     

Effects of cycle periods and pressure amplitudes of alternating pressure on sacral skin blood flow responses

BackgroundThere are no guidelines on selecting alternating pressure (AP) configurations on increasing sacral skin blood flow (SBF).AimThe specific aims were to compare different cycle periods and pressure amplitudes of AP on sacral SBF responses in healthy people to establish the efficacy and safety of the protocols.MethodsTwo studies were tested, including the cycle period study (8 2.5-min vs 4 5-min protocols) and the pressure amplitude study (75/5 vs 65/15 mmHg protocols). Sacral SBF was measured using laser Doppler flowmetry (LDF) in 20 participants. AP loads were randomly applied using an indenter through the rigid LDF probe. Each protocol included a 10-min baseline, 20-min AP and 10-min recovery periods. A 30-min washout period was provided. The SBF response was normalized to the baseline SBF of each condition of each participant.ResultsFor the cycle period study, the 4 5-min cycle protocol partially restored more SBF than the 8 2.5-min cycle protocol at the low-pressure phase (0.87 ± 0.04 vs 0.71 ± 0.03, p < 0.05) and at the high-pressure phase (0.25 ± 0.03 vs 0.19 ± 0.03, p < 0.05). For the pressure amplitude study, the 75/5 mmHg protocol partially restored more sacral SBF than the 65/15 mmHg protocol at the low-pressure phase (0.87 ± 0.1 vs 0.25 ± 0.03, p < 0.05) but not at the high-pressure phase (0.23 ± 0.02 vs 0.21 ± 0.02, non-significant).ConclusionThis study demonstrated that 1) a cycle period of 5 min was better than 2.5 min and 2) a pressure amplitude of 75/5 mmHg was better than 65/15 mmHg. The finding provides insights for selecting the AP configurations for increasing SBF.     

Associations between skin structural and functional changes after loading in healthy aged females at sacral and heel skin: A secondary data analysis

Aim of the studyMechanical loading causes skin occlusion and deformation, which influences structural and functional skin properties. Aims of the study were to measure structural and functional skin parameters after loading at the sacral and heel skin and to describe possible associations.Material and methodsA secondary data analysis based on a clinical trial with n = 15 aged women was conducted. Changes of transepidermal water loss, stratum corneum hydration, epidermal hydration, erythema, temperature, structural stiffness, elastic recovery, elastic function, and mean roughness after 120 min loading were described and compared. Spearman's rho (r_s) was used to estimate possible associations.ResultsLoading caused an increase of transepidermal water loss, stratum corneum and epidermal hydration, erythema and temperature at sacral and heel skin. There was a decrease of median roughness at the heel skin surface (-8.5 (IQR -10.5 to 5.5) μm). Strongest positive associations were observed between changes of elastic function and elastic recovery (r_s = 0.9 at heel and sacral skin) and between changes of epidermal and stratum corneum hydration at both skin areas (r_s = 0.7 at sacral skin and r_s = 0.5 at the heel).ConclusionTwo hours loading on a standard foam mattress leads to skin occlusion at the skin surface and mechanical deformation. Skin occlusion seems primarily to increase temperature, stratum corneum and epidermal hydration that may affect mechanical skin properties. Mechanical deformation seems to be responsible for the erythematous response of the dermal skin layer.     

A quantitative analysis of microcirculation in sore-prone pressure areas on conventional and pressure relief hospital mattresses using laser Doppler flowmetry and tissue spectrophotometry

BackgroundPressure ulcers are associated with severe impairment for the patients and high economic load. With this study we wanted to gain more insight to the skin perfusion dynamics due to external loading. Furthermore, we evaluated the effect of different types of pressure relief mattresses.MethodsA total of 25 healthy volunteers were enrolled in the study. Perfusion dynamics of the sacral and the heel area were assessed using the O2C-device, which combines a laser light, to determine blood flow, and white light to determine the relative amount of hemoglobin. Three mattresses were evaluated compared to a hard surface: a standard hospital foam mattress bed, a visco-elastic foam mattress, and an air-fluidized bed.ResultsIn the heel area, only the air-fluidized bed was able to maintain the blood circulation (mean blood flow of 13.6 ± 6 versus 3.9 ± 3 AU and mean relative amount of hemoglobin of 44.0 ± 14 versus 32.7 ± 12 AU.) In the sacral area, all used mattresses revealed an improvement of blood circulation compared to the hard surface.ConclusionThe results of this study form a more precise pattern of perfusion changes due to external loading on various pressure relief mattresses. This knowledge may reduce the incidence of pressure ulcers and may be an influencing factor in pressure relief mattress selection.     

Incidence and risk factors for pressure injury in hospitalized non-small cell lung cancer patients: A retrospective observational study

AimThis study aimed to identify the incidence and risk factors for pressure injury in patients hospitalized for non-small cell lung cancer (NSCLC).MethodsThis retrospective observational study was conducted in 645 adults who were hospitalized for NSCLC. Clinicopathological characteristics were compared between NSCLC patients with pressure injury and those without pressure injury.ResultsAmong total 645 patients, 180 patients showed pressure injury with an incidence of 27.9%. Patients with pressure injury showed increased serum C-reactive protein (CRP) levels (P < 0.001), increased neutrophil-lymphocyte ratio (P = 0.002), and increased platelet-lymphocyte ratio (P = 0.001) more often. Increase in serum CRP levels at the time of admission was the major risk factor for development of pressure injury in NSCLC patients (OR = 2.20; 95% CI [1.40–3.45]; P = 0.001). Also, among major inflammatory markers, serum CRP levels at the time of admission showed weak negative correlation with the period from admission to the development of pressure injury (r = −0.216, P = 0.004).ConclusionBy checking serum CRP levels at the time of admission, the NSCLC patients at high risk for the development of pressure injury can be identified in advance and the occurrence of pressure injury can be reduced by applying more active preventive nursing care.Clinical trial registration numberKCT0006570.     

The relationship of subepidermal moisture and early stage pressure injury by visual skin assessment

AimThe purpose of this study was to examine the relationship of subepidermal moisture and early stage pressure injury by visual skin assessment in elderly Korean.MethodsTwenty-nine elderly participated at a particular nursing home. Data were collected for 12 weeks by one wound care nurse. Visual skin assessment and subepidermal moisture value were measured at both buttocks, both ischia, both trochanters, sacrum, and coccyx of each subject once a week.ResultsSubepidermal moisture value of stage 1 pressure injury was significantly higher than that of no injury and blanching erythema. After adjustment with covariates, odds ratios of blanching erythema to normal skin and stage 1 pressure injury to blanching erythema/normal skin were statistically significant (p < 0.05). Odds ratio of blanching erythema to normal skin was 1.003 (p = .047) by 1-week prior subepidermal moisture value, and that of concurrent subepidermal moisture value was 1.004 (p = .011). Odds ratio of stage 1 pressure injury to normal skin/blanching erythema was 1.003 (p = .005) by 1-week prior subepidermal moisture value, and that for concurrent subepidermal moisture value was 1.007 (p = .030). Subepidermal moisture was associated with concurrent and future (1 week later) skin damage at both trochanters.ConclusionSubepidermal moisture would be used to predict early skin damage in clinical nursing field for the effective pressure injury prevention.     

Upright vs. supine shape-capturing comparison for custom-contoured cushions

AimsThis study aims to explore best practices of shape capturing methods for creating custom-contoured wheelchair cushions for the purpose of reducing pressure injury risk.Materials and methodsPressure redistribution qualities were measured by peak pressure index (PPI) and compared between custom-contoured seating systems molded in supine vs. upright shape-capturing positions. Subjects consisted of 14 able-bodied participants in a within-subjects comparison.ResultsA Wilcoxon signed-rank test and paired t-test were calculated to compare the mean differences of the PPI between shape-capturing positions. Supine shape-capturing resulted in a statistically significant lower PPI compared to upright (z = 2.040, p < . 05) (t = −2.28, p < .05).ConclusionShape-capturing in the supine position provided greater pressure distribution as opposed to an upright position. Creating custom-contoured cushions molded in a supine position can reduce the risk of pressure injury to the patient.     

Dermatosis en pacientes con sobrepeso y obesidad y su relación con la insulina

IntroductionThe prevalence of obesity has increased worldwide in recent years. Some authors have described skin conditions associated with obesity, but there is little evidence on the association between insulin levels and such disorders.ObjectiveTo describe the skin disorders present in overweight and obese patients and analyze their association with insulin levels.Material and methodsThe study included nondiabetic male and female patients over 6 years of age who were seen at our hospital between January and April 2011. All the patients were evaluated by a dermatologist, who performed a physical examination, including anthropometry, and reviewed their medical history and medication record; fasting blood glucose and insulin were also measured. The patients were grouped according to degree of overweight or obesity and the data were compared using analysis of variance or the χ² test depending on the type of variable. The independence of the associations was assessed using regression analysis.ResultsIn total, 109 patients (95 adults and 13 children, 83.5% female) were studied. The mean (SD) age was 38 (14) years and the mean body mass index was 39.6 ± 8 kg/m². The skin conditions observed were acanthosis nigricans (AN) (in 97% of patients), skin tags (77%), keratosis pilaris (42%), and plantar hyperkeratosis (38%). Statistically significant associations were found between degree of obesity and AN (P = .003), skin tags (P = .001), and plantar hyperkeratosis. Number of skin tags, AN neck severity score, and AN distribution were significantly and independently associated with insulin levels.ConclusionsAN and skin tags should be considered clinical markers of hyperinsulinemia in nondiabetic, obese patients.     

Differential expression of BAFF and its receptors in discoid lupus erythematosus patients

BackgroundB-cell activating factor of the TNF family (BAFF) promotes the maturation and survival of B cells. Because BAFF levels are elevated in systemic lupus erythematosus (SLE) patients, BAFF has been the target of emerging therapies for SLE, such as belimumab. Levels of BAFF and its receptors in discoid lupus erythematosus (DLE) patients are unknown.ObjectiveTo compare skin and blood mRNA and protein levels of BAFF and its receptors BAFF-R, TACI, and BCMA in DLE subjects with (DLE+/SLE+ (N = 28)) and without SLE (DLE+/SLE− (N = 35)), psoriasis subjects (N = 11), and normal subjects (N = 42).MethodsWe used quantitative real-time PCR to measure blood and skin BAFF, BAFF-R, TACI, and BCMA mRNA, sandwich ELISAs to measure sera BAFF, and immunohistochemistry to evaluate BAFF and BAFF-R skin protein expression.ResultsBAFF mRNA and protein levels were highest in DLE+/SLE+blood, followed by DLE+/SLE−, psoriasis, and normal blood. BAFF protein also correlated with anti-nuclear antibodies, and autoantibodies against double-stranded DNA, single-stranded DNA, and ribonucleoprotein, and Systemic Lupus Erythematosus Disease Activity Index scores in DLE patients. While showing no difference between DLE+/SLE+ and DLE+/SLE− skin, BAFF and its receptors mRNA were up-regulated in DLE skin vs. normal and psoriasis skin. DLE skin had higher percentages of BAFF-R⁺ inflammatory cells, likely T cells and macrophages, than psoriasis and normal skin.ConclusionsBAFF may be a serologic marker of systemic disease in DLE patients. BAFF and its receptors are elevated in DLE skin, suggesting that targeted therapies against these proteins could treat refractory DLE patients.     

Effects of local cooling on sacral skin perfusion response to pressure: Implications for pressure ulcer prevention

People with spinal cord injuries are at high risk for developing pressure ulcers. Increased skin temperature is one of the extrinsic causative factors for this multi-factorial disease. Previous animal studies revealed that local skin cooling reduced the severity of ulceration, and cooling is widely used in plastic surgery and organ transplants for tissue preservation. The objectives of this pilot study were to develop test protocols and instrumentation and to investigate the effect of local cooling on skin perfusion response to pressure on young healthy human subjects. Reactive hyperemia was quantified in this study to compare the effects of pressure with and without cooling. Reactive hyperemia is a normal physiological response occurring after vessel occlusion. Laser Doppler flowmetry was used to measure skin blood flow. Time-dependent spectral analysis was used to analyze and decompose the blood flow data into frequency ranges associated with specific blood flow control mechanisms. The study used a repeated measures design with two test conditions: 8 kPa of pressure with and without cooling to 25 °C. We hypothesized that local cooling would reduce the post-ischemic reactive hyperemic response induced by the rigid indenter. Time series results showed that normalized peak perfusion response was significantly lower with cooling (p = 0.019). Time-dependent spectral analysis results suggested that both metabolic and myogenic responses contribute to this protective effect. Findings from our study on humans were consistent with previous animal studies. Additional studies on individuals with spinal cord injury are planned to further evaluate the cooling effect in a high-risk population.     

The effect of the moisture content of a local heat source on the blood flow response of the skin

Numerous studies have examined the effect of local and global heating of the body on skin blood flow. However, the effect of the moisture content of the heat source on the skin blood flow response has not been examined. Thirty-three subjects, without diabetes or cardiovascular disease, between the ages of 22 and 32 were examined to determine the relationship between the effects of dry vs. moist heat applied for the same length of time and with the skin clamped at the same skin temperature on the blood flow response of the skin. The skin, heated with an infrared heat lamp (skin temperature monitored with a thermocouple) to 40°C for 15 min, was either kept moist with wet towels or, in a separate experiment, kept dry with Drierite (a desiccant) between the towels to remove any moisture. Before and after heat exposure of the forearm, blood pressure, heart rate, skin moisture content, skin temperature, and skin blood flow were recorded. The results of the experiment showed that there was no change in skin moisture after 15 min exposure to dry heat at 40°C. However, with moist heat, skin moisture increased by 43.7%, a significant increase (P < 0.05). With dry heat, blood flow increased from the resting value by 282.3% whereas with moist heat, blood flow increased by 386% over rest, a significant increase over dry heat (P < 0.05). Thus, with a set increase in skin temperature, moist heat was a better heating modality than dry heat. The reason may be linked to moisture sensitivity in calcium channels in the vascular endothelial cell.     

Reliability of B-mode ultrasound and shear wave elastography in evaluating sacral bone and soft tissue characteristics in young adults with clinical feasibility in elderly

BackgroundPhysiologic aging is associated with loss of mobility, sarcopenia, skin atrophy and loss of elasticity. These factors contribute, in the elderly, to the occurrence of a pressure ulcer (PU). Brightness mode ultrasound (US) and shear wave elastography (SWE) have been proposed as a patient-specific, bedside, and predictive tool for PU. However, reliability and clinical feasibility in application to the sacral region have not been clearly established.MethodThe current study aimed to propose a simple bedside protocol combining US and SWE. The protocol was first tested on a group of 19 healthy young subjects by two operators. The measurements were repeated three times. Eight parameters were evaluated at the medial sacral crest. Intraclass Correlation Coefficient (ICC) was used for reliability assessment and the modified Bland Altman plot analysis for agreement assessment. The protocol was then evaluated for clinical feasibility on a healthy older group of 11 subjects with a mean age of 65 ± 2.4 yrs.FindingsICC showed poor to good reliability except for skin SWE and hypodermis thickness with an ICC (reported as: mean (95%CI)) of 0.78 (0.50–0.91) and 0.98 (0.95–0.99) respectively. No significant differences were observed between the young and older group except for the muscle Shear Wave Speed (SWS) (respectively 2.11 ± 0.27 m/s vs 1.70 ± 0.17 m/s).InterpretationThis is the first protocol combining US and SWE that can be proposed on a large scale in nursing homes. Reliability, however, was unsatisfactory for most parameters despite efforts to standardize the protocol and measurement definitions. Further studies are needed to improve reliability.     

Not just quantity: Gluteus maximus muscle characteristics in able-bodied and SCI individuals – Implications for tissue viability

Study aimSome individuals with spinal cord injury (SCI) remain pressure ulcer (PU) free whilst others experience a recurring cycle of tissue breakdown. Detailed analysis of gluteal muscle characteristics may provide insights to local tissue viability variability. The study hypothesis was that SCI individuals have altered muscle composition compared to able-bodied (AB).MaterialsTen AB and ten SCI received a supine pelvic CT scan, with contrast.MethodsCross-sectional area (CSA) and overall muscle volume were derived using image analysis. Gluteal muscle tissue type was classified at the S2/S3 sacral vertebrae midpoint, the superior greater trochanters margin (GT) and the inferior ischial tuberosities margin (IT) using the linear transformation Hounsfield Unit scale.ResultsSCI gluteal CSA was less than for AB throughout the muscle, with the greatest relative atrophy at the IT (48%). Average AB gluteal volume was nearly double SCI. Eight SCI had over 20% infiltrative adipose tissue, three with over 50%. SCI gluteal CSA and intramuscular fat infiltration were significantly negatively correlated (p < 0.05). SCI IT axial slices showed less lean muscle and higher intramuscular fat infiltration than more proximally (p < 0.05).ConclusionSCI gluteal muscle characteristics were indicative of impaired tissue viability. SCI disuse muscle atrophy was anticipated; the analytic approach further indicated that intramuscular atrophy was not uniform. SCI muscle composition showed increased proportions of both low density muscle and adipose tissue. CT scan with contrast is effective for gluteal muscle characterization. This assessment technique may contribute to determination of personalized risk for PU development and other secondary complications.     

Adaptation of a MR imaging protocol into a real-time clinical biometric ultrasound protocol for persons with spinal cord injury at risk for deep tissue injury: A reliability study

BackgroundHigh strain in soft tissues that overly bony prominences are considered a risk factor for pressure ulcers (PUs) following spinal cord impairment (SCI) and have been computed using Finite Element methods (FEM). The aim of this study was to translate a MRI protocol into ultrasound (US) and determine between-operator reliability of expert sonographers measuring diameter of the inferior curvature of the ischial tuberosity (IT) and the thickness of the overlying soft tissue layers on able-bodied (AB) and SCI using real-time ultrasound.Material and methodsPart 1: Fourteen AB participants with a mean age of 36.7 ± 12.09 years with 7 males and 7 females had their 3 soft tissue layers in loaded and unloaded sitting measured independently by 2 sonographers: tendon/muscle, skin/fat and total soft tissue and the diameter of the IT in its short and long axis. Part 2: Nineteen participants with SCI were screened, three were excluded due to abnormal skin signs, and eight participants (42%) were excluded for abnormal US signs with normal skin. Eight SCI participants with a mean age of 31.6 ± 13.6 years and all male with 4 paraplegics and 4 tetraplegics were measured by the same sonographers for skin, fat, tendon, muscle and total. Skin/fat and tendon/muscle were computed.ResultsAB between-operator reliability was good (ICC = 0.81–0.90) for 3 soft tissues layers in unloaded and loaded sitting and poor for both IT short and long axis (ICC = −0.028 and −0.01). SCI between-operator reliability was good in unloaded and loaded for total, muscle, fat, skin/fat, tendon/muscle (ICC = 0.75–0.97) and poor for tendon (ICC = 0.26 unloaded and ICC = −0.71 loaded) and skin (ICC = 0.37 unloaded and ICC = 0.10).ConclusionA MRI protocol was successfully adapted for a reliable 3 soft tissue layer model and could be used in a 2-D FEM model designed to estimate soft tissue strain as a novel risk factor for the development of a PU.     

Effect of local cooling on pro-inflammatory cytokines and blood flow of the skin under surface pressure in rats: Feasibility study

The primary purpose of this feasibility study was to establish a correlation between pro-inflammatory cytokine accumulation and severity of tissue damage during local pressure with various temperatures. The secondary purpose was to compare skin blood flow patterns for assessing the efficacy of local cooling on reducing skin ischemia under surface pressure. Eight Sprague–Dawley rats were assigned to two protocols, including pressure with local cooling (Δt = −10 °C) and pressure with local heating (Δt = 10 °C). Pressure of 700 mmHg was applied to the right trochanter area of rats for 3 h. Skin perfusion quantified by laser Doppler flowmetry and TNF-1 and IL-1β levels were measured. Our results showed that TNF-α concentrations were increased more significantly with local heating than with local cooling under pressure whereas IL-1β did not change. Our results support the notion that weight bearing soft tissue damage may be reduced through temperature modulation and that non-invasive perfusion measurements using laser Doppler flowmetry may be capable of assessing viability. Furthermore, these results show that perfusion response to loading pressure may be correlated with changes in local pro-inflammatory cytokines. These relationships may be relevant for the development of cooling technologies for reducing risk of pressure ulcers.