压疮危险因素评估的研究进展

压疮危险因素的准确评估是制定有效预防和治疗策略最为至关重要的一步,目前临床应用的各种压疮危险因素评估表中的各个参数赋予相等的权重、总评分只是各参数计分的算术和,评判过于简单、主观性过强.压疮危险因素评估的发展趋势是由经过正规训练、经验丰富的护士对患者进行评估,并应用计算机压力监测装置、皮肤血流激光多普勒,同时将不同权重记分法与先进的统计技术相结合研发出更确切的数据驱动的RASs系统.     

Establishing the validity of pressure ulcer risk assessment scales: a novel approach using illustrated patient scenarios.

Preventing pressure ulcers is an important nursing goal and over the years a number of risk assessment scales (RASs) have been developed to expedite clinical judgement. The aim of this study was to examine the validity of the three most commonly used RASs compared to nurses' own clinical judgement. Patient simulations were presented to 236 clinical nurses. Nine hundred and forty one assessments were completed and compared to the ratings from a panel of tissue viability experts. Clinical judgement exactly matched expert opinion (69.1%) more often than assessment with any of the RASs. The Waterlow Score matched exactly in 20% of cases, the Braden Scale in 8.5% of cases and the Norton Score in 4.6% of cases. Thus none of these RASs can be considered valid, assuming that the expert panel genuinely reflected the 'gold standard' in terms of the external criterion. The implications for clinical practice are far-reaching considering the extent to which RASs are currently used to reach important clinical decisions relating to the deployment of expensive pressure-relieving aids and nursing time.     

Examining the validity of pressure ulcer risk assessment scales: a replication study

Risk assessment scales (RASs) intended to identify patients most at risk of developing pressure ulcers have been widely used for many years. Numerous studies have evaluated their predictive validity but potential bias has been inherent in the design of all. To overcome these problems a simulation study was conducted in which clinical nurses were asked to identify the degree of risk experienced by four patients employing the three RASs discussed most frequently in the literature (Norton, Braden and Waterlow Scores). These findings were compared with nurses' clinical judgment rated on a visual analogue scale. The simulations consisted of high-resolution photographs accompanied by case studies of the patients. The nurses' scores were compared to estimates of risk generated by an expert panel. Nurses' clinical judgment agreed much more closely with expert opinion than any of the RASs. A replication study was undertaken to confirm these findings. One hundred and fifteen nurses participated in replication. Again the nurses' clinical judgment matched expert opinion much more closely than the results of the RASs. Replication also drew attention to a number of methodological issues which deserve consideration when using simulation to test the effectiveness of clinical tools and the need to establish adequate measures of external validity whenever use of this method is contemplated.     

Complications of adapting pressure ulcer risk assessment scales

This article challenges recommendations to adapt a pressure ulcer risk assessment scale (RAS) according to the clinical context. The transformation of the Cubbin and Jackson (1991) RAS is used to illustrate problems in scale development. When new factors are added to an existing scale, this can lead to unnecessary complexity. When words are changed by a person developing a scale this illustrates their differing beliefs and value judgements. Arbitrary scores for factors are misleading and in some cases mystifying, yet appear to be objective. This article suggests that the relationship between sub-scales and the whole scale have not been adequately accounted for -- they can't simply be added up arithmetically. The paradox of risk is debated, namely, that the more something is thought to be a risk, the less risky it becomes. RASs should be replaced by risk reduction scales linking a risk factor with its outcome following intervention.     

Development and initial psychometric evaluation of the participation measure for post-acute care (PM-PAC)

OBJECTIVE: To evaluate a patient-reported participation measure constructed within the framework of the International Classification of Functioning, Disability, and Health. DESIGN: The Participation Measure for Post-Acute Care (PM-PAC) contains 51 items that assess participation in nine domains: mobility; role functioning; community, social, and civic life; domestic life/self-care; economic life; interpersonal relationships; communication; work; and education. Self-reported data were collected by interview with 395 noninstitutionalized rehabilitation patients. Psychometric analyses were conducted to test assumptions underlying the scaling and scoring of PM-PAC scales and to evaluate reliability and validity. RESULTS: In general, analyses supported assignment of items to hypothesized scales. However, the community, social, and civic life, interpersonal relationships, and communication domains were highly correlated. Item response theory models indicated that items were directed primarily at people with worse than average limitations in participation than the average patient in this rehabilitation sample. Test and retest scale scores did not differ significantly (intraclass correlation coefficient range, 0.61-0.86). Groups with more severe conditions scored worse on PM-PAC scales, as hypothesized. CONCLUSIONS: PM-PAC is a promising new measure of patient-reported participation as defined by the International Classification of Functioning, Disability, and Health. Information about PM-PAC items from this study will be useful in developing a computerized, adaptive measure of participation.     

An analysis of the literature pertaining to pressure sore risk-assessment scales

• ? The purpose of this analysis was to determine which pressure sore risk-assessment scale was the most valid and reliable for use outside the elderly setting.
• ? It includes a review of the causes of pressure sores to determine the factors which should be included in a scoring system, an overview of the risk-assessment scales developed and an analysis of the research performed to test their validity and reliability.
• ? The study has shown that the Gosnell, Knoll, and Douglas scales have had little or no validity studies conducted and should therefore not be used in the clinical setting and the Pressure Sore Prediction Score should be used with caution outside an orthopaedic setting. The Waterlow scale has also not been fully validated and the Norton scale requires further validation to make it applicable to patients outside the elderly setting. The Norton scale has been shown to overpredict the risk of pressure sores, but the Waterlow scale may actually overpredict this risk even more.
• ? The Braden scale appears to be the most appropriate to use because it has been tested on a representative sample of patients with a wide age range (14–102). It also has a sensitivity of 100% and a specificity of 64–90% compared with the Norton scale's sensitivity of 88% and specificity of 36%.
• ? The analysis concludes that more research is required on all of the scales to determine validity and reliability outside of the elderly setting and therefore all scales should be used with caution bearing in mind the limitations of each.

     

Characteristics of the psychological status of patients with peptic ulcer

The article discusses changes in the psychological status and the forming of various types of attitude towards the disease in patients with a favorable and unfavorable course of peptic ulcer (PU). The subjects of the study were 82 patients with exacerbation of PU; among them there were 30 patients with a favorable and 52 patient with a complicated course. Patients with a favorable course of PU did not displayed prominent peaks in SMOL profile, which reflected a relatively benign state of their psychological status. Favorable type of response to the disease--harmonic and anosognostic--with lesser social disadaptation prevailed in these patients. On the contrary, patients with a complicated course of PU displayed a relative increase in the profile on the scales, reflecting a higher tension in combination with diadaptive response to the disesase, which should be taking into account when correcting treatment.     

Nurses'' attitudes and satisfaction in two psychogeriatric wards: their structure and correlates

This study investigated the structure and correlates of previously published job satisfaction and attitude measures for nurses through an analysis of responses from staff working in two psychogeriatric wards. A number of inter-correlations were found between the attitude and satisfaction scales. Factor analysis revealed that one of the attitude scales was multi-dimensional and it is suggested that future research should not assume the uni-dimensionality of attitude and satisfaction constructs. It is concluded that psychometric research has important limitations, that a multiplicity of research strategies (both quantitative and qualitative) should be employed in future investigations and that more importance should be accorded to the organizational context of job satisfaction.     

Waterlow计分表在神经内科预防压疮中的应用

目的评价Waterlow计分表对神经内科卧床患者压疮的预测效果。方法应用Waterlow计分表作为评估工具,通过对新入神经内科患者进行评估,根据分值采用不同的预防措施。结果 2014年神经内科压疮高危患者上报率显著增加(P0.01),高危患者院内压疮发生率显著下降(P0.01)。结论 Waterlow计分表应用于神经内科临床预防压疮具有可靠性、有效性。     

No Worries, No Cares: An Investigation into Self-Reported "Nondistress" in College Students

An important methodological issue in depressionanalog research is whether individuals who scoreextremely low on self-report measures like the BeckDepression Inventory (BDI) should be included innondepressed control groups. Joiner, Schmidt, and Metalsky(1994) found that college students with BDI scores of 0or 1 evidenced a fake-good test taking style as measuredby the MMPI validity scales. The present study investigated whether very low BDI scores (BDI= 0 or 1; n = 21) might be associated with an elevatedpositive mood state, extreme optimism, positiveattributional style or social desirability. Resultsindicated that the very low scoring BDI subjects scoredhigher on social desirability than the low scoring group(BDI = 2 9, n = 63). Significant differences on mood,symptom and cognitive measures disappeared when social desirability was entered as a covariate.Findings support Kendall, Hollon, Beck, Hammen, andIngram's (1987) recommendation that subjects who score0 or 1 on the BDI should be excluded from a nondepressed control group.     

Training program for caregivers to prevent pressure ulcers among elderly residents at geriatric homes

Objectives: Pressure ulcer (PU) is one of the most common problem among the bedridden elderly and has significantly more burden on elderly and caregivers. This study is aimed to evaluate the effects of the training program for caregivers to prevent PUs among elderly residents at geriatric homes.Methods: A quasi-experimental design was used to carry out the current study. A purposive sample comprised of all formal (39 nurses) or informal caregivers (39) and all immobilized elderly residents (35) who are found in all geriatric centers in Helwan district. A structured questionnaire was used to assess caregivers' socio-demographic characteristics, knowledge, attitude, and observational checklists for their practice for prevention of PU at pre- and posttest and during follow-up. Results: After the training program, there were improvements in the level of knowledge, practice, and positive attitude of caregivers about PU prevention with a statistically significant difference between pre-, post-, and follow-up training programs (P < 0.001). Conclusions: The study revealed that the training program seemed to change the knowledge, practice, and attitude of the subjects to PU prevention. This, in turn, implies that adequate knowledge affects directly the elderly caregivers' attitudes as well as practice for prevention could be impor tant in reducing the burden of PU among the elderly. Thus, conducting a training program for caregivers at different geriatric homes about caring skills for elders can prevent PU, and using spontaneous reposition is very effective to prevent PUs.     

Comparing alternative measures of functional limitation

BACKGROUND: Functional limitation is a central concept in the disability process, but its operationalization has varied widely, making it impossible to compare results across studies. OBJECTIVE: Our goal is to systematically compare the effectiveness of alternative measures of functional limitations to predict disability and to provide guidelines for their standardization. DESIGN: Over 100 alternative scales of functional limitations are compared in regression models of disability. The Bayesian information criterion is used to compare the performance of measures. SUBJECTS: The subjects were 5,764 women, aged 37 to 68, from the Mature and Young Women's cohorts of the National Longitudinal Surveys. MEASURES: Scales are constructed from 9 indicators of activity limitations: (1) grasping, (2) lifting/carrying up to 10 pounds, (3) lifting/carrying heavy weights, (4) reaching, (5) sitting, (6) stairs, (7) standing, (8) stooping, and (9) walking. Respondents were asked whether they could perform the activity without difficulty, with difficulty, or could not perform it at all. The 4 disability outcomes include binary and ordinal measures of work limitation, a single ADL measure (bathing), and total number of ADLs. RESULTS: The 3 best scales used all 9 indicators. The top scale truncated values above 5, while the others logged the sum. Two scales were based on sums of binary indicators, while the third used 3 category indicators. CONCLUSIONS: Simple scales perform better than complex scales that separate upper and lower body limitations or weight some limitations more than others. Scales that transform higher values are preferable.     

Sensitivity to changes in disability after stroke: a comparison of four scales useful in clinical trials

Although most current stroke intervention trials use disability scales to determine outcome, little is known about the sensitivity to change of these scales. The use of a more sensitive measure would increase the statistical power of rehabilitation treatment trials. We applied four well-known disability scales to a group of stroke rehabilitation inpatients to compare sensitivity to change. Ninety-five consecutive admissions to a stroke rehabilitation service were assessed for disability on admission and discharge. Two global scales, the Modified Rankin Scale (MRS) and the International Stroke Trial Measure (ISTM), were compared with two activities of daily living (ADL) scales, the Barthel Index (BI) and the Functional Independence Measure (FIM). We determined the number of patients that each scale detected a clinically significant change in disability. Standardized response means (SRM) and receiver operating characteristic (ROC) analyses were performed. The MRS detected change in 55 subjects, including all who changed on the ISTM; the ISTM detected change in only 23 subjects. The BI detected change in 71 subjects but demonstrated ceiling effects with 26% of subjects scoring >95. The FIM was most sensitive, detecting change in 91 subjects; no patient achieved a maximum score. The SRM of the FIM was superior to that of the BI (2.18 versus 1.72), and ROC analysis revealed C-statistics of 0.82 for the BI, 0.59 for the MRS, and 0.51 for the ISTM. Global scales were much less sensitive to changes in disability than were ADL scales. Though ADL scales may take longer to administer, their increased sensitivity may make them more useful in treatment trials by allowing fewer subjects to be enrolled.     

Models for predicting non‐sentinel lymph node positivity in sentinel node positive breast cancer: the importance of scoring system

Background: Although delayed axillary lymph node dissection is the gold standard for evaluating axillary status after identification of a positive sentinel lymph node (SLN), between 40% and 70% of sentinel lymph node positive patients will have negative non‐sentinel nodes and undergo a non‐therapeutic axillary dissection. Accurate estimates of the likelihood of additional disease in the axilla can assist decision‐making about further treatment. To predict non‐SLN metastases in patients with a positive SLN biopsy, four different nomograms have been created. Method: This paper reviews the scoring systems and nomograms reported in the literature and compares their predictive probability of non‐SLN involvement in patients with SLN positive breast cancer. Result: There are several published scoring systems that contain different parameters to estimate the rate of non‐SLN metastases in SLN positive patients. We reviewed Memorial Sloan‐Kettering Cancer Center (MSKCC), Tenon, Stanford and Cambridge nomograms published and used scoring systems including three to eight variables. We found that the MSKCC nomogram is the most validated model in the literature to predict non‐SLN status accurately. The other three models have not yet been verified in outside institutions. Conclusion: Despite having some limitations, the MSKCC nomogram is the most validated model in the literature. These models should be tested and verified in different programs and different patient groups before they are widely accepted.     

Interferon-free treatment choice according to baseline RASs leads to high SVR rates in HCV genotype 1 infected patients

Aim

Different combinations of direct antiviral agents (DAA) lead to high SVR rates in HCV genotype 1 infected patients. However, presence of baseline resistance-associated substitutions (RASs) represents a major risk factor for treatment failure. It is unknown whether choice of treatment based on RASs has the potential to decrease virologic failure rates.

Impact of long-term systemic glucocorticoid therapy for bronchial asthma on the occurrence and course of peptic ulcer

The study was undertaken to examine the incidence and specific features of peptic ulcer (PU) of the gastroduodenal area (GDA) in bronchial asthma (BA) and the impact of long-term oral maintenance therapy with systemic glucocorticosteroids (GCS) on the occurrence and course of peptic ulcer. Among the 260 examined patients with BA, GDA PU was revealed in 70(26.9%). The commonest site of an ulcerative process in the duodenum (90%) and its frequent combination with reflux esophagitis (84.1%) are noteworthy, which is likely to import some specific features to the clinical picture of GDA PU in BA. The latter is characterized by mild pain and a predominance of dyspepsia, which should be taken into account in assessing the clinical picture in patients with BA when there is a high risk for PU and in defining indications for esophagogastroduodenoscopy. The clinical and endoscopic features of the course of PU in patients with comorbidity were analyzed in relation to the use of GCS therapy. The analysis revealed that the incidence of PU did not depend on the severity and type of BA and on the use of GCS therapy. The study failed to provide evidence for the generally accepted idea of the leading role of GCS in the development of PU in BA. There was no significant negative impact of long-term small-dose GCS therapy on the clinical and endoscopic picture of PU in BA. The findings suggest that in BA, favorable conditions arose for realizing the predisposition to PU, which makes it necessary to carry out further studies to reveal the possible mechanisms that are responsible for the formation of concomitant diseases; this may be of fundamental importance in developing pathogenetically substantiated therapy for the above category of patients.     

Frailty scales – their potential in interprofessional working with older people: a discussion paper

New models of interprofessional working are continuously being proposed to address the burgeoning health and social care needs of older people with complex and long-term health conditions. Evaluations of the effectiveness of these models tend to focus on process measures rather than outcomes for the older person. This discussion paper argues that the concept of frailty, and measures based on it, may provide a more user-centred tool for the evaluation of interprofessional services – a tool that cuts across unidisciplinary preoccupations and definitions of effectiveness. Numerous frailty scales have been developed for case identification and stratification of risk of adverse outcomes. We suggest that they may also be particularly suitable for evaluating the effectiveness of interprofessional working with community-dwelling older people. Several exemplars of frailty scales that might serve this purpose are identified, and their potential contributions and limitations are discussed. Further work is required to establish which is the most suitable scales for this application. The development of an appropriate frailty scale could provide an opportunity for interprofessional debate about the forms of care and treatment that should be prioritised to improve the health and well-being of this population.     

Secondary conditions in spinal cord injury: results from a prospective survey

Study design. Prospective, self-report mail survey with two points of measurement one year apart.

Objectives. To determine significant predictors of pressure ulcers (PU) and urinary tract infections (UTI) in adults with spinal cord injury (SCI) over 2 years.

Setting. Non-institutionalized adults with SCI living in the United States of America.

Methods. Secondary data analysis from 2 consecutive years. Independent variables included demographic, healthcare-related, functional, access to care, and health behavior measures. Dependent variables were the occurrence of PU and UTI at Time 2.

Results. Bivariate analyses showed significant associations between various independent variables and the occurrence of PU and UTI at Time 2. Separate logistic regression analyses for PU and UTI at Time 2 as dependent variables showed that PU at Time 1, not being married or cohabiting, not having access to primary care services when needed, and reporting a greater number of activities of daily living (ADL) requiring assistance were significant predictors of PU at Time 2. UTI at Time 1, a greater number of ADLs requiring assistance, and not engaging in weekly exercise are significant predictors of subsequent occurrence of UTI.

Conclusions. Findings support previous research, and indicate the need for increased efforts to provide SCI self-management education to at-risk subpopulations, including individuals with greater personal assistance needs and functional limitations.