A randomised controlled trial of the effectiveness of soft silicone multi‐layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial

The prevention of hospital acquired pressure ulcers in critically ill patients remains a significant clinical challenge. The aim of this trial was to investigate the effectiveness of multi‐layered soft silicone foam dressings in preventing intensive care unit (ICU) pressure ulcers when applied in the emergency department to 440 trauma and critically ill patients. Intervention group patients (n = 219) had Mepilex^® Border Sacrum and Mepilex^® Heel dressings applied in the emergency department and maintained throughout their ICU stay. Results revealed that there were significantly fewer patients with pressure ulcers in the intervention group compared to the control group (5 versus 20, P = 0·001). This represented a 10% difference in incidence between the groups (3·1% versus 13·1%) and a number needed to treat of ten patients to prevent one pressure ulcer. Overall there were fewer sacral (2 versus 8, P = 0·05) and heel pressure ulcers (5 versus 19, P = 0·002) and pressure injuries overall (7 versus 27, P = 0·002) in interventions than in controls. The time to injury survival analysis indicated that intervention group patients had a hazard ratio of 0·19 (P = 0·002) compared to control group patients. We conclude that multi‐layered soft silicone foam dressings are effective in preventing pressure ulcers in critically ill patients when applied in the emergency department prior to ICU transfer.     

Albumin administration prevents the onset of pressure ulcers in intensive care unit patients

Pressure ulcers (PUs) are a common problem in critically ill patients admitted to the intensive care units (ICUs) and they account for more than 70% of patients with low serum albumin at admission. The aim of this study was to test the efficacy of intravenous administration of albumin in patients with low serum albumin < 3·3 g/dl. In a 1‐year period, a total of 73 patients were admitted to the ICU (males 45, 61·64% and females 28, 38·36%); of these, 21 patients were admitted with hypoalbuminaemia (serum albumin < 3·3 g/dl) and randomised into two groups: 11 patients were treated with 25 g intravenous albumin for the first 3 days within the first week of ICU stay (group A) and 10 patients did not receive albumin (group B). Three patients (27·27%) showed the onset of PUs in group A, whereas seven patients (70%) showed the onset of PUs within the first 7 days of stay in group B. Moreover, ulcers of group B were more severe than those of group A. This study shows that intravenous administration of albumin reduces the onset of PUs in patients admitted to the ICU and in some cases it also reduces the risk of progression to advanced stages of PUs.     

Multiple ulcers of the ileum due toCytomegalovirus infection in a patient who showed no evidence of an immunocompromised state

68-year-old woman presented with abdominal pain and vomiting. After initial conservative therapy, laparotomy showed multiple ulcers of the ileum, one of which had perforated and adhered to the uterus. The affected segment of the ileum was resected. Numerous cytomegalic cells, corresponding to endothelia and macrophages, with intranuclear inclusion bodies, were found in microscopic sections of the ulcerated lesions. These findings were consistent with cytomegalic vasculitis and enteritis.Cytomegalovirus infections of the alimentary tract have been, reported mainly in severely immunocompromised patients or those with predisposing disorders such as ulcerative colitis; their prognosis is usually poor. In our patient, there was no obvious immunocompromised state or other gastrointestinal disorders. The postoperative course has been uneventful for 2 years after surgery. The prognosis ofCytomegalovirus-associated lesions in the alimentary tract may be quite good in the immunocompetent patient.     

Profiling nursing homes using Bayesian hierarchical modeling

OBJECTIVES: New methods developed to improve the statistical basis of provider profiling may be particularly applicable to nursing homes. We examine the use of Bayesian hierarchical modeling in profiling nursing homes on their rate of pressure ulcer development. DESIGN: Observational study using Minimum Data Set data from 1997 and 1998. SETTING: A for-profit nursing home chain. PARTICIPANTS: Residents of 108 nursing homes who were without a pressure ulcer on an index assessment. MEASUREMENTS: Nursing homes were compared on their performance on risk-adjusted rates of pressure ulcer development calculated using standard statistical techniques and Bayesian hierarchical modeling. RESULTS: Bayesian estimates of nursing home performance differed considerably from rates calculated using standard statistical techniques. The range of risk-adjusted rates among nursing homes was 0% to 14.3% using standard methods and 1.0% to 4.8% using Bayesian analysis. Fifteen nursing homes were designated as outliers based on their z scores, and two were outliers using Bayesian modeling. Only one nursing home had greater than a 50% probability of having a true rate of ulcer development exceeding 4%. CONCLUSIONS: Bayesian hierarchical modeling can be successfully applied to the problem of profiling nursing homes. Results obtained from Bayesian modeling are different from those obtained using standard statistical techniques. The continued evaluation and application of this new methodology in nursing homes may ensure that consumers and providers have the most accurate information regarding performance.     

加巴喷丁联合血液透析滤过治疗尿毒症不宁腿综合征

目的探讨加巴喷丁联合血液透析滤过(HDF)治疗尿毒症不宁腿综合征(RLS)临床疗效。方法 60例尿毒症并发RLS患者简单随机分成两组,试验组(HDF+加巴喷丁)、对照组(HDF),各30例,治疗前和1个月后,测定血清中甲状旁腺激素(PTH)、铁蛋白浓度,并分别采用RLS病情严重程度评分量表和匹兹堡睡眠质量表评估疗效。结果两组PTH水平、RLS量化评分和匹兹堡睡眠质量表评分治疗后比治疗前显著降低,差异有统计学意义(P<0.01);试验组治疗后RLS量化评分和匹兹堡睡眠质量评分较对照组治疗后低(P<0.01);试验组有轻度嗜睡反应。结论加巴喷丁联合HDF可以有效治疗尿毒症RLS。     

补肾活血中药联合耳穴压豆干预肾虚血瘀型胚胎移植不孕症患者的临床研究

[目的]分析和总结姚新苗教授采取"温阳祛瘀"法治疗足痹的临床经验和学术思想。[方法]通过跟师临诊,收集整理姚师治疗足痹的病案,对其病机病因、治疗原则及遣方用药之独特之处加以归纳总结,并列举验案两则予以佐证。[结果]足痹多由痹邪侵袭日久,迁延不愈,致阳气虚衰,阳虚则寒凝脉络,四肢末端气血瘀滞,脉道失于贯注温养,发为该病。姚师从"久病多虚"和"久病多瘀"的角度,选择温阳祛瘀的经方桂枝茯苓汤加减治疗,疗效显著。所举医案分别为久病及外伤术后,外邪侵踞,或虚瘀夹杂,以致阳气虚衰,或内生血瘀,虚、邪、瘀胶着不去,深入肌肤、骨节而致足痹,以桂枝茯苓汤合四味健步汤加减以温阳祛瘀通络,治疗后随访1年未见复发。[结论]姚师治疗足痹,以"温阳祛瘀"为治疗原则,首重扶正而兼顾祛邪,温阳祛瘀通络,为临床诊疗提供了新思路,值得推广。     

神经肽P物质在糖尿病足溃疡皮肤中的表达变化

目的 探讨神经肽P物质（SP）在糖尿病足溃疡（DFU）皮肤中的表达变化. 方法 免疫组织化学法观察对照（Con）、非糖尿病DFU（NDFU）组和DFU组皮肤组织中SP及增殖细胞核抗原（PC-NA）的表达特点. 结果 SP表达量在Con、NDFU和DFU组分别为79.64、65.12和45.30 （P＜0.01）.PCNA阳性细胞率在Con、NDFU和DFU组分别为（35.120±7.314）％,（33.880±4.055）％和（28.320±9.332）％,NDFU组与Con、DFU组比较差异有统计学意义（P＜0.01）,但NDFU组和Con组比较差异无统计学意义（P＞0.05）. 结论 DFU患者边缘皮肤中SP表达量减少,可能是导致糖尿病患者创面炎症反应异常及创面修复细胞增殖功能受损,从而引起创面修复受损的原因之一.     

Confusing untypical intestinal Behcet's disease:Skip ulcers with severe lower gastrointestinal hemorrhage

Behcet's disease(BD) is a rare and life-long disorder characterized by inflammation of blood vessels throughout the body. BD was originally described in 1937 as a syndrome involving oral and genital ulceration in addition to ocular inflammation. Intestinal BD refers to colonic ulcerative lesions documented by objective measures in patients with BD. Many studies have shown that over 40% of BD patients have gastrointestinal complaints. Symptoms include abdominal pain, diarrhea, nausea, anorexia and abdominal distension. Although gastrointestinal symptoms are common, the demonstration of gastrointestinal ulcers is rare. This so-called intestinal BD accounts for approximately 1% of cases. There is no specific test for BD, and the diagnosis is based on clinical criteria. The manifestations of intestinal BD are similar to those of other colitis conditions such as Crohn's disease or intestinal tuberculosis, thus, it is challenging for gastroenterologists to accurately diagnose intestinal BD in patients with ileocolonic ulcers. However, giant ulcers distributed in the esophagus and ileocecal junction with gastrointestinal hemorrhage are rare in intestinal BD. Here, we present a case of untypical intestinal BD. The patient had recurrent aphthous ulceration of the oral mucosa, and esophageal and ileo-colonic ulceration, but no typical extra-intestinal symptoms. During examination, the patient had massive acute lower gastrointestinal bleeding. The patient underwent ileostomy after an emergency right hemicolectomy and partial ileectomy, and was subsequently diagnosed with incomplete-type intestinal BD by pathology. The literature on the evaluation and management of this condition is reviewed.     

Unitary step of gliding machinery in Mycoplasma mobile

Among the bacteria that glide on substrate surfaces, Mycoplasma mobile is one of the fastest, exhibiting smooth movement with a speed of 2.0–4.5 μm⋅s⁻¹ with a cycle of attachment to and detachment from sialylated oligosaccharides. To study the gliding mechanism at the molecular level, we applied an assay with a fluorescently labeled and membrane-permeabilized ghost model, and investigated the motility by high precision colocalization microscopy. Under conditions designed to reduce the number of motor interactions on a randomly oriented substrate, ghosts took unitary 70-nm steps in the direction of gliding. Although it remains possible that the stepping behavior is produced by multiple interactions, our data suggest that these steps are produced by a unitary gliding machine that need not move between sites arranged on a cytoskeletal lattice.The fastest of the Mycoplasma species is Mycoplasma mobile (M. mobile); they glide with a speed of 2.0–4.5 μm⋅s⁻¹ (1, 2). Under an optimal-growth condition, cultivated single M. mobile cells are flask-shaped (Fig. 1A) and glide smoothly across a substrate covered with surface-immobilized sialylated oligosaccharides (3) in the direction of protrusion at a constant speed (Movie S1). Genomic sequencing and analysis have revealed that the mechanism must differ from other forms of motor protein systems and bacterial motility, because M. mobile lacks genes encoding conventional motor proteins in eukaryotes, such as myosin, kinesin, and dynein, in addition to lacking other motility structures in bacteria, such as flagella and pili (4). So far, three proteins have been identified as a part of the gliding machinery (Fig. 1B, Bottom): Gli123 (5), Gli521 (6), and Gli349 (7). The machinery units localize around the cell neck, and their number has been estimated to be ∼450 (2, 5, 8). Gli349 extends out from the cell membrane and shows a rod structure, ∼100 nm in total, with two flexible hinges when isolated (9). Notably, the machinery is driven by hydrolysis of ATP to ADP and inorganic phosphate, caused by an unknown ATPase (10). Because of the large size and characteristic structure of Gli349, and a series of studies with mutants and inhibitory antibodies (2, 11), it has been hypothesized that Gli349 works as a “leg” by binding to and releasing from a substrate covered with randomly arranged sialylated oligosaccharides (2) consuming the chemical energy of ATP. In addition, the pivoting movement of an elongated cell suggests that there are units working not simultaneously but rather independently to propel the cell forward (12). To test this hypothesis and identify conformational changes of a key part of the gliding machinery, we here designed an assay to detect the movement of M. mobile by high precision colocalization microscopy. In the presence of an excess number of binding targets in the solution, which decreased the number of active legs, stepwise displacement was shown for the first time, to our knowledge, to occur in gliding bacteria.Open in a separate windowFig. 1.Nanometer-scale tracking of Mycoplasma gliding. (A) A dark-field image of M. mobile. The image was captured with center-stop optics to maintain the high numerical aperture of the objective, which enabled a high spatial resolution (35). (Scale bar: 1 μm.) (B, Upper) Illustration of the fluorescent ghost. The gliding machinery was distributed around the neck portion, but only the active machinery bound to the glass is shown for simplicity. (Bottom) A construction model of the gliding machinery comprising three proteins: Gli123, Gli521, and Gli349. See the review by Miyata (2) for more detail. (C) A fluorescent image of the labeled ghost was acquired with a time resolution of 2 ms. (Scale bar: 1 μm; pixel size: 240 nm.) (D) The intensity profile of C. The XY area is 5 × 5 μm. (E) Gaussian fitting to D. Nanometer-scale tracking is achieved by positioning the peak of the 2D Gaussian function fitting to the intensity profile of the ghost. (F, Left) The speed of gliding ghosts at different [ATP]s in the solution (n = 129). The cyan curve shows a fit with Michaelis–Menten kinetics; Vmaxspeed and K_m are 2.6 µm⋅s⁻¹ and 61 µM, respectively. The dotted cyan curve shows a fit with the kinetics including the Hill coefficient; Vmaxspeed, [ATP₅₀] and n are 2.2 µm⋅s⁻¹, 43 µM, and 2.4, respectively. (Right) The speed of living cells with no ATP in the solution (2.1 ± 0.1 µm⋅s⁻¹; n = 22). (G) Effect of SL on the gliding velocity of the ghost at saturated [ATP]s, 0.3–1.0 mM (n = 50).