小柳 礼恵

皮膚・排泄ケア認定看護師(WOCN)の資格をもちWOC領域の専門外来に従事している11名にアンケートとインタビューを行い、以下の項目について調査した結果を報告した。1)実施している特定行為の内容。2)従事している専門外来の概要。3)同行訪問の状況。4)専門外来における診療報酬の算定。5)専門外来におけるアウトカム評価。6)主治医との連携。7)病棟との連携。8)訪問看護師との連携。9)在宅医療との連携。10)高齢者施設との連携。11)施設管理職との関係性。12)所属する施設の組織体制。13)所属施設での環境調整。14)施設の医師との関係性。15)施設の職員との関係性。16)複数のWOCN間の連携。17)WOCNの業務の調整。18)物品の調達。19)専門外来におけるWOCNの存在意義。20)専門外来におけるWOCNの役割。

AIM: We aim to identify measures implemented by hospital nursing directors early in the COVID-19 pandemic and enabling factors. BACKGROUND: Managerial factors affect nurses' physical and mental health and willingness to work, especially early in a pandemic. METHOD: We used multiple-case study of 15 hospitals, comparing management approaches by interviewing 28 nursing directors and their assistants from August to December 2020. RESULTS: Hospitals that accepted COVID-19 patients and hospitals that unexpectedly experienced clusters underwent a nursing provision system organization phase, followed by an adjustment phase to maintain nursing organization function. Two factors aided measure implementation: an emergency system and staff protection policies. CONCLUSION: Early epidemic management strategies apply across contexts. The hospital's basic attitude is key to effective implementation of the strategies. IMPLICATIONS FOR NURSING MANAGEMENT: The results suggest that hospitals, nursing directors and nurses can each prepare for future emerging infectious disease epidemics.

AIM: Temporary lodging facilities which were non-medical facilities were established to secure beds for severely and moderately ill patients with COVID-19, as well as for isolation, non-contact observation, and care of mildly ill and asymptomatic patients in Japan. This study aims to understand nursing management practices adopted in these facilities by examining cases of their establishment and operation. METHODS: A multiple-case study design was used. Interviews for qualitative data collection were conducted from August to October 2020. After analyzing the nursing management practices in four temporary lodging facilities, common points were collated and integrated. RESULTS: For the establishment and operation of temporary lodging facilities, a three-layer structure based on disaster management methods was adopted: headquarters at the helm as overseers, field supervisors in the middle, and frontline nursing staff at the base. The structure had clear roles, facilitated information exchange, and provided efficient and effective nursing care. Field supervisors mainly provided psychological and clinical support for staff and served as information and interprofessional hubs. CONCLUSION: It is recommended that temporary lodging facilities should be organized based on principles of the division of labor. The workforce should comprise nursing staff, and experienced nursing professionals should be recruited to the higher echelons.

AIMS: The study aimed to identify the aspects and items of nurse turnover impact on organizations as perceived by nursing management. BACKGROUND: Turnover rate does not capture the extent to which an organization is affected by turnover. Another indicator is required to assess the control status of turnover impact. METHODS: A Delphi study was conducted in 2021, where 2670 managers of nursing at 712 hospitals were asked to complete the survey three times. Factor analysis was conducted on these items for which a consensus was reached. RESULTS: Overall, 232 managers who responded multiple times, including the third survey, were included in the analysis. Consensus was reached for 36 items affected by turnover and considered important for nursing management. Using exploratory factor analysis, the following six factors were extracted: quality of nursing care, physical and mental health of nursing staff, workload and working conditions of nursing staff, relationships among nursing staff members, sense of responsibility among nursing staff, and cost and benefit of hiring replacement personnel. CONCLUSIONS: Six factors consisting of 36 items were extracted that can be used to assess the impact of nurse turnover. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers can assess the status of the organization more appropriately by understanding the factors that impact nurse turnover in vaious facilitites and look at strategies to overcome the impact on nurse staffing.

AIM: This study investigates which work-related communication mediates the relationship between diversity climate and psychological empowerment among part-time nurses. BACKGROUND: Part-time nurses' high psychological empowerment is desirable because it may lead to high quality nursing practice. METHODS: Anonymous self-report questionnaires or web-based surveys were used to measure diversity climate (Climate for Inclusion Scale), psychological empowerment (Japanese version of the Psychological Empowerment Scale) and work-related communication (scale developed in this study). The respondents were part-time nurses from departments with shift work in six Japanese hospitals having over 200 beds. The surveys were conducted from September to October 2020. Multiple regression analyses and a significance test of indirect effects were then conducted. RESULTS: Among the work-related communication components, 'expressing thoughts about their work' fully mediated the relationship between diversity climate and psychological empowerment. CONCLUSIONS: It is important for part-time nurses to be actively 'expressing thoughts about their work' to enhance their psychological empowerment. Positive diversity climate is also important because it allows part-time nurses to express their thoughts regarding work. IMPLICATIONS FOR NURSING MANAGEMENT: Managers can enhance part-time nurses' psychological empowerment by encouraging them to express their work-related opinions based on the diversity climate.

Background: Cellulitis is frequently encountered in patients with lymphedema despite existing prevention protocols. To resolve this issue, social aspects surrounding patients, such as communication with patients and professionals, are necessary to consider new approaches. This study aimed to clarify the association between the history of cellulitis in patients with lymphedema and access to specialists after adjustment for relevant confounding factors. Methods and Results: This study was a secondary analysis of the Lymphoedema IMpact and PRevalence-INTernational (LIMPRINT) study using a national Japanese database of adult lymphedema compiled between 2014 and 2015 (n = 113). Descriptive data were collected for patient characteristics. Multivariate logistic regression analysis was conducted to explore possible risk factors for patients having experienced cellulitis. The duration of edema ranged from <6 months (16.2%) to 10 years or longer (25.2%), with varying severity. History of cellulitis was observed in 31.9% of patients. The prevalent treatment techniques within the context of complex decongestive therapy included skin care advice (52.2%), compression garments (55.8%), exercise advice (41.6%), multilayer bandages (38.1%), cellulitis advice (49.6%), and massage (61.1%). Overall, 57.1% of patients had access to lymphedema specialists. Longer duration of lymphedema (adjusted odds ratio [AOR] = 4.10, p = 0.005) and access to lymphedema specialists (AOR = 0.28, p = 0.009) were significantly associated with a history of cellulitis. Conclusions: A history of cellulitis in patients with lymphedema is associated with limited access to specialists. To support self-care in this patient population, reasonable consideration systems, including telehealth, should be developed to facilitate communication between specialists and patients and decrease the occurrence of cellulitis in lymphedema.

AIMS: Critical colonization in pressure ulcers delays healing and has been studied. However, local wound management includes no clear strategy for preventing the development of biofilms. Therefore, this multicenter, prospective, observational study was conducted to examine the effect of local management on the biofilm area of pressure ulcers with critical colonization. METHODS: Participants were 34 patients with a pressure ulcer deeper than the dermis and in a state of critical colonization. The primary outcome was the change over a week in the proportion of the biofilm area in relation to that of the pressure ulcer area. We investigated the relationship between primary outcome and local wound management. The wound-blotting method was used for determining the biofilm area. To calculate the change in the biofilm area, baseline proportion was subtracted from proportion 1 week later. RESULTS: Six types of topical treatment were used in three facilities. The proportion of the biofilm area at 1 week follow-up was significantly smaller with iodine ointment than that without iodine ointment (p = .02). The standardized partial regression coefficient of iodine ointment adjusted by the type of medical facility was -0.26 (p = .003). CONCLUSION: This study revealed that the use of iodine ointment reduced the proportion of the biofilm area in the pressure ulcer surface. To manage pressure ulcers in a state of critical colonization, these results suggest that local management include the use of iodine ointment.

AimsCritical colonization has attracted attention as a cause of delayed healing of pressure ulcers. However, there is no clear strategy for local wound management in such cases. Here, we prospectively investigated exudate, infection, and pressure ulcer status in a critical colonization state to determine the optimal strategy for local wound management of such pressure ulcers.MethodsThis prospective cohort study was conducted in three facilities: a university hospital, a general hospital, and a long-term care hospital. Subjects were patients with pressure ulcers at a depth deeper than the dermis with a diagnosis of critical colonization by a dermatologist or wound ostomy continence nurse. Patients were divided into three groups according to local wound management: Group A, hydrating ointment with infection control or low exudate-absorption dressing material; Group B, high exudate-absorption dressing material; and Group C, hydrating ointment with exudate-absorption and infection control. Exudate, the moisture of the surrounding wound skin, stratum corneum hydration, area of biofilm, bacterial count, and wound severity assessed by DESIGN-R, were measured at baseline and at 1 week. The relative changes in these variables at 1 week were calculated for the analysis. ResultsOverall, 16 patients were classified into Group A (n = 7), Group B (n = 5), and Group C (n = 4). The patients in all three groups ranged in age from 78 to 86 years old and ≥ 50% were male. At baseline, the median proportion of wound area covered by the biofilm was similar between the three groups (0.50, 0.59, and 0.30, respectively). The median total DESIGN-R score in Group A was lower than those in the other groups (12, 24, and 21.5, respectively). With regard to the changes after 1 week, the proportion of wound area covered by the biofilm in Group C was larger than those in the other groups (-0.18, -0.27, and -0.87, respectively). However, the change in total DESIGN-R score in Group C was smaller than those in the other groups (-0.12, -0.11, and -0.01, respectively).ConclusionChanges in infection and pressure ulcer status in cases of critical colonization were described according to local wound management. However, due to the small number of patients, it was not possible to determine the most appropriate local wound management for pressure ulcers in a critical colonization state.【目的】クリティカルコロナイゼーションは、褥瘡の治癒遅延の原因として、最近注目を受けている。しかし、クリティカルコロナイゼーション状態への局所管理に関する対策は明らかでない。この研究において、私たちは、クリティカルコロナイゼーション状態の褥瘡の局所管理の最適な方法を検討するために、滲出液、感染と褥瘡状態を前向きに調査した。【方法】本研究は、前向きコホート研究であり、大学病院、総合病院、長期ケア病院の 3施設で実施した。対象者は、皮膚科医師または皮膚・排泄ケア認定看護師によって真皮より深い褥瘡で、かつクリティカルコロナイゼーション状態であると判断された褥瘡を有する入院患者である。患者は、局所管理方法によって 3 つの群に分けられた：A 群（補水と感染制御作用がある外用薬または滲出液吸収作用の低いドレッシング材）;B 群（滲出液吸収作用が高いドレッシング材）;C 群（滲出液吸収作用と感染制御作用がある外用薬）。滲出液、褥瘡周囲皮膚と健常皮膚の角質水分量、バイオフィルム面積、褥瘡表面の細菌数と DESIGN-R による褥瘡状態得点を、ベースラインと 1 週間後に測定した。これらの変数の 1 週間後の変化量の相対値により分析した。【結果】全 16 例の患者は、A 群（n = 7 ）、B 群（n = 5 ）、C 群（n = 4 ）に分類された。3 群の年齢の中央値は 78 〜 86 歳であった。また患者の 50% 以上は男性だった。ベースライン時に、バイオフィフムの面積が創面の面積に占める割合の中央値は同程度であった(0.50 vs. 0.59 vs. 0.30)。さらに、A 群のDESIGN-R 総点の中央値は、他の群より低かった（12 vs. 24 vs. 21.5）。一方、 1 週間後の変化量の相対値は、バイオフィフムの面積が創面の面積に占める割合は C 群が他の群より大きかった（-0.18 vs. -0.27 vs. -0.87）。DESIGN-R の合計点は C 群が他の群より低かった（-0.12 vs. -0.11 vs. -0.01）。【結論】本研究では、褥瘡の局所管理方法別に、バイオフィルムの面積、バイオフィルムの面積が創面の面積に占める割合、褥瘡表面の細菌数、DESIGN-R による創傷治癒過程を記述した。しかし、症例数が少なく、クリティカルコロナイゼーションの褥瘡の管理方法を明らかにすることはできなかった。

治癒遅延状態にある褥瘡に使用する創傷被覆材を変更し、創底滲出液量と創周囲皮膚に接触する滲出液をコントロールすることで不顕性感染に影響するのかについて検討した。褥瘡回診チームが介入している滲出液を伴うd2の褥瘡を有する患者2名(89歳男性、82歳女性)を対象とした。症例1、2ともに、感染コントロールと滲出液コントロールのために、スクロードパスタを選択していたが、キュティメドシルテックL(P/Sドレッシング)へ変更していた。P/Sドレッシングへ変更後、DESIGN-Rにおける滲出液量は変化しなかったが、褥瘡創面から褥瘡周囲に接触する滲出液量は1〜2週目までの間に減少していた。Bates-Jensen Wound Assessment Toolの滲出液量における評価では、P/Sドレッシングへ変更前の「湿潤状態」から、変更後1週目は「湿った状態」に変化していた。

<p>【はじめに】</p><p></p><p>平成28年度の診療報酬改定で排尿自立指導料が新設され，多職種で構成された排尿ケアチームと病棟看護師等が排尿自立に対して包括的ケアを実施するシステムが動き始めた。当院では，平成28年6月より排尿ケアチームによる活動が開始している。今回，当院での排尿ケアチームの活動経過を振り返り，対象者の特徴を調査した。これらを通しチーム内での理学療法士（以下PT）の役割と今後の課題について検討したので報告する。</p><p></p><p>【方法】</p><p></p><p>排尿自立指導料算定に向けた事務部門との連携，排尿ケアチームの結成，施設基準申請に必要な院内勉強会の開催など，当院における一連の活動を振り返った。さらに平成28年6月の算定開始から8月までに排尿自立指導料を算定した入院患者150名及びリハビリテーション（以下リハ）科医師の処方を経てPTが個別療法として介入した33名を対象としてその特徴を検討した。</p><p></p><p>【結果】</p><p></p><p>当院では平成28年4月から関係部署のスタッフが集まり，診療計画書の作成や対象病棟・対象患者の院内基準の決定，コンサルト手順などのシステム作りを開始した。その上で，排尿自立指導料に関わる説明会，勉強会を実施し院内スタッフへの周知を行い，6月から算定を開始した。これまでに排尿自立指導料の対象となった患者は実人数150名，診療科は泌尿器科113名，整形外科23名，その他の診療科14名であった。そのうち通常のリハ処方を経てPTが介入したのは33名（23.2％）で，平均年齢は61.1±20.3歳，整形外科23名，泌尿器科6名，その他の診療科4名，手術目的での入院が28名であった。また，PT介入時に移動を含めたセルフケアが自立していたのは29名であり，リハ依頼は主に術後の安静度拡大に応じた動作指導，機能回復などが目的であった。</p><p></p><p>【結論】</p><p></p><p>多職種からなる排尿ケアチームの中で，PTは専門性を生かして排泄動作の妨げとなっている機能障害を評価し，病棟看護師等に対して安全な動作の誘導方法や環境設定を提案する役割を持つ。今回の調査では，当院での指導料算定対象病棟が外科中心であったため，リハ医の処方を経たPT介入目的は主に術後の身体機能へのアプローチであったことがわかった。今後の排尿ケアチームにおけるPTの役割として，術後の身体機能へのアプローチ以外にも疾患特性や既往歴などから判断して，低体力や骨盤底機能低下，巧緻運動機能低下などの個別に対応が必要と考えられる患者をスクリーニングし，積極的に個別療法の対象として提案していくことも重要であると考える。</p>

ストーマ療法看護師(ET)、皮膚・排泄ケア認定看護師(WOCN)の会員が在職している施設を対象に、スキン・テア(皮膚裂傷)の実態を把握するための調査を実施した。診療計画書、看護記録等から情報を収集した。調査協力に同意したET/WOCNが所属する374施設に調査を依頼し、257施設から回答が得られた。全調査施設の患者総数は93820名、スキン・テア有病患者総数は720名、スキン・テア総部位は925部位であった。スキン・テアの有病率は、一般病院(療養病床あり)1.26%、その他1.00%、一般病院(療養病床なし)0.91%、国立病院0.88%、大学病院0.46%、小児専門病院0.29%、訪問看護ステーション0.00%であり、施設種間で有意差がみられた。また、統合分類による診療科の平均有病率の上位3位は、皮膚科1.65%、膠原病科1.54%、ICU・救急科1.41%であった。スキン・テア保有者の平均年齢は79.6歳、男性が448名、女性が272名であった。

Early detection and intervention of deep tissue injury are important to lead good outcome. Although the efficiency of ultrasonographic assessment of deep tissue injury has been reported previously, it requires a certain level of skill for accurate assessment. In this study, we present an investigation of the combination of thermographic and ultrasonographic assessments for early detection of deep tissue injury. We retrospectively reviewed 28 early-stage pressure ulcers (21 patients) presenting at the University of Tokyo Hospital between April 2009 and February 2010, surveying the associated thermographic and ultrasonographic findings. The wound temperature patterns were divided into low, even and high compared with the surrounding skin. Ultrasonographic findings were classified into unclear layer structure, hypoechoic lesion, discontinuous fascia and heterogeneous hypoechoic area. All 13 ulcers that were associated with low temperature showed good outcome; three ulcers had even temperatures and 12 ulcers showed high temperature on thermographic assessment. The two deep tissue injuries were rated high on thermographic assessment and showed heterogeneous hypoechoic area findings on ultrasonographic assessment. No non-deep tissue injury lesion was associated with these two findings simultaneously. The combination of thermographic and ultrasonographic assessments is expected to increase the accuracy of the early detection of deep tissue injuries.

Objective: Granulation tissue colour may be an indicator for nutritional assessment in pressure ulcer (PU) care. This study evaluated the relationship between nutritional status, anaemia and diabetes, and granulation tissue colour of PUs by colour analysis of digital photographs in the clinical setting. Method: The cross-sectional study included 42 older patients with 51 full-thickness PUs from 10 institutions. Patient demographics, wound status, nutritional status and dietary intakes were obtained from medical charts. From a wound image, the granulation red index was processed by computer software and the proportion of pixels exceeding the threshold intensity of 80 for the granulation tissue surface (% GRI80) was calculated. Results: Haemoglobin levels were positively associated with % GRI80 levels (p=0.007) in the crude model, but not in the adjusted model (p=0.260). The interaction term between diabetes and protein intake was significantly associated with % GRI80 levels in the adjusted models (p=0.010). At protein intakes of 0.95 g/kg or higher, diabetic wounds exhibited lower % GRI80 levels than non-diabetic wounds (p=0.002). At protein intakes of less than 0.95 g/kg, % GRI80 levels did not differ between diabetic and non-diabetic patients (p=0.247). Protein intakes of 0.95 g/kg or higher were associated with higher % GRI80 levels in non-diabetic patients (p=0.015), but not in diabetic patients (p=0.127). Conclusion: Granulation tissue colour, evaluated by the objective and quantitative analysis of digital photography, is related to haemoglobin level, diabetes and dietary intakes in clinical settings.

Accurate assessment is necessary to evaluate peristomal skin condition, but objective methods are lacking. The purpose of this prospective, repeated-measures study was to evaluate the reliability and validity of color indicators using digital image analysis of peristomal skin photographs. The 6-month study was conducted among 21 patients (mean age 65.1 years old, 15 men) with ostomies (14 colostomies, six ileostomies, and one urostomy) at four outpatient clinics. Photographs taken by nurses of the peristomal area using point-and-shoot cameras were processed using digital image analysis, which involved color calibration, image processing, and indicator calculation. An erythema index (EI), melanin index (MI), and hypopigmentation index were created to represent increased degrees of red, black, and white color, respectively, and their average values in the peristomal region of an image were calculated relative to values for intact skin. Reproducibility was evaluated using the interclass correlation coefficient (ICC). ICCs of color indicators for intact skin were >0.7 between baseline and the end of follow-up for the 16 participants with two or more clinic visits. Differences in these indices between peristomal and intact regions were evaluated using a linear mixed model. The EI and MI of peristomal skin were significantly higher than those of intact skin (n=42, P<0.001). All color indicators in adjacent regions and areas where adhesive was applied were associated with the discoloration severity score and visual analogue pain score (all P<0.05). This objective and simple method had adequate reproducibility and criterion-related validity and may be useful for peristomal skin assessment. Further research is warranted.

Because wound exudate includes secreted proteins that affect wound healing, its biochemical analysis is useful for objective assessment of chronic wounds. Wound blotting allows for collection of fresh exudate by attaching a nitrocellulose membrane onto the wound surface. To determine its applicability for several analysis methods and its executability in clinical wound assessment, this study comprised an animal experiment and clinical case reports. In the animal experiment, full-thickness wounds were created on the dorsal skin of mice, and exudate samples were collected daily by a conventional method and by wound blotting. Extremely small but adequate volumes of exudate were collected by wound blotting for subsequent analysis in the animal experiments. Immunostaining showed the concentration and distribution of tumor necrosis factor (TNF) alpha. The activity of alkaline phosphatase was visualized by reaction with chemiluminescent substrate. The TNF distribution analysis indicated three different patterns: wound edge distribution, wound bed distribution, and a mostly negative pattern in both the animal and clinical studies, suggesting association between the TNF distribution pattern and wound healing. Our results indicate that wound blotting is a convenient method for biochemical analysis of exudate and a candidate tool with which to predict the healing/deterioration of chronic ulcers.

This multicenter prospective cohort study examined the predictive validity of granulation tissue color evaluated by digital image analysis for deep pressure ulcer healing. Ninety-one patients with deep pressure ulcers were followed for 3 weeks. From a wound photograph taken at baseline, an image representing the granulation red index (GRI) was processed in which a redder color represented higher values. We calculated the average GRI over granulation tissue and the proportion of pixels exceeding the threshold intensity of 80 for the granulation tissue surface (%GRI80) and wound surface (%wound red index 80). In the receiver operating characteristics curve analysis, most GRI parameters had adequate discriminative values for both improvement of the DESIGN-R total score and wound closure. Ulcers were categorized by the obtained cutoff points of the average GRI (≤80, &gt;80), %GRI80 (≤55, &gt;55-80, &gt;80%), and %wound red index 80 (≤25, &gt;25-50, &gt;50%). In the linear mixed model, higher classes for all GRI parameters showed significantly greater relative improvement in overall wound severity during the 3 weeks after adjustment for patient characteristics and wound locations. Assessment of granulation tissue color by digital image analysis will be useful as an objective monitoring tool for granulation tissue quality or surrogate outcomes of pressure ulcer healing. © 2012 by the Wound Healing Society.

滲出液管理は、全層欠損褥瘡の局所管理に重要である。適切な管理方法の選択には、滲出液量の評価が必須となる。従来の評価法である創傷被覆材交換回数や重量による推定は半定量的であり、妥当性と信頼性に限界がある。本研究の目的は、全層欠損褥瘡の滲出液量分布を明らかにし、褥瘡の重症度を用いた滲出液量の定量的推定アルゴリズムを検討することである。研究デザインは横断研究であり、60歳以上の全層欠損褥瘡保有患者36名44褥瘡を対象とした。基準として、ポリウレタンフィルムを貼付し、中に貯留させた滲出液量を測定した。滲出液量の中央値(範囲)は4.2(0.1-47.0)ml/日であった。一般線形モデルを用いて滲出液量実測値の推定モデルを検討した結果、ガーゼ交換回数を用いた評価法単独よりも(R2=0.44)、ガーゼ交換回数と22点ごとにカテゴリー化したDESIGN-R総点、治癒過程を組み合わせた計5クラスを用いたモデルのあてはまりが最も高かった(R2=0.67)。滲出液量予測値(ml/日)の平均(95%信頼区間)は、クラス1:0.2(0.1-0.4)、クラス2:1.2(0.6-2.2)、クラス3:4.7(2.2-10.0)、クラス4:7.3(3.4-15.7)、クラス5:27.3(9.8-76.0)であった。以上より、定量的な滲出液量推定アルゴリズムが開発され、褥瘡の滲出液管理方法の標準化に貢献できる。(著者抄録)

UNLABELLED: The ability to predict the prognosis of a pressure ulcer is re- quired to establish appropriate management in the early phase. The present study reports the usefulness of a combined assessment tech- nique using ultrasonography and thermography for predicting delayed wound healing. METHODS: This retrospective cohort study included 37 patients with Stage I or II pressure ulcers. The patients were followed up for at least 3 weeks. The ultrasonographic and thermographic as- sessments were conducted at the initial multidisciplinary team round. The presence of four ultrasonographic features (unclear layered struc- ture, hypoechoic lesion, discontinuous fascia, and heterogeneous hy- poechoic area) and one thermographic feature (increased temperature) were determined from within the wound bed. Wound healing was re- assessed after 2 weeks and the rate of area reduction was calculated to determine whether the pressure ulcer was healing properly. A mul- tivariate logistic analysis was used to assess the predictive values of the possible assessment features. RESULTS: A comprehensive review of the ultrasonographic and thermographic assessments of the pressure ulcers found that the combination of unclear layered structure and increased temperature was beneficial for predicting wound healing. When a pressure ulcer presented with an unclear layered structure and increased temperature in the wound bed, the risk of delayed wound healing or wound deterioration was 6.85 times higher compared with a pressure ulcer that did not have these manifestations. CONCLUSION: The combination of ultrasonographic and thermographic assessments facilitates precise prediction of pressure ulcer outcomes.

OBJECTIVE: Protein loss from wound fluid is usually recognized as one of the factors contributing to the deterioration of the nutritional status in older patients with severe pressure ulcers. We quantified the protein loss owing to pressure ulcers and investigated associations with wound-related factors and nutritional status. METHODS: This cross-sectional study included 25 patients (>or=60 y) from 10 institutions, with full-thickness pressure ulcers. Wound fluid was collected once after accumulating beneath a film dressing. The amount of protein loss per day was estimated by the volume of wound fluid per hour and the total protein concentration in the wound fluid. Wound evaluations and nutritional assessments were performed. Correlations between variables were obtained using Spearman's rank correlation. RESULTS: The median age of the patients was 79 y (range 61-100), and median body mass index was 19.6 kg/m(2) (12.2-24.9). The median amount of protein loss was 0.2g/d (0.04-2.1), which corresponded to 0.01 g x kg(-1) x d(-1) (<0.01-0.04) and 0.6% (0.1-13.8) of protein intake. Four wounds characterized as infected or surgically debrided lost 1.5-2.1g of protein per day, which was substantially higher than other wounds lost. Protein loss was correlated with wound severity including area, depth, the wound severity score, and infectious markers (all Ps<0.05), but not with body mass index or arm muscle circumference (P>0.05). CONCLUSION: The amount of protein loss could be small and thus may not be related directly to nutritional status, although it increased as the wound became more severe.

Objective: To investigate whether thermography can be used to detect latent inflammation in pressure ulcers and predict pressure ulcer prognosis in a clinical setting. Method: For this cohort study, we recruited 35 patients with stage II-IV pressure ulcers on the torso, who underwent thermographic assessment on discovery of their pressure ulcer. The patients were followed up for at least 3 weeks. Thermography was performed immediately after dressing removal. Pressure ulcers were classified into two groups depending on whether or not the wound site temperature was lower or higher than the periwound skin: the low temperature group and the high temperature group respectively. A generalised estimation equation was used to estimate the relative risk of delayed healing of pressure ulcers, comparing wounds with high temperatures and low temperatures. Results: Of the 35 patients, 21 had &#039;low temperature&#039; wounds and 14 had &#039;high temperature&#039; wounds at baseline. Two patients in the high temperature group presented with overt infection, and were excluded from further analysis. Twenty-two pressure ulcers were considered to heal &#039;normally&#039; (that is, the wound area reduced by 30% or more within 3 weeks) and 16 did not heal. The baseline DESIGN score (a measure of gross wound status) did not differ in any subscales between the high and low temperature groups. The relative risk for delayed healing in high temperature cases was 2.25 (95% confidence intervals; 1.13-4.47, p=0.021). Sensitivity was 0.56, specificity was 0.82, positive predictive value was 0.75, and negative predictive value was 0.67. Conclusion: Our results indicate that using thermography to classify pressure ulcers according to temperature could be a useful predictor of healing at 3 weeks, even though wound appearances may not differ at the point of thermographical assessment. The higher temperature in the wound site, when compared with periwound skin, may imply the presence of critical colonisation, or other factors which disturb the wound healing. Conflict of interest: None.

Evaluation of wound fluid characteristics for pressure ulcer (PU) assessment in clinical settings remains subjective, requiring considerable expertise. This cross-sectional study focused on nutritional markers in wound fluid as possible objective tools and investigated whether they reflect the PU status according to the healing phase, infection, and granulation, especially after adjusting for serum values. Twenty-eight patients with 32 full-thickness PUs were studied. The concentration of albumin, total protein, glucose, and zinc in wound fluid were measured. For PU status, the healing phases and infection were evaluated by clinical signs, and the degree of granulation tissue formation was determined as the hydroxyproline concentration. The wound fluid/serum ratio for albumin was significantly lower during the inflammatory phase than during the proliferative phase (p=0.020). Infected wound fluid contained less glucose (0.3-1.0 mmol/L) than noninfected ones did (5.0-7.6 mmol/L) in an intraindividual comparison of three cases. The wound fluid/serum ratio for glucose was negatively correlated with hydroxyproline level in the proliferative phase (ρ=-0.73, p=0.007), while zinc level in wound fluid showed a positive correlation (ρ=0.61, p=0.028). Our results suggest that these traditional nutritional markers in wound fluid, especially wound fluid/serum ratio may be useful to evaluate local PU status. © 2010 by the Wound Healing Society.

Evaluation of wound fluid characteristics for pressure ulcer (PU) assessment in clinical settings remains subjective, requiring considerable expertise. This cross-sectional study focused on nutritional markers in wound fluid as possible objective tools and investigated whether they reflect the PU status according to the healing phase, infection, and granulation, especially after adjusting for serum values. Twenty-eight patients with 32 full-thickness PUs were studied. The concentration of albumin, total protein, glucose, and zinc in wound fluid were measured. For PU status, the healing phases and infection were evaluated by clinical signs, and the degree of granulation tissue formation was determined as the hydroxyproline concentration. The wound fluid/serum ratio for albumin was significantly lower during the inflammatory phase than during the proliferative phase (p=0.020). Infected wound fluid contained less glucose (0.3-1.0 mmol/L) than noninfected ones did (5.0-7.6 mmol/L) in an intraindividual comparison of three cases. The wound fluid/serum ratio for glucose was negatively correlated with hydroxyproline level in the proliferative phase (=-0.73, p=0.007), while zinc level in wound fluid showed a positive correlation (=0.61, p=0.028). Our results suggest that these traditional nutritional markers in wound fluid, especially wound fluid/serum ratio may be useful to evaluate local PU status.

褥瘡からの蛋白質漏出量を滲出液中の総蛋白濃度と滲出液量より推定する方法の再現性を重度褥瘡保有高齢者3名(男1名、女2名、77〜91歳)で確認した。次に同様の15名(男7名、女8名、平均年齢76.9歳)を対象として空腹時の滲出液から蛋白質漏出量を推定し、栄養状態・褥瘡の重症度との関連を検討した。15名の蛋白質漏出量の中央値は0.4g/日、蛋白質摂取量に占める割合は1.2%であり、血清アルブミンやBMIなどの栄養指標との関連は認めなかった。褥瘡からの蛋白質漏出量は患者の栄養状態に直接影響するほど多くはないことが示唆された。

High-resolution ultrasound may be able to detect pressure ulcers before clinical signs emerge. This retrospective study found that one such early indicator is inflammatory oedema in the subcutaneous fat, which resolves as healing occurs.