須釜 淳子

目的:高齢者の浮腫保有率は高いが転帰は不明で積極的に介入すべき症状か否か曖昧である。そこで、高齢者の浮腫の範囲と程度の変化を明らかにするため、施設入所高齢者に前向き縦断調査を行った。方法:施設入所中の65歳以上の浮腫保有者を3-5ヵ月後に再調査した。浮腫評価は全身を55に区分し、区分別に研究者らが検証した圧痕テストを行った。grade 0-3と非圧痕性浮腫(NPE)の5段階で評価し、1区分以上にgrade 2、3、NPEを有する者を[浮腫あり]とした。初回と第2回の浮腫部位数と程度の変化を比較した。結果:入所者579名のうち包含基準適合205名に初回浮腫評価し、追跡時脱落94名にて第2回は111名に実施した。第2回[浮腫あり]は83名に減少した。浮腫部位数は386部から452部に有意に増加した(p=0.018)。[浮腫なし]からgrade 2・NPEに有意に増強した(p<0.01)。grade 3は不変であった(p<0.01)。浮腫程度の有意な増強部位は、下腿遠位後面(p<0.001)・前面、下腿近位後面・前面、足趾、外果(おのおのp<0.01)であった。また浮腫部位数も有意に増加した部位は下腿遠位後面(p=0.001)、足趾(p=0.012)、下腿近位前面(p=0.040)であった。結論:施設入所高齢者の浮腫の前向き調査にて浮腫程度は下肢で重症化しNPEが出現した。また、浮腫部位数が有意に増加し、下腿-足部にみられた。以上から、高齢者の下肢浮腫は拡大かつ重症化しており、症状緩和ケアの必要性が示唆された。(著者抄録)

We developed a new assessment tool for diabetic foot ulcers because no such tool specifically for diabetic foot ulcer exists. The diabetic foot ulcer assessment scale (DFUAS) has 11 domain items. The minimum and maximum scores on this scale are 0 and 98, respectively; higher scores indicate more severe wounds. The aim of this study was to evaluate the concurrent validity, construct validity and predictive validity of DFUAS in Indonesia. A prospective cohort study was conducted on patients with diabetic foot ulcer at Kitamura wound clinic in Indonesia. A total of 62 patients with 70 diabetic foot ulcers were assessed with DFUAS tool, Bates-Jensen wound assessment tool (BWAT), and pressure ulcer scale for healing (PUSH). Concurrent validity was determined by correlation of the DFUAS total score with the external criterion (BWAT, PUSH, and wound surface area). A comparison between the total DFUAS score and chronic wound status was made to determine construct validity. We also analyzed 41 wounds that were followed for 4 weeks to evaluate predictive validity. The correlation coefficient total scores of the DFUAS against the BWAT, PUSH, and wound surface area were 0.92, 0.87, and 0.82, respectively. The comparison of the total DFUAS score with chronic wound status was p < 0.001. The predictive validity test indicated that a DFUAS cutoff score of 12 produced the best balance of sensitivity, specificity, positive predictive value, and negative predictive value (89%, 71%, 86%, and 77%, respectively). In conclusion, the newly developed DFUAS is a valid tool for assessing diabetic foot ulcers.

各種ポケットエコーを用い、経時的な膀胱内尿量および残尿評価を試みた結果、以下のことが明らかになった。1.継時的に膀胱内尿量が増加するにつれて、各種ポケットエコーによる測定値のバラツキが大きくなる傾向がある一方、残尿量は50ml以下の計測が可能であった。2.測定値を算出する所要時間は5分以内であり、各種ポケットエコーにより短時間で、膀胱内尿量および残尿評価が可能であった。以上より、各種ポケットエコーで簡便に膀胱内尿量および残尿を評価でき、排尿ケアのアセスメントに有効なため、看護師がベッドサイドで積極的に臨床応用する有用性が示唆された。(著者抄録)

Targeting invisible veins might result in venepuncture complications or failure. In November 2014, we compared the diameter, depth and skin colour of invisible veins used for intravenous access with those of visible veins, aiming to provide information to improve venepuncture techniques. We measured artery depth to identify how close skin arteries were to the nearest venepuncture site. Study participants were hospitalized elderly patients. Vein diameter and vein and artery depths were measured using ultrasonic diagnostic equipment. Visualization became difficult for veins with diameters 2.3mm and at depths 2.5mm. The shallowest depth of arteries nearest the puncture site was 7.0mm. Therefore, venepuncture techniques for intravenous injection should improve by targeting invisible veins with depths of 2.5 to &lt;7mm in hospitalized elderly patients.

Observing small changes (SCs) at specific sites is a new form of managing changes in position. We investigated SCs at specific sites considering interface pressure, contact area, body alignment and physical sensation in nine healthy female adults and evaluated SCs using the air mattress that was divided into six cells (A-F). Thirty-three SC combinations at one or several sites were evaluated. Pressure in the sacral region significantly decreased in 28 SC combinations compared with the supine position (p &lt; 0.05), and the effect of pressure redistribution was greater when SCs were applied at several instead of a single site. The contact area at 17 of the 28 SC combinations significantly increased (p &lt; 0.05). Among sites ranked based on interface pressure, body alignment and physical sensation, SCs at sites BCE, AE and BD were the most favorable. The common feature among these three combinations was that they involved tilting the buttock region and one other site. The findings suggested that SCs at the buttock region could reduce disruptions in alignment as well as the impact on physical sensation caused by the body sinking into the mattress and improve interface pressure redistribution via increased contact area with the mattress. (c) 2015 The Authors. Published by Elsevier Ltd on behalf of Tissue Viability Society.

皮膚・排泄ケア認定看護師(以下WOCN)が褥瘡管理を円滑に行うためには、他職種を調整する能力を身につけることが重要である。そこで先行研究で開発した調整力自己評価尺度について、セルフラーニングのための教育コンテンツとしての活用可能性を探った。創傷に関するセミナーに参加したWOCNを対象に横断調査を行った。WOCN歴群別調整力得点は、専従のWOCNにおいて、褥瘡管理メンバー以外はWOCN歴5-9年の得点が最も高かった。一方、非専従では、経験年数が上がるにつれて得点が高かった。また、調整力発揮割合が最も低かった医療者は、専従のWOCNにおいて、WOCN歴3、4年群をのぞき、いずれの群も病院管理者であった。非専従では、すべてのWOCN歴群において、調整力発揮割合が最も低かった医療者は病院管理者であった。以上より、4点について示唆された。1点目に、本尺度はWOCN歴10年以上のWOCNにおいても、自己評価ツールとして利用する価値が示唆された。2点目に本尺度は、専従のWOCNでは、WOCN歴5-9年の得点を目標点とし使用することが適当と考えられた。非専従では、勤務形態を考慮した目標点を定める必要がある。3点目に、WOCNは調整力の向上に努めるとともに、病院管理者に褥瘡管理活動を理解してもらい、褥瘡管理しやすい環境づくりのための支援を得ることが重要である。4点目に、本尺度の活用方法として、各医療者に対して、調整力を発揮できているのか否かを確認するツールとして使用することが適当といえる。 (著者抄録)

The identification of appropriate skin tear prevention guidelines for the elderly requires clinicians to focus on local risk factors such as structural alterations of the epidermis and dermis related to skin tears. The aim of this cross-sectional study is to explore the prevalence of skin tears and to explore skin properties related to skin tears in elderly Japanese patients at a long-term medical facility. After doing the prevalence study, 18 participants with skin tears and 18 without were recruited and an evaluation of their skin properties using 20-MHz ultrasonography, skin blotting and also Corneometer CM-825, Skin-pH-meterPH905, VapoMeter, Moisture Meter-D and CutometerMPA580 was undertaken. A total of 410 patients were examined, the median age was 87 years and 73·2% were women. The prevalence of skin tears was 3·9%, and 50% of skin tears occurred on the dorsal forearm. The changes in skin properties associated with skin tears included increased low-echogenic pixels (LEP) by 20-MHz ultrasonography, decreased type IV collagen and matrix metalloproteinase-2, and increased tumour necrosis factor-α by skin blotting. In conclusion, this study suggests that increased dermal LEP, including solar elastosis, may represent a risk factor for skin tears; this indicates that skin tear risk factors might not only represent chronological ageing but also photoageing.

Background: Acute dermatolymphangioadenitis (ADLA) is a risk factor for increasing of edema and worsening severity. Reducing ADLA frequency is an important objective of lymphedema management because ADLA episodes are strongly associated with poor quality of life. Lymphedema changes dermal and subcutaneous structure, favoring ADLA; ADLA recurrence may be caused by structural change of the dermis. However, the structure of the skin following ADLA episodes has not been studied in depth. The aim of this study was to examine changes in the skin after episodes of ADLA in breast cancer-related lymphedema (BCRL) using histogram analysis of ultrasonography findings. Methods and Results: This was a case-control study with matching for the duration of lymphedema. We compared 10 limbs (5 BCRL patients, Cases) with a history of ADLA and 14 limbs (7 BCRL patients, Controls) without. Ultrasonography was performed using a 20-MHz probe, and measurements were made at a site 10cm proximal to the ulnar styloid process. We compared skewness of the images in the dermis from the histogram analysis. This study was approved by the Ethics Committee of Kanazawa University. Skewness was significantly different between the affected and unaffected limbs (p=0.02). Cases showed a positive value (median 0.74, range -0.18 to 1.26), whereas Controls showed a negative value (median -0.21, range -0.45 to 0.31). Conclusions: Episodes of ADLA changed the distribution of echogenicity on imaging, which indicates a change in the collagen fibers in the dermis. These findings might contribute to improving the management of lymphedema and prevention of recurrent ADLA.

<p>Purpose: The purpose was to investigate whether the echogenicity of images obtained using different high-frequency ultrasonography devices could be standardized through the use of phantoms. Methods: We imaged a site on the forearms of healthy adults using two high-frequency ultrasonography devices. We calculated the echogenicity ratios by dividing echogenicity in lower dermis by phantom echogenicity. We created silicon pads that included grain for use as phantoms. We calculated the error between the dermal echogenicity of ultrasound A and B as well as the echogenicity ratio error.Results: The values of the dermal echogenicity and echogenicity ratio were respectively significantly different between two devices. The error of the dermal echogenicity between two devices was 25%, whereas that of the echogenicity ratio was 14%. Discussion and Conclusion: Because the error between the echogenicity ratios was lower than the one when using phantoms, it is possible to standardize echogenicity by calculating echogenicity ratio.</p>

<p>Objective We investigated the effects of NPPV mask placement on the skin by observing skin temperature changes on thermal imaging.Methods Eight healthy subjects were required to wear a NPPV mask for 1 h. Visual examination and thermal imaging of the facial area were performed before and after fitting the NPPV mask. Skin temperature at sites where the skin came in contact with the NPPV mask was calculated by thermographic analysis, and the relationship between skin changes and skin temperature was investigated.Results Skin changes occurred in all subjects in the form of reactive hyperemia at the forehead and nasal root. Median value change in skin temperature after fitting the NPPV mask was +0.43 degree at the forehead, and -0.15 degree at the nasal.Conclusion Reactive hyperemia was observed at the forehead and nasal, but skin temperature at the nasal root actually decreased, suggesting reduced blood flow to the skin.</p>

【目的】浮腫があると愛護的なケアを提供するが、浮腫がある部位に皮膚損傷が発生しているか不明であるために、ケアの有効性がわからない。そのため、本研究の目的は、浮腫を有する高齢者の浮腫と外力による皮膚損傷との関係を見出すことである。【方法】研究デザインは横断観察研究である。対象は、石川県内の長期療養施設および特別養護老人ホーム入所中の65歳以上の高齢者である。対象施設では、褥瘡や外力による損傷の予防ケアが標準化されている。除外基準は、対象者またはその家族が研究参加に同意しない者、医師・看護師が調査不可能と判断した者とした。調査項目は、基本属性(年齢、性別、疾患、BMI、麻痺・関節拘縮、ブレーデンスケール)と、身体各部位(55部位)の浮腫および皮膚損傷とした。浮腫は深沢変法にて浮腫2度以上を浮腫ありとした。皮膚損傷とは、医療機器関連創傷を含む褥瘡、スキンテア、その他外力による損傷とした。【結果】入所者579名から除外基準適合者269名を除外し、310名を調査対象とした。浮腫あり群は205名で、平均年齢87.2歳±7.3歳、女性75.1%、BMI18.2、脳血管障害62.0%、ブレーデンスケール合計点12、寝たきりが73.2%、麻痺・関節拘縮は約60%であった。205名の観察部位は10,968部で、浮腫2度以上は828部(7.5%)で下肢に88.2%認めた。皮膚損傷は41部で、下肢に58.5%認めた。浮腫保有部と皮膚損傷との一致は5部(12.2%)で、全て下肢であった。皮膚損傷に対する浮腫のオッズ比は0.87であった。【結論】褥瘡対策の体圧分散寝具選択基準を有し、スキンテア予防ケアが標準化している施設において高齢者の浮腫と皮膚損傷の関係を検討した。浮腫と皮膚損傷には有意な関係はなかった。浮腫と皮膚損傷の部位一致は下肢のみであった。これらの結果が示唆することは、外力調整のケアにより浮腫を有する高齢者の皮膚損傷を低減できるということである。(著者抄録)

高齢者の多くは、加齢に伴い皮膚表面が粗ぞう化し乾燥している。看護師は皮膚の状態を十分確認し保湿ケアを行うが、主観を訴えることの困難な寝たきり高齢者では、ケアの効果を評価することはむずかしい。そこで、ドライスキンの回復を評価する客観的指標が必要と考えた。この前向きコホート研究では、高齢者のドライスキンに対する保湿ケア効果の評価指標として、デジタル画像解析の有用性を検討した。長期療養施設で、前腕がドライスキンである高齢患者を対象とした。保湿ケアは2週間毎日1回、前腕のドライスキンに対して行い、皮膚の水分量と形態を、保湿ケア前後で比較した。皮膚の形態は、デジタル画像解析により定量化した。最終的に16人の高齢者の調査が完了した。保湿ケア後、皮膚の水分量が有意に増加し、ドライスキンの回復を示した。皮溝の平均太さ、太さの分散、相対鱗屑面積が保湿ケア前後で有意に減少し、水分量の回復との関連を示した。(著者抄録)

振動は慢性浮腫の腫脹のコントロールに効果があるといわれているが、慢性浮腫に効果のある振動条件については明らかにされていない。本研究の目的は、振動方向の違いが血流に影響するかを検討することである。研究デザインは、準実験研究であり、金沢大学医学倫理審査委員会の承認を得て実施された(承認番号515-1)。対象者は健康女性名とし、クッションで下腿を挙上させ、振動器(周波数47Hz、水平加速度1.78m/s2)を用いて下肢に振動を与えた。実験群は、下肢に対して長軸方向(長軸群)、短軸方向(短軸群)の振動を与える群とし、対照群は、振動を与えず下肢挙上を保った。対象者は計3回の実験を行い、振動直後、振動10分、20分、30分後の大伏在静脈の血管断面積を超音波診断装置(周波数18MHz)を用いて測定した。その結果、振動方向と振動時間に交互作用は認められず(P=0.906)、長軸群と短軸群は対照群より有意に血管断面積が大きかった(P&lt;0.01,P&lt;0.01)。長軸群と短軸群には血管断面積に差がみられなかった。以上より、振動方向は血流に影響を与えず、長軸方向、短軸方向どちらの方向から振動を与えても、血流量の増加を示すことが明らかとなった。(著者抄録)

【目的】圧痕テストは浮腫評価方法として標準的手技ではあるが、統一された手法はなく浮腫有病率を正確に算出する上で課題である。国際疫学研究cLIMPRINTfを行う第一段階として、the Anatomical locations of oedema(部位)、Force required to pit(圧力)、the amount of Time(時間)、Definition of oedema(浮腫の定義)、を統一したAFTD-pittingテストを用いて、慢性浮腫評価に対する評定者間信頼性を検証した。【方法】本研究は横断観察研究であり、石川県内の長期療養型病院施設で実施した。浮腫を有する高齢者名に対し、4名の評定者が評価した。評定者は全員看護師で、エキスパートである名をゴールドスタンダードとし、4名の評定をエキスパートと比較し、一致率及びCohen《sκ係数を算出した。評定者は母指で10秒間、対象者の身体のうち特定の34部位を圧痕テストして浮腫の有無を評価した。圧力はエキスパートと一致するよう事前演習を行い、深沢変法を用いて浮腫の有無を評価した。本研究は、金沢大学医学倫理審査委員会の承認を得て実施した。【結果】評定者は、浮腫管理を月に5〜6症例実施している看護師で、リファレンス評定者は国際疫学研究cLIMPRINTfの統括者で慢性浮腫の看護ケア・研究のエキスパートであった。患者対象者は全員80歳以上で、日常生活に看護・介護が全面的に必要な寝たきりの者であった。4名の評価者とエキスパートとの評定者間一致率は0.85以上であり、Cohen《sκ係数は名が高い一致(0.81)、3名が中等度の一致(0.51から0.60)であった。【考察・結論】AFTD-pittingテストの評定者間信頼性は高い一致率と良いκ係数であった。AFTD-pittingテストは浮腫有病率調査に有用な方法であることが示唆された。キーワ(著者抄録)

本研究の目的は底づき回避機能が褥瘡部位の接触圧、底づき、積算値(接触圧×底づき時間)に影響するかどうか検証することである。対象は65歳以上、坐骨結節部、尾骨部に褥瘡のある、もしくは、それらの部位に既往がある者で座位姿勢に問題のある者とした。クッションは自動圧切り替え型クッションを使用した。本研究は、クロスオーバーデザインである。介入群は、クッションの機能である底づき回避機能をONにし、対照群は底づき回避機能をOFFにした。結果、17名を分析対象者とし、接触圧、総底づき時間割合、積算値を算出した。介入群の接触圧(座位A)は、クッションの適正体圧時と非底づき時に有意差はなかったが(p=.16)、対照群では適正体圧時より非底づき時のほうが有意に高かった(p=.00)(座位A:バックレストに背中が触れている状態)。介入群における総底づき時間割合(座位A、B、D)は、対照群よりも有意に低かった(座位B:バックレストから背中が離れ、荷重が垂直にかかる状態、座位C:丁足の動作により、荷重の位置が移動する状態D:座位A、B、Cの座位後の状態)(P=.00)介入群における積算値は、対照群よりも有意に低かった(p=.03)。以上より、圧切り替え型クッションにおける底づき回避機能は褥瘡部位または既往部位における接触圧、底づき、積算値に対して静止型より有効性を示した。(著者抄録)

AIM: Adequate nutritional intake is essential for pressure ulcer healing. Recently, the estimated energy requirement (30 kcal/kg) and the average protein requirement (0.95 g/kg) necessary to maintain metabolic balance have been reported. The purpose was to evaluate the clinical validity of these requirements in older hospitalized patients with pressure ulcers by assessing nutritional status and wound healing. METHODS: This multicenter prospective study carried out as a secondary analysis of a clinical trial included 194 patients with pressure ulcers aged ≥65 years from 29 institutions. Nutritional status including anthropometry and biochemical tests, and wound status by a structured severity tool, were evaluated over 3 weeks. Energy and protein intake were determined from medical records on a typical day and dichotomized by meeting the estimated average requirement. Longitudinal data were analyzed with a multivariate mixed-effects model. RESULTS: Meeting the energy requirement was associated with changes in weight (P < 0.001), arm muscle circumference (P = 0.003) and serum albumin level (P = 0.016). Meeting the protein requirement was associated with changes in weight (P < 0.001) and serum albumin level (P = 0.043). These markers decreased in patients who did not meet the requirement, but were stable or increased in those who did. Energy and protein intake were associated with wound healing for deep ulcers (P = 0.013 for both), improving exudates and necrotic tissue, but not for superficial ulcers. CONCLUSIONS: Estimated energy requirement and average protein requirement were clinically validated for prevention of nutritional decline and of impaired healing of deep pressure ulcers.

The high prevalence of severe pressure ulcers (PUs) is an important issue that requires to be highlighted in Japan. In a previous study, we devised an advanced PU management protocol to enable early detection of and intervention for deep tissue injury and critical colonization. This protocol was effective for preventing more severe PUs. The present study aimed to compare the cost-effectiveness of the care provided using an advanced PU management protocol, from a medical provider's perspective, implemented by trained wound, ostomy, and continence nurses (WOCNs), with that of conventional care provided by a control group of WOCNs. A Markov model was constructed for a 1-year time horizon to determine the incremental cost-effectiveness ratio of advanced PU management compared with conventional care. The number of quality-adjusted life-years gained, and the cost in Japanese yen (yen) ($US1=yen120; 2015) was used as the outcome. Model inputs for clinical probabilities and related costs were based on our previous clinical trial results. Univariate sensitivity analyses were performed. Furthermore, a Bayesian multivariate probability sensitivity analysis was performed using Monte Carlo simulations with advanced PU management. Two different models were created for initial cohort distribution. For both models, the expected effectiveness for the intervention group using advanced PU management techniques was high, with a low expected cost value. The sensitivity analyses suggested that the results were robust. Intervention by WOCNs using advanced PU management techniques was more effective and cost-effective than conventional care.

A simple technique is tested to improve the contractile effect of a cold plasma jet on acute wounds of mice. Distilled water on the order of microliters is dropped onto wounds before treatment. To assess the fate of the water, an infrared thermal imager is applied. To evaluate the healing effect, macroscopic and immunohistological studies are conducted. Regarding the wound contractile effect, we show that combination treatment of plasma with dropped water seemed to have a greater effect than plasma treatment alone. Plasma may modify the wound surface through such water, chemically and physically. The histological stiffness of the wound surface during maturation and remodeling, however, may also influence the fate of the water during treatment. © 2015 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

目的:Incontinence-associated dermatitis(以下IAD)は尿や便の接触により会陰部や生殖器周辺に発生する皮膚炎であり、失禁を有する高齢者において問題となっている。そこで、IADの保有や有病率に影響を与える質指標を検討するために、介護療養型医療施設にてIAD有病率、組織体制および看護ケアの実態について調査した。方法:A県にて介護療養型医療施設として登録されているすべての病院の各病棟を対象とし、自記式質問紙による調査を行った。調査項目は、Donabedianによる医療の質評価モデルの概念に基づき、「構造」については組織体制、「過程」については看護ケア、「結果」についてはIAD保有者数をあげた。なお本研究は静岡県立大学研究倫理審査委員会の承認を得て行われた。結果:平均有病率は5.9%であった。IAD保有患者の有無と構造および過程要件との関係を検討した結果、「陰部洗浄の方法:微温湯と洗浄剤使用」のみ有意な関連を認めた(オッズ比:0.134,95%信頼区間:0.025-0.707,P=0.018)。結論:本研究により、介護療養型医療施設におけるIAD有病率が5.9%であり、微温湯と洗浄剤を使用することによりIAD保有者が存在する確率が有意に減少することが明らかとなった。スキンケアがIADの発生に寄与している可能性が本研究により示唆された。(著者抄録)

本研究の目的は、特定行為を実施する皮膚・排泄ケア認定看護師(Tokutei Nurse、TN)がどのように特定行為の安全を確保しチーム医療に関与しているのか実践を明らかにすることである。対象は2011-12年に特定看護師養成調査試行事業の研修を修了し業務施行事業に施設が参加している皮膚・排泄ケア認定看護師(Wound,Ostomy,and Continence Nurse、WOCN)6名である。対象者の1週間の日勤時間帯に研究者が直接参加観察を実施し、質的記述的研究方法で分析をした。その結果、TNは、『WOCNとして培ってきた創傷管理技術と調整力を基盤とした、低侵襲で安全・安楽な特定行為の実践』をしていた。TNは、安全に関するルール・手順・プロトコールを遵守し[自分にできる特定行為による治療]を実施し、特定行為の安全を確保していた。さらに、[適切な治療のために診療科を調整]、[WOCNの創傷管理技術と調整力を基盤とした安全・安楽な療養環境の提供]ではノンテクニカルスキルを使用し、チームメンバーができる方法を選択することでメンバーは専門性を発揮し、安全な療養環境の調整に貢献していた。TNの[苦痛を最小限にした侵襲的な治療と関わり]では、特定行為を通じて患者の安全・安楽と自立を促進し、看護技術の要素を含んでいることが明らかとなった。(著者抄録)

AIM: There is a lack of data from cohort studies for the incidence of skin tears among an elderly population in an Asian country. We estimated the cumulative incidence of skin tear, and identify its risk factor. METHODS: The present prospective cohort study was carried out at a long-term medical facility in Japan. Participants included patients (n = 368) aged 65 years or older receiving hospital care. The 3-month cumulative incidence of skin tears was estimated by identifying them using direct inspection of the extremities. In order to find the risk factors for the skin tear incidence, odds ratios and their 95% confidence intervals of skin tear development in association with the factors were estimated using logistic regression analyses. RESULTS: A total of 14 patients developed skin tears, and their cumulative incidence was 3.8%. No patients with skin tears developed multiple wounds on their extremities. Half of the skin tears occurred on the outside of the right forearm, and just three skin tears were found in the lower legs. Multiple logistic analyses showed that pre-existing skin tears (odds ratio 15.42, 95% confidence interval 3.53-67.43, P < 0.001) and a 6-point decrease in the total score of the Braden Scale (odds ratio 0.10, 95% confidence interval 0.01-0.83, P < 0.033) were significantly associated with skin tear development. CONCLUSIONS: Patients with pre-existing skin tears and a low score of the Braden Scale have a higher risk of skin tear development during 3 months. These factors could be used to identify patients requiring prevention care for skin tears.

BACKGROUND: Lymphoedema is not currently curable, and it is important that symptoms are alleviated by appropriate treatment. Treatments aim to delay the progression of swelling and to improve patients' quality of life (QOL). There are many objective and subjective outcomes of lymphoedema, but it is unclear which outcomes should be used to evaluate lymphoedema treatments. OBJECTIVE: This study aimed to examine the associations between lymphoedema treatments and outcomes. DESIGN: A cross-sectional observational study. SETTING: Lymphoedema outpatient clinics in Japan. PARTICIPANTS: A total of 170 patients with lymphoedema were recruited from four outpatient clinics. METHODS: The data were collected from medical records, physical assessments, and interviews. The following objective outcomes were evaluated: circumference measurements, Stemmer sign, cellulitis, and skin hardness. The following subjective outcomes were evaluated: satisfaction with treatment, subjective symptoms, EuroQol-5 dimensions, and a quality of life measure for limb lymphoedema (LYMQOL). Multiple regression analysis was performed to examine the associations between lymphoedema treatments and their outcomes. RESULTS: Secondary lymphoedema was present in 158 patients (92.9%), and 91 patients (53.5%) had lower lymphoedema. The patients using compression garments were 2.63 times more likely to have a positive Stemmer sign and 2.85 times more likely to be satisfied with their treatment than those who were not using compression garments (p = 0.02 for Stemmer sign, p &lt; 0.01 for satisfaction). The patients treated with simple lymphatic drainage (SLD) exhibited a 2.26-fold greater level of satisfaction with treatment than those not receiving this treatment (p &lt; 0.01). The patients treated with complete decongestive therapy (CDT) had higher QOL than did those not receiving this therapy (beta = -0.19, p = 0.04). CONCLUSIONS: The progression of swelling can be evaluated using the Stemmer sign with regard to compression therapy. The degree of satisfaction can be evaluated as the patient's satisfaction with their lymphoedema regarding compression garments and SLD, and improvements in QOL can be evaluated using the LYMQOL with regard to CDT. The subjective outcomes were not associated with every lymphoedema treatment in this study, and the effectiveness of lymphoedema treatment can be evaluated using several different outcomes. (C) 2015 Elsevier Ltd. All rights reserved.

Deep-tissue injury (DTI) is a unique type of pressure ulcer (PU) in which deep-tissue damage expands outwards to the superficial skin. DTI progresses rapidly into a severe PU, despite initially appearing as only a bruise or darkened tissue in the superficial skin. Although some DTI detection methods are available, there is currently no strategy for treating deteriorating DTI. This study investigated the efficacy of vibration therapy for preventing DTI deterioration through down-regulation of the hypoxia-inducible factor-1 matrix metalloproteinase (MMP) axis in rats. We prepared a conventional PU rat model (PU group) and a DTI deterioration rat model (DTI group). The DTI group was further divided into two groups subjected to vibration and control treatments, respectively. Macroscopic and histological features, hypoxia, oxidative stress, apoptosis, and MMP2 and MMP9 activities in compressed skin were analyzed. Hypoxia, oxidative stress, and MMP activity were enhanced in the DTI group compared with the PU group. Vibration remarkably inhibited DTI deterioration, hypoxia, and the expression/activities of MMP2 and MMP9. These results suggest that vibration therapy can effectively attenuate deterioration of DTI. This report provides the first evidence for a therapeutic treatment for deteriorating DTI.

Deep tissue injuries (DTIs) can become significant problems because of their rapid deterioration into deep pressure ulcers. Presently, no animal model of DTI deterioration has been developed. By concentrating pressure and shear stress in deep tissues while minimising pressure and shear stress in the overlying skin, we produced an effective rat model of DTI deterioration. Two-dimensional finite element method (FEM) simulated the distribution of pressure and shear stress under several pressure-loading conditions. FEM showed that concentrated shear stress in deep tissue with minimum shear stress in the overlying skin could be created by using a prominence and a cushion, respectively. On the basis of the results of FEM analysis, we selected suitable conditions for testing the rat DTI deterioration model. The compressed area was macroscopically observed until day 13, and histopathologic analysis via haematoxylin and eosin (H&E) staining was performed on days 3, 7 and 13. H&E staining showed that the distribution of tissue damage was similar to the predicted FEM results. Deep ulceration and tissue damage extending from deep tissues to the overlying skin and surrounding tissues were observed in the DTI deterioration model, which are similar to the clinical manifestations of DTI deterioration. In conclusion, a representative DTI deterioration model was established by concentrating high shear stress in deep tissues while minimising shear stress in the overlying skin. This model will allow a better understanding of the mechanisms behind DTI deterioration and the development of preventative strategies.

PURPOSE: To investigate the effect of alternating air cells of a newly developed dynamic cushion on interface pressure and tissue oxygenation levels. METHOD: This cross-over experimental study included 19 healthy volunteers. The dynamic cushion used has an automatic self-regulating alternating pressure air-cell system with 35 small and four large air cells for maintaining posture while seated. This cushion also has 17 bottoming-out detectors that automatically inflate the air cells to release a high interface pressure. To assess the effect of this alternating system, participants sat on the new cushion with an alternating system or static system for 30 min and then performed push-ups. The interface pressure was monitored by pressure-sensitive and conductive ink film sensors and tissue oxygenation levels were monitored by near-infrared spectroscopy. A reactive hyperaemia indicator was calculated using tissue oxygenation levels as an outcome measure. RESULTS: The peak interface pressure was not significantly different between the groups. The reactive hyperaemia indicator was significantly higher in the static group than in the alternating group. CONCLUSIONS: An alternating system has beneficial effects on blood oxygenation levels without increasing interface pressure. Therefore, our new cushion is promising for preventing pressure ulcers with patients with limited ability to perform push-ups. Implications for Rehabilitation A dynamic cushion was developed, which consists of a uniquely-designed air-cell layout, detectors for bottoming out, and an alternating system with multiple air-cell lines. The alternating system did not increase interface pressure and it significantly reduced reactive hyperaemia after 30 min of sitting in healthy volunteers. This cushion is a new option for individuals who require stable posture but have limitations in performing scheduled push-ups for prevention of pressure ulcers.

This study aims to evaluate the microclimate and development of pressure ulcers and superficial skin changes. A prospective cohort study was conducted in an acute care ward in Indonesia. Risk factors for pressure ulcers and superficial skin changes were identified based on the Bergstrom Braden conceptual model. Microclimate data were collected every 3 days for 15 days while the development of pressure ulcers and superficial skin changes was observed every day. Pressure ulcers and superficial skin changes were developed in 20 of the 71 participants. Total mean difference in skin temperature was higher for patients with pressure ulcers and superficial skin changes (09 +/- 06 degrees C) compared with controls (06 +/- 08 degrees C) (P = 0071). Binary logistic regression predictor values for pressure ulcers and superficial skin changes were 0111 for type of sheet and 0347 for Braden Scale results. In conclusion, difference in skin temperature seems to be a predictor for pressure ulcer development and superficial skin changes, while synthetic fibre sheets are able to maintain a beneficial microclimate.

目的:糖尿病は末梢動脈疾患のリスクであり、下肢動脈が狭窄・閉塞することにより下肢切断にいたることがある。糖尿病患者のフットアセスメントの一つに皮膚の観察があり、早期発見のため、日々観察が行われている。本研究では皮膚の色および皮膚の表面形態と測定機器を用いて数値化し、下肢血流低下との関連があるかを調査した。方法:32名の糖尿病患者の足部皮膚外観(皮膚の色と皮膚表面形態)を測定し、ABIとサーモグラフィーで分類した「下肢血流低下群」14名と「下肢血流正常群」18名で比較した。結果:皮膚色a*とb*が2群間で差があり、下肢血流低下に最も関連したのはa*であった。a*のROC曲線下面積は0.706であった。カットオフ値は2.80であり、感度78.6%、特異度55.6%であった。考察:糖尿病患者においてPADを示唆する下肢血流低下の状態では皮膚色はより暗い赤みを呈し、今後皮膚色を用いてアセスメントすることの有用性が示唆された。(著者抄録)

意識障害のある寝たきり高齢者1名において、24時間の睡眠評価を行い、深部体温、心拍数、呼吸数のモニタリングをすることにより、新たな看護観察法の可能性を検討することを目的とし調査を行った。睡眠の質の評価のため24時間の脳波、眼球運動および筋電図を測定した。バイタルサインズの評価のため72時間の腹部深部体温と24時間の呼吸数および心拍数を測定した。24時間の睡眠効率は98.0%であった。深部体温は8時間周期を示した。呼吸数、心拍数において昼間と夜間との間に差はみられなかった。本対象者では全日型の睡眠をとることが明らかになり、そのため呼吸・心拍の日内変動が不明瞭となる可能性が考えられる。昼間に覚醒回数が多くなることから、日中の看護ケアなどの働きかけが睡眠覚醒リズムや体内リズムに変化を及ぼしうる可能性があると考える。今後は生体計測指標と看護ケアとの関連を明らかにする必要があると考える。(著者抄録)

No previous study has satisfactorily clarified the nature of sleep in elderly bedridden people with disorders of consciousness (DOC). The objective of the present study was to clarify the sleep states of 10 elderly bedridden patients with DOC in a Japanese hospital to facilitate provision of evidence-based nursing care and appropriate adjustment of patients' environments. Nocturnal polysomnography recordings were analyzed according to the standard scoring criteria, and the patients' sleep stages and quality were investigated. Of the 10 patients, 9 showed slow wave sleep (SWS), 4 showed very high values for sleep efficiency (96-100%), and in 3 of these patients, the percentage of SWS was 20%. Furthermore, three of these four patients had 200 or more changes in sleep stage. Although the mechanism is unknown, the amount of SWS combined with the value of sleep efficiency suggests that the quality of sleep is poor in elderly bedridden patients with DOC. Further study is needed to determine better indicators of good sleep in this population.

A common complication in patients with incontinence is perineal skin lesions, which are recognized as a form of dermatitis. In these patients, perineal skin is exposed to digestive enzymes and intestinal bacterial flora, as well as excessive water. The relative contributions of digestive enzymes and intestinal bacterial flora to skin lesion formation have not been fully shown. This study was conducted to reveal the process of histopathological changes caused by proteases and bacterial inoculation in skin maceration. For skin maceration, agarose gel containing proteases was applied to the dorsal skin of male Sprague-Dawley rats for 4 h, followed by Pseudomonas aeruginosa inoculation for 30 min. Macroscopic changes, histological changes, bacterial distribution, inflammatory response, and keratinocyte proliferation and differentiation were examined. Proteases induced digestion in the prickle cell layer of the epidermis, and slight bleeding in the papillary dermis and around hair follicles in the macerated skin without macroscopic evidence of erosion. Bacterial inoculation of the skin macerated by proteolytic solution resulted in the formation of bacteria-rich clusters comprising numerous microorganisms and inflammatory cells within the papillary dermis, with remarkable tissue damage around the clusters. Tissue damage expanded by day 2. On day 3, the proliferative keratinocyte layer was elongated from the bulge region of the hair follicles. Application of proteases and P. aeruginosa induced skin lesion formation internally without macroscopic erosion of the overhydrated area, suggesting that the histopathology might be different from regular dermatitis. The healing process of this lesion is similar to transepidermal elimination.