Exogenous hyaluronic acid and wound healing: an updated vision

Hyaluronic acid (HA), an endogenous substance whose concentration increases during the process of wound repair, can be manufactured in order to use it as an exogenous intervention able to reduce the time to wound repair and improve the quality of the scar. The role of HA as a key component of the extracellular matrix structure has been recognized for many decades, while its actions on cells involved in the process of tissue repair has been partly clarified only in the last few years. Fibroblasts, endothelial cells and macrophages are key players in the tissue repair process and a concerted activation of specific functions of these cells may substantially improve the process of wound closure. Hyaluronan, as well as its degradation products that are generated in the wounds, are capable to activate specific responses in all the cells involved in the process; in particular, fibroblast proliferation and new vessel formation have been extensively studied. The molecular patterns leading to cell activation have been substantially clarified and it is now widely accepted that cellular actions of hyaluronic acid are mediated by specific surface receptors, including CD44, RHAMM and toll like receptors. Elucidation of the mechanisms of cellular activation will allow an optimal use of exogenous hyaluronan and its derivatives in the wound care setting.     

“一次性耗材伤口护理专项培训考核”效果的评价研究

目的:通过"一次性耗材伤口护理专项培训考核",研究伤口护理学组护士安全使用医用一次性耗材的效果。方法:由耗材供应商和医院伤口护理组专家共同制订和实施培训计划,采用理论考核、实际操作和安全管理相结合进行伤口护理效果的统计评价。结果:通过对全院35名护士培训前后的考评对比,伤口护理效果明显,尤其是护龄<5年的护士其理论基础和实际操作能力的进步更显著。结论:进行"一次性耗材伤口护理专项培训考核",提高了护士对医用一次性耗材的安全使用认识和管理效能,有利于在医院全面推广。     

MDS 3.0 section M: Skin Conditions: what the medical director needs to know

The Centers for Medicare and Medicaid Services has released the new Resident Assessment Instrument version 3.0, which went into effect October 1, 2010. The intention of the revised Resident Assessment Instrument is to improve health-related quality of life and care planning, and incorporate evolving standards of terminology, assessment, and technology. To reach this goal, Section M: Skin Conditions has been greatly expanded and will alter the process of pressure ulcer assessment in all long-term care facilities across America. Details of this assessment instrument include upgraded criteria for risk factors, staging, identification, tracking, and evolution of pressure ulcers. The medical director can and should assume a leadership role in education and collaboration with primary care physicians and wound clinicians to accommodate changes in revised Section M. Integrating the medical director into the facility's wound care program will improve the quality of care for residents of long-term care facilities.     

Bacterial resistance to silver in wound care

Ionic silver exhibits antimicrobial activity against a broad range of micro-organisms. As a consequence, silver is included in many commercially available healthcare products. The use of silver is increasing rapidly in the field of wound care, and a wide variety of silver-containing dressings are now commonplace (e.g. Hydrofiber dressing, polyurethane foams and gauzes). However, concerns associated with the overuse of silver and the consequent emergence of bacterial resistance are being raised. The current understanding of the biochemical and molecular basis behind silver resistance has been documented since 1998. Despite the sporadic evidence of bacterial resistance to silver, there have been very few studies undertaken and documented to ascertain its prevalence. The risks of antibacterial resistance developing from the use of biocides may well have been overstated. It is proposed that hygiene should be emphasized and targeted towards those applications that have demonstrable benefits in wound care. It is the purpose of this review to assess the likelihood of widespread resistance to silver and the potential for silver to induce cross-resistance to antibiotics, in light of its increasing usage within the healthcare setting.     

Integrating behavior change theory into geriatric case management practice

Case management practices have continued to grow despite a lack of clear evidence of their efficacy. With the expanding segment of the elderly population, there is a critical need to develop and identify programs that will address the many needs of the aging. Geriatric Case Management has been the avenue selected by many health care providers to address these issues, focusing on maintaining health status and improving linkages with medical and community resources. Studies testing the effectiveness of these models have failed to demonstrate their effectiveness in reducing depression, reducing acute care service use, and improving or maintaining health status. The Geriatric Case Management models presented in these lack an evidence-based, theoretical framework that provides definition and direction for case management practice. This article introduces behavior change theories as a method of structuring and delineating the case management intervention. The Transtheoretical Model and the Theory of Planned Behavior are discussed and methods of integrating these theories into practice are discussed.     

Outing lesbian health in medical education

Lesbian health is emerging as a distinct discipline in practice and research. Evidence is increasingly available that lesbians are a unique and underserved population in the health care system. They display reduced health seeking behaviors and have specific risk factors which potentially affect their health and well being. They also have specific health issues in fields as diverse as fertility, sexual health and mental health, which require specific knowledge from health care practitioners. Above all, lesbian health care consumers repeatedly decry the lack of sensitivity and knowledge that they experience in their interactions with providers, and call for improved training. However, medical education generally ignores lesbian health at all levels. In this paper, the inclusion of lesbian health in medical education programs is reviewed, and recent political initiatives involving gay and lesbian health in Australia are discussed. The paper concludes with suggestions to integrate lesbian health in medical training.     

伤口专科护理小组在压疮护理管理中的作用

目的观察开展伤口专科小组对压疮护理记录的影响效果。方法选择2009年1月至2009年12月成立伤口专科小组前的50例护理记录为实施前组,选择2012年1月至2012年12月成立伤口专科小组运作1年后的56例护理记录为实施后组．通过回顾调查实施前后两组病历中与压疮预防、治疗、处理等有关的护理记录内容进行对比分析效果。结果压疮大小、减压措施采用率及压疮风险评估、告知制度落实均明显提高,与实施前比较差异具有统计学意义（P〈0．05）。结论建立伤1：2小组使压疮伤口护理记录更规范．培养护士防治压疮的新理念．减少护理不良事件的发生．     

Nutrients and wound healing: still searching for the magic bullet.

Clinicians in nearly all practice areas are confronted with the challenges associated with delayed and impaired wound healing. Although nutrition plays a critical role in the healing process, controversy exists regarding the optimal nutrition regimen. This article reviews literature related to nutrition interventions that facilitate wound healing. The limitations of the research that forms the scientific basis of many nutrition recommendations are also examined. The limited availability of rigorously performed clinical studies to develop evidence-based guidelines for nutrition support in wound care emphasizes the need for further research and underscores the importance of individualizing the nutrition care plan for each patient.     

Antibacterial honey (Medihoney?) for wound care of immunocompromised pediatric oncology patients

The physiologic process of wound healing is impaired and prolonged in paediatic patients receiving chemotherapy. Due to profound immunosuppression, wound infection can easily spread and act as the source of sepsis. Referring to in vitro studies, which confirmed the antibacterial potency of special honey preparations against typical isolates of nosocomially acquired wound infections (including MRSA and VRE) and considering the encouraging reports from other groups, Medihoney™ has now been used in wound care at the Department of Pediatric Oncology, Children''s Hospital, University of Bonn for three years. Supplemented with exemplary clinical data from pediatric oncology patients, this presentation reviews the scientific background and our promising experience with Medihoney™ in wound care issues at our institution.     

Integrating Behavior Change Theory into Geriatric Case Management Practice

ABSTRACT

Case management practices have continued to grow despite a lack of clear evidence of their efficacy. With the expanding segment of the elderly population, there is a critical need to develop and identify programs that will address the many needs of the aging. Geriatric Case Management has been the avenue selected by many health care providers to address these issues, focusing on maintaining health status and improving linkages with medical and community resources. Studies testing the effectiveness of these models have failed to demonstrate their effectiveness in reducing depression, reducing acute care service use, and improving or maintaining health status. The Geriatric Case Management models presented in these lack an evidence-based, theoretical framework that provides definition and direction for case management practice. This article introduces behavior change theories as a method of structuring and delineating the case management intervention. The Transtheoretical Model and the Theory of Planned Behavior are discussed and methods of integrating these theories into practice are discussed.     

Evaluating the policy role of the small area variations and physician practice style hypotheses

The primary purpose of this article is to develop a framework for reinterpreting the role of physician practice style in the small area variations phenomenon. This phenomenon deals with the wide interarea variations in per capita use rates which have been found for many medical and surgical procedures. The variations have been interpreted by many to suggest that large amounts of unnecessary care are being provided. The variations and corresponding perceptions of unnecessary care have also led to a US health policy which is increasingly emphasizing patient outcomes research. I show, however, that most of the empirical studies of the variations phenomenon have inappropriately aggregated either across procedures or across market areas so as to obscure the role of practice style. Its role has also been obscured by the common failure to distinguish practice style from other determinants of utilization. As a result, small area methods can lead to substantial error in identifying procedures associated either with major differences in practice style or with substantial amounts of unnecessary care if all variation is attributed to practice style.     

Teaching wound care in the home

A survey of Medicare-certified agencies in Alaska, Idaho, Montana, Oregon, and Washington identified wound care and teaching wound care as being among the highest ranked clinical problems related to earlier hospital discharges that have resulted from Medicare Diagnostic Related Groupings (DRGs). Home care nurses are treating increasingly complex wounds and are required to teach complex wound care skills to clients and caregivers. This paper provides guidelines and resources to home care nurses for teaching wound care to their elderly clients and caregivers. The process of developing and implementing a teaching plan is described through the use of the community health nursing process. Following the presentation of the process content, a sample teaching wound care plan and sample teaching handouts are presented with a list of available teaching resources about wound care.     

Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients

ObjectiveWe investigated the potential of a high-protein, arginine- and micronutrient-enriched oral nutritional supplement (ONS) to improve healing of pressure ulcers in non-malnourished patients who would usually not be considered for extra nutritional support.MethodsForty-three non-malnourished subjects with stage III or IV pressure ulcers were included in a multicountry, randomized, controlled, double-blind, parallel group trial. They were offered 200 mL of the specific ONS or a non-caloric control product three times per day, in addition to their regular diet and standard wound care, for a maximum of 8 wk. Results were compared with repeated-measures mixed models (RMMM), analysis of variance, or Fisher's exact tests for categorical parameters.ResultsSupplementation with the specific ONS accelerated pressure ulcer healing, indicated by a significantly different decrease in ulcer size compared with the control, over the period of 8 wk (P ≤ 0.016, RMMM). The decrease in severity score (Pressure Ulcer Scale for Healing) in the supplemented group differed significantly (P ≤ 0.033, RMMM) from the control. Moreover, significantly fewer dressings were required per week in the ONS group compared with the control (P ≤ 0.045, RMMM) and less time was spent per week on changing the dressings (P ≤ 0.022, RMMM). At the end of the study, blood vitamin C levels had significantly increased in the ONS group compared with the control (P = 0.015, analysis of variance).ConclusionSpecific nutritional supplementation accelerated healing of pressure ulcers and decreased wound care intensity in non-malnourished patients, which is likely to decrease overall costs of pressure ulcer treatment.     

Honey in wound care: antibacterial properties

Honey is an ancient wound treatment that was re-introduced into modern medical practice in Australasia and Europe following the development of regulated wound care products. Its therapeutic properties are attributed to its antimicrobial activity and its ability to stimulate rapid wound healing. This review will briefly describe the evidence that demonstrates its antimicrobial activity in vitro and in vivo.     

Serum albumin level is a limited nutritional marker for predicting wound healing in patients with pressure ulcer: two multicenter prospective cohort studies

Background & aims

We aimed to investigate the predictive validity of serum albumin for pressure ulcer healing, according to patient condition and wound characteristics.

Methods

This study was a secondary analysis of pooled data from two multicentre cohort studies undertaken in 2005 and 2007. All adult patients with pressure ulcer were included and were tracked until wound healing or discharge from care. Baseline serum albumin data were obtained from medical charts.

Results

A total of 2530 patients were analyzed. By multivariate Cox proportional hazards analysis, higher serum albumin level was associated with wound healing of only superficial pressure ulcers for patients in acute/postoperative conditions (hazard ratio 1.29, 95% confidence interval 1.13–1.46) and the cutoff point was 24/25 g/L. However, the addition of serum albumin level to other factors resulted in little increase in the ability to predict wound healing as measured by the overall C-statistics. For patients in chronic/palliative conditions, serum albumin level as the continuous variable was not significantly associated with ulcer healing.

Conclusions

The addition of serum albumin marker may not have much advantage to predict pressure ulcer healing although its level can be associated with ulcer healing, depending on patient condition and wound depth.     

Conceptual issues in the analysis of cost data within cluster randomized trials

Cluster randomized controlled trials (RCTs) are increasingly used in economic evaluations of social, educational and health care interventions. Methodological research has, therefore, been spread across several disciplines, with the result that it has taken many years for guidelines on good statistical practice in the design and analysis of such trials to become easily accessible to health service researchers. These guidelines remain incomplete, however, because they do not take account of issues specific to the analysis of cost data. In particular, they fail to recognize that the calculation of confidence intervals around costs needed to inform health care priority setting raises unique methodological issues. If poorly designed trials are to be avoided in future (including those by the authors), then collaboration between triallists and health economists is required. This paper sets out a framework that should facilitate such collaboration and draws attention to problems that must be addressed quickly in the design of cluster-based economic evaluations.     

The interaction between research and practice: a pan-European approach to managing H.pylori infection in primary care

The transposition of evidence into clinical care presents many challenges. New knowledge may be immediately translatable to the practice setting, with barriers to be overcome before implementation. The early guidelines on Helicobacter pylori management presented an overview but were not able to take into account local factors and health care traditions, such as the non-availability of tests and established primary-secondary care relationships. Primary care is a specific specialty across most of Europe, existing within different health care systems and clinical traditions. The creation of H. pylori management guidelines, aimed at European primary care but adaptable to local national circumstances, presented a challenge in methodology and formulation. The process exposed similarities but also tensions between differing health care systems, as well as variations in the conditions in which GPs practise. Clinical differences, such as varying ulcer prevalence and drug resistance rates, highlighted the importance of guidelines being adaptable. This paper analyses the European Society for Primary Care Gastroenterology process of pan-European primary care agreement towards H.pylori management and how diverse views, traditions and national settings were reconciled through an evidence-based approach.     

Neonatal Care Management

Neonatology has become a prime target for specialty care management or population management services. As the cost of caring for the neonatal intensive care unit (NICU) population steadily rises, with no accompanying increase in quality information, health plans and large self-insured groups have increasingly taken notice. Some plans have attempted to manage this challenging population on their own; others have sought outside solutions. One such program is that developed by Paidos Health Management Services, founded in 1996.This article identifies the key issues surrounding neonatology and medically complex newborns and suggests factors that need to be addressed by a comprehensive neonatal care management program. It explains elements of the Paidos program and how this model becomes operational. Using key program elements including a specific patient grouper system, clinical management guidelines, physician advisory boards, outcome measurements and family satisfaction, the success of the program is described.Wide variation in clinical practice is demonstrated by the duration of methyl-xanthine therapy with a 2-fold difference seen in various regions. The cornerstone of improvement in practice is the use of sound clinical management guidelines.As documentation that improvement can be made, a revised feeding guideline improved the time to first feeds by as much as 50% at certain gestational ages. Guideline compliance overall averaged greater than 90%. This success was achieved by developing these evidence-based guidelines in cooperation with practicing physicians.With a fully implemented program, cost savings can reach 10% but vary depending on hospital contracts. Absolute reduction in length of stay and leveling of care are components of cost reductions. For those health plans lacking different contracted levels, there exist opportunities in future contracting with the level-of-care approach. Timely discharge of an infant depends on competent, high quality home care services being available. The high degree of family satisfaction with the program indicates that measures to contain utilization as part of the care management process are not burdensome.There are significant barriers and challenges to overcome when establishing a neonatal care management program. These include the relatively closed practice style of neonatology, financial concerns of physicians and hospitals and the issues of ‘control’ over what is best for the patient. However, given the current climate of managed care, a comprehensive, integrated approach can offer a successful solution.     

Nutritional issues in long-term care

Because long-term care residents often have chronic illnesses and complex care regimens, nutritional issues are common in these populations. Furthermore, management is complicated because some residents are terminally ill and under palliative care treatment plans that allow for dehydration and low oral intake. As a result, the medical management of nutrition is complex and challenging for medical providers caring for residents of nursing homes, assisted living facilities, and other long-term care settings. Quality nutritional practice in long-term care involves careful assessment of barriers to adequate nutrition; reduction of risk factors; attention to specialized diets, food presentation, and supplements, when appropriate; awareness of the importance of psychosocial and environmental issues; and consideration of the role of medication both as a cause and a therapeutic adjunct. Optimal practice at a facility level would involve a systematic approach to applying the best evidence-based approaches, with a focus on individualizing each resident's nutritional management.     

In my opinion . . .Top ten “no cost”; features

This paper focuses on some of the major issues surrounding the measurement of children's pain, particularly as they relate to problems of definition, level of measurement, dimensionality, reliability, and validity. The authors briefly describe some of the tools used with children and point out some of the problems that have resulted from the lack of well-tested, thoroughly validated instruments for children. As a common experience of hospitalized children, pediatric pain is creating concern within the health care community. The authors recommend that more attention be paid to the measurement issues surrounding this clinical phenomenon.