須釜 淳子

Objectives To estimate protein requirements in older hospitalized adults with pressure ulcers (PrU) according to systemic conditions and wound severity. Design Secondary nitrogen balance study over 3 days. Setting Long-term care facility. Participants Twenty-eight older adults with PrU using a urinary catheter. Measurements Nitrogen balance over 3 days was evaluated from habitual nitrogen intake measured using a food weighing record and nitrogen excretion from urine, feces and wound exudate. Nitrogen intake required to maintain nitrogen equilibrium was estimated as an average protein requirement using a linear mixed model. Results Nitrogen intake at nitrogen equilibrium was 0.151 gN/kg per day (95% confidence interval = 0.127-0.175 gN/kg per day) for all participants. The amount of protein loss from wound exudate contributed little to total nitrogen excretion. A Charlson comorbidity index of 4 or greater (the median value) was related to lower nitrogen intake at nitrogen equilibrium (P = .005). Severe PrU with heavy exudate amounts and measured wound areas of 7.9 cm(2) or greater (the median value) were related to higher nitrogen intake at nitrogen equilibrium in individuals with a Charlson comorbidity index of 3 or less (both P = .04). Larger wound area (correlation coefficient (r) = 0.55, P = .003) and heavier exudate volume (r = 0.53, P = .004) were associated with muscle protein hypercatabolism measured according to 3-methylhistidine/creatinine ratio. Conclusion The average protein requirement is 0.95 g/kg per day for older hospitalized Japanese adults with PrU, but protein requirements depend on an individual's condition and wound severity and range from 0.75 to 1.30 g/kg per day. Severe PrU can require higher protein intakes because of muscle protein hypercatabolism rather than direct loss of protein from wound exudate. J Am Geriatr Soc 60: 2027-2034, 2012.

Obesity is recognized as a risk factor for delayed cutaneous wound healing. The authors hypothesized that the secretion of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) from subcutaneous adipose tissue correlates with disorder of the healing process in obese subjects. Findings from previous studies on the expression of MMPs and TIMPs in obese adipose tissue are inconsistent. Since these conflicting results could be due to the effect of several intrinsic factors, the authors conducted a simple in vitro experiment to clarify the change in profile of MMPs and TIMPs in excessively matured adipocytes. The authors cultured the induced adipocytes under conditions of high or low glucose and with or without insulin supplementation. Oil red O staining and its dye extraction assay revealed excessive lipid accumulation in high glucose and insulin-supplemented adipocytes. Additionally, there was altered expression of adipokines, similar to the change in adipose tissue in obese subjects. Under these conditions, the expression/activity of MMP8 was promoted and the expression of MMP3 and TIMP3 was inhibited. Further studies to determine the effect of other obesity-related factors, such as insulin resistance, on MMPs and TIMPs are required.

There are few studies on predictive validity of methods to monitor the healing process of pressure ulcers. We evaluated whether the change of DESIGN-R (rating) score could predict subsequent healing, and determined the optimal cutoff points. In a multicenter prospective cohort study, patients were followed until wound healing or censoring. Wound severity was evaluated by the DESIGN-R tool every week, and the score change was calculated over 14 weeks (n?=?411, 286, 224, and 170, respectively). In the multivariate analyses stratified by depth, a one-point improvement in DESIGN-R score over any period was positively associated with healing within the next 30 days independent of initial wound severity (hazard ratios over each 14 weeks ranging from 1.16 to 1.33 for superficial ulcers and from 1.21 to 1.27 for deep ulcers; all p?<?0.05). The optimal cutoff points over 14 weeks were set as negative change for superficial ulcers and as positive change of =two points for deep ulcers. Nonhealing rate was higher for ulcers with DESIGN-R score change below the cutoff points than that aforementioned for both depths. Weekly monitoring by the DESIGN-R tool will be advantageous for evaluating prognosis of pressure ulcers independent of initial wound severity and depth.

センサー数・配置を改良した新マルチパッド型簡易体圧測定器の信頼性と妥当性について検討した。看護師6名が健康成人6名の仰臥位時における仙骨部の体圧を測定した結果、評定者内級内相関係数は0.992〜1.000で、評定者間級内相関係数0.737、経験3年以下看護師は0.747、10年以上は0.861であった。次に療養病棟入院患者46名の体圧を測定して皮膚観察結果との関係について検討した。皮膚所見は発赤ありが17名で、消退する発赤・反応性充血15名、消退しない発赤・d1褥瘡2名であった。体圧は発赤あり群で中央値67.9mmHg、発赤なし群が36.2mmHgと有意差が認められた。ROC解析の結果、褥瘡発生予測のカットオフ値を陽性尤度比が4.54と最も大きい50mmHgとした場合、感度94.1%、特異度79.3%であった。新マルチパッド型簡易体圧測定器は従来よりも利便性と正確性が備わり、臨床で使用できる有効な測定器具であることが示唆された。

BACKGROUND: Most older adults with urinary incontinence use absorbent pads. Because of exposure to moisture and chemical irritating substances in urine, the perineal skin region is always at risk for development of incontinence-associated dermatitis (IAD). The aim of this study was to examine the efficacy of an improved absorbent pad against IAD. METHODS: A cluster randomized controlled design was used to compare the efficacy of two absorbent pads. Female inpatients aged ≥65 years who had IAD and used an absorbent pad or diaper all day were enrolled. Healing rate of IAD and variables of skin barrier function such as skin pH and skin moisture were compared between the usual absorbent pad group (n = 30) and the test absorbent pad group (n = 30). RESULTS: Thirteen patients (43.3%) from the test absorbent pad group and 4 patients (13.3%) from the usual absorbent pad group recovered completely from IAD. Moreover, the test absorbent pad group healed significantly faster than the usual absorbent pad group (p = 0.009). On the other hand, there were no significant differences between the two groups in skin barrier function. CONCLUSION: The test absorbent pad for older adults with urinary incontinence might be more efficacious against IAD than usual absorbent pad. TRIAL REGISTRATION: UMIN-CTR: UMIN000006188.

The purpose of this study was to investigate the effectiveness of Indonesian honey in wound healing compared to Tegaderm hydrocolloid dressing and Manuka honey. Three groups of male mice were treated to produce 2 circular, full-thickness skin wounds on the dorsum. They were then randomly allocated to receive daily Indonesian honey, Manuka honey, or hydrocolloid (control). Macroscopic findings were observed from day 0 to 14 after wounding. Microscopic findings on days 3, 7, 11, and 14 after wounding were obtained. The ratios of wound areas for honey groups on day 3 were smaller than those of the control group. Wound areas of honey groups gradually decreased to almost the same wound area as the control group on day 14, while the control group wound area peaked on day 5 and rapidly decreased until day 14. On day 3, myofibroblasts and new blood capillaries in wound tissue of honey groups were observed, but were not seen in the control group. After day 7, microscopic findings were almost the same among the 3 groups. These results indicate that Indonesian honey is almost as effective for wound healing as Manuka honey and hydrocolloid dressing.

Both physiological skin aging and pathologic photo-aging caused by ultraviolet (UV) irradiation are mediated by latent inflammation and oxidative stress. Although numerous animal skin-aging models have used UV irradiation, most require massive doses or long-term irradiation. To establish a more refined skin-aging model, we focused on an animal model of metabolic syndrome (MS) because MS involves damage to various organs via oxidative stress or inflammation, similar to the changes associated with aging. We hypothesized that MS skin might exhibit more aging-like changes after milder, shorter-term UV irradiation than would normal animal skin under similar conditions, thus providing a useful model for skin aging. The authors therefore examined the skin from Tsumura Suzuki obese diabetic (TSOD) mice (MS model) and control Tsumura Suzuki non-obese (TSNO) mice before and after UV irradiation. Skin from TSOD mice had a thinner epidermis and dermis, a thicker fatty layer, reduced density and convolution of the fragmented collagen fibers, and upregulated expression of tumor necrosis factor (TNF)-α, a dual marker for inflammation and aging, compared to the skin from TSNO mice. UV irradiation affected TSOD skin more severely than TSNO skin, resulting in various changes resembling those in aged human skin, including damage to the dermis and subcutaneous fatty tissue, infiltration of inflammatory cells, and further upregulation of TNF-α expression. These results suggest that UV-irradiated TSOD mice may provide a new model of skin aging and imply that skin from humans with MS is more susceptible to UV- or aging-related damage than normal human skin.

The purpose of this study was to test the hypothesis that obese diabetic mice exhibit marked skin fragility, which is caused by increased oxidative stress and increased matrix metalloproteinase (MMP) gene expression in the subcutaneous adipose tissue. Scanning electron microscopy of skin samples from Tsumura-Suzuki obese diabetic (TSOD) mice revealed thinner collagen bundles, and decreased density and convolution of the collagen fibres. Furthermore, skin tensile strength measurements confirmed that the dorsal skin of TSOD mice was more fragile to tensile force than that of non-obese mice. The mRNA expressions of heme oxygenase 1 (Hmox1), a marker of oxidative stress, Mmp2 and Mmp14 were increased in the adipose tissue of TSOD mice. Antioxidant experiments were subsequently performed to determine whether the changes in collagen fibres and skin fragility were caused by oxidative stress. Strikingly, oral administration of the antioxidant dl-α-tocopherol acetate (vitamin E) decreased Hmox1, Mmp2 and Mmp14 mRNA expressions, and improved the skin tensile strength and structure of collagen fibres in TSOD mice. These findings suggest that the skin fragility in TSOD mice is associated with dermal collagen damage and weakened tensile strength, and that oxidative stress and MMP overexpression in the subcutaneous adipose tissue may, at least in part, affect dermal fragility via a paracrine pathway. These observations may contribute to novel clinical interventions, such as dietary supplementation with antioxidants or application of skin cream containing antioxidants, which may overcome skin fragility in obese patients with diabetes.

Objective: The availability of nutritional screening tools for older adults is limited, depending on their physical characteristics or the setting. We investigated the relationships between various nutritional indicators and skin conditions as possible screening indicators. Design: Cross-sectional study. Setting: A long-term care hospital in Japan. Participants: 90 elderly residents who were aged 65 years old. Measurements: The nutritional status of the residents was assessed by body mass index (BMI), involuntary weight loss, arm muscle area, and serum albumin and prealbumin levels. Leg skin condition was evaluated by: 1) functional factors including pH, hydration and transepidermal water loss; 2) skin color including L*, a*, b* and individual typology angle (ITA) using a tristimulus colorimetric instrument; and 3) skin morphology. Repeated measures analysis of variance was employed, adjusted for demographic characteristics and room temperature, with measurement site as the repeated variable. Results: Among the skin indicators, b* was significantly correlated with BMI (p=0.018), and weight loss over the previous month (p=0.042) and 6 months (p=0.002). Additionally, ITA was associated with weight loss over 1 month (p=0.013). Both b* and ITA showed the area under the receiver operating characteristic curve of 0.64 to 0.80 for weight loss >2% over I month. Conclusions: Residents with poorer nutritional status had yellower and darker skin color.

本研究は、皮膚・排泄ケア認定看護師(以下WOCN)が褥瘡管理体制を組織化するための調整力自己評価尺度の信頼性と妥当性の検証を目的とした。尺度は先行研究より項目を抽出し作成した。調査方法は、全国の病院に勤務するWOCNに無記名自記式質問紙調査を実施した。妥当性の検証は因子妥当性、判別妥当性、併存妥当性の観点より分析した。信頼性の検証は、内的一貫性の観点より6ドメインにおける各因子のクロンバックα係数を算出した。その結果、尺度は、対病棟管理者調整力1因子、対スタッフナース調整力3因子、対医師調整力1因子、対管理組織調整力1因子、対多職種調整力1因子、褥瘡を治癒させるスキル1因子の計64項目で構成された。各ドメインの累積因子寄与率は46〜61%であり、因子妥当性が検証された。WOCN歴3年以上群は、褥瘡を治癒させるスキル以外の5ドメインで合計得点が有意に低く、経験年数が多いほうが調整力が高かったことから、判別妥当性が検証された。褥瘡ハイリスク患者ケア加算導入の有無で5ドメイン、WOCNが横断的に活動できる環境の有無で6ドメインの合計得点で有意差がみられた。このことから、一部併存妥当性が検証された。信頼性の検証では、1因子以外すべてα係数0.80以上であり、内的整合性が検証された。以上より、本尺度は、WOCNの調整力をアセスメントする参考資料としての活用可能性が示唆された。(著者抄録)

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. (C) 2011 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Objective: To reveal the specific ultrasonic imaging findings of non-visible necrotic tissue in pressure ulcers (PUs) with undermining and describe the images objectively. The predictive validity of the specific images of the undermined necrotic tissue was also determined. Method: Using digital ultrasonography (12MHz linear transducer, MyLab25; Hitachi Medical Corporation), we imaged PUs with undermining every 2 weeks. PUs were also monitored by DESIGN-R, a PU assessment tool, at the same time. Results: Ten patients had 11 PUs with undermining and all ulcers were located in the sacral region. The necrotic tissue showed high echogenicity with no layers, unclear borders and an uneven gray level (cloud-like image). Granulation tissue appeared as a low echoic image which had no layers, was of coarse resolution and an even gray level. There were significant differences between the pixel uniformity of the necrotic tissue (84.0) and granulation tissue (53.9) compared with uninjured tissue (65.5; p=0.000 and 0.005, respectively). The sensitivity, specificity, and positive and negative predictive values of cloud-like image were 87.5%, 91.7%, 77.8% and 95.6%, respectively. Conclusion: The results suggest that cloud-like image is the most useful diagnostic indicator for non-visible necrotic tissue in PUs with undermining and is the best prognostic indicator for PU healing. Declaration of interest: The authors have no conflicts of interest to declare. There were no external sources of funding for this study.

著者らは腹臥位手術において褥瘡発生率が高い原因として、患者が四点支持器の上に腹臥位固定されることで四点支持器と身体との接触面積が小さく、また骨突起出部にかかる圧が高くなり、更に時間経過とともに身体がずれて底づきすることで骨突出部にかかる圧が高くなるためではないかと考えた。そこで、腹臥位手術を受ける患者を対象に腹臥位固定中の四点支持器と右腸骨部皮膚との接触面の圧力を連続測定して褥瘡の有無別に比較した。その結果、1)18名中14名(男性9名、女性5名、年齢33〜81歳、平均年70.5歳)に反応性充血、4名(男性1名、女性3名、年齢43〜78歳、平均年齢62.0歳)にStage Iの褥瘡が生じていたが、3日目までには悪化することなく、全例で治癒していた。2)Stage Iの褥瘡発生者の最大体圧値は平均225.1mmHgで、反応性充血発生者の104.9mmHgと比べ有意に高値であった。また、両群の腹臥位固定開始時と終了時の平均体圧値、最大体圧値、皮膚変化部位の面積には有意差は認められなかった。以上より、腹臥位手術における褥瘡予防の指標として、腹臥位固定時の最大体圧値を用いることで除圧ケアの介入が可能であることが示唆された。

In the initial treatment of acute myocardial infarction, it is important to administer oral low-dose acetylsalicylic acid (ASA) within 10 min of arrival at the hospital. However, ASA is supplied as an enteric-coated tablet or buffered tablet to prevent gastric irritation. Although current guidelines recommended that patients should chew their initial dose of ASA, there is little evidence as to whether this is efficacious. Therefore, we aimed to make a direct comparison of the pharmacokinetics and pharmacodynamics of ASA after ingestion of intact and chewed nonenteric-coated buffered ASA tablet (NBA) and enteric-coated ASA tablet (ECA) in a quadruple crossover study in healthy volunteers. Chewing ECA accelerated t(max) of ASA absorption, which became equivalent to that after ingestion of intact or chewed NBA. A significant decrease in serum thromboxane B(2) was observed 20 min after ingestion of chewed ECA, or intact or chewed NBA, and inhibition of platelet aggregation was also observed within 20 min. Thus, chewing of the ECA appears to result in a similar timing of ASA action to that in the case of chewed or unchewed NBA. (C) 2011 Wiley-Liss, Inc. and the American Pharmacists Association J Pharm Sci 100:3884-3891, 2011

There are few clinical tools with both predictive validity for pressure ulcer healing and availability in broad populations. We evaluated whether the total scores from DESIGN-R tool could predict pressure ulcer healing. We followed 3,196 patients with pressure ulcers from two multicenter cohort studies until wound healing, patient death, or discharge. Wound severity was evaluated by DESIGN-R tool from 0 (healed) to 66 (greatest severity). In the multivariate Cox proportional hazard model, higher DESIGN-R total scores at baseline were associated with lower healing rates (hazard ratio 0.90, 95% confidence interval 0.89-0.92), independent of the patient's characteristics, setting types, and wound depth or location. DESIGN-R had discriminative value for wound healing up to 90 days; the area under the receiver-operating characteristics curve from univariate analysis was 0.81 for healing within 30 days and 0.74 for healing within 30-90 days. The cutoff points were 9 for healing within 30 days and 18 within 30-90 days (positive and negative predictive value 78.8 and 74.1%; 63.9 and 81.1%, respectively). These points were validated for both superficial and deep ulcers. DESIGN-R can be a useful tool to predict pressure ulcer healing for a wide range of patient populations, settings, and wound locations.

臨床においてもう一つの重要な創評価である「経過評価」の妥当性、即ちDESIGN-Rが次の評価週まで何点減少すればよいかについて検証した。データセット中に含まれた761例中、解析対象は1週後411例、2週後286例、3週後224例、4週後170例であった。そのうち、追跡後、最終的に治癒したものは1週後245例(56.9%)、2週後154例(53.8%)、3週後123例(543.9%)、4週後93例(54.7%)であった。浅い褥瘡、深い褥瘡それぞれについて合計点変化は褥瘡治癒を予測でき、1週間から4週間後の至適カットオフ値が得られた。一方、深さや評価週によりカットオフ値とその推定精度が異なる点を考慮する必要があると思われた。

心臓・大血管術後患者の安静期・離床期においてデュアルフィットエアセルマットレス使用による褥瘡予防効果を確認し、従来のエアマットレスと比較し、寝心地が良好か検討した。実験群(25名)、対照群(29名)とでは基本属性、術式、手術侵襲に有意差がなかった。褥瘡は対照群に1名認められた。安静期の寝心地でビジュアルアナログスケール(VAS)に有意差があった項目は「ずれ」、「背部圧迫感」で実験群がよかった。離床期の寝心地でVASに有意差があったの項目は、「沈み込み」、「ずれ」、「起き上がり」、「坐位安定感」、「背部圧迫感」で実験群でよかった。動作回数と体位バランスの項目で有意差があった。実験群の方が「長坐位から端坐位」、「端坐位から立位」の動作回数が少なく、「側臥位時の角度」が大きかった。

BACKGROUND: Skin maceration is recognized as a risk factor for the development of certain skin lesions. In health care settings, incontinence-associated skin maceration is highly prevalent in the elderly. However, the effect of senescence on maceration has not been fully elucidated. OBJECTIVE: To reveal the enhancement of the maceration-induced ultrastructural alteration and barrier function of the epidermis by aging. METHODS: Skin maceration was reproduced by exposure to agarose gel in human and rat. The ultrastructural alterations in human and rat tissue were observed by transmission electron microscopy. The skin barrier function was evaluated by noninvasive methods in human, and by the transdermal penetration of small- and large-fluorescent molecules in rat. In order to reveal the effect of aging on the skin maceration, we compared these parameters between young and aged rats. RESULTS: In macerated skin, we observed expansion of the interstices of the stratum corneum, spinosum, and basale of the epidermis; disruption of the intercellular lipid structure in the stratum corneum; a decreased number of cell processes in the stratum spinosum and basale. The transdermal penetration test in the rat using two types of fluorescein indicated that maceration disrupted skin barrier function. Furthermore, senescence-enhanced ultrastructural and functional alterations were revealed in the rodent studies. CONCLUSION: This study demonstrates that aging enhances skin maceration. Considering that maceration is a risk factor for the skin damage, the development of technology to promote skin barrier recovery after maceration in the elderly is warranted.

Pressure ulcers are a common problem, especially in older patients. In Japan, most institutionalized older people are malnourished and show extreme bony prominence (EBP). EBP is a significant factor in the development of pressure ulcers due to increased interface pressure concentrated at the skin surface over the EBP. The use of support surfaces is recommended for the prophylaxis of pressure ulcers. However, the present equivocal criteria for evaluating the pressure redistribution of support surfaces are inadequate. Since pressure redistribution is influenced by physique and posture, evaluations using human subjects are limited. For this reason, models that can substitute for humans are necessary. We developed a new EBP model based on the anthropometric measurements, including pelvic inclination, of 100 bedridden elderly people. A comparison between the pressure distribution charts of our model and bedridden elderly subjects demonstrated that maximum contact pressure values, buttock contact pressure values, and bone prominence rates corresponded closely. This indicates that the model provides a good approximation of the features of elderly people with EBP. We subsequently examined the validity of the model through quantitative assessment of pressure redistribution functions consisting of immersion, envelopment, and contact area change. The model was able to detect differences in the hardness of urethane foam, differences in the internal pressure of an air mattress, and sequential changes during the pressure switching mode. These results demonstrate the validity of our new buttock model in evaluating pressure redistribution for a variety of surfaces. (C) 2010 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

DESIGN is a seven-item (depth, exudates, size, inflammation/infection, granulation, necrosis, and pocket) monitoring scale for pressure ulcers developed in 2002 by the scientific education committee of the Japanese Society of Pressure Ulcers. DESIGN is a very useful tool for chronological monitoring of each pressure ulcer, but a key limitation of this tool is its inability to compare the wound-healing process among different pressure ulcers in different patients due to a lack of statistical item weighting. Our aim was to weight DESIGN items by statistical analysis and develop a new validated tool to overcome this limitation. Subjects comprised 3,601 patients with pressure ulcers. Patients were followed every week during the study period. To establish the weighting of each item and grade, we estimated the probabilities of wound healing at 12-month follow-up using multivariable Cox's regression analysis. Weighting (-beta value) for each item in order of the highest rank was: pocket, 2.289; size, 1.573; inflammation/infection, 0.778; granulation tissue, 0.682; exudate, 0.543; and necrotic tissue, 0.529. Based on these findings, a new, validated "DESIGN-Rating tool" for monitoring the progression of pressure ulcer healing was developed, implying the development of an absolute evaluation tool and clinical indicator to assess the quality of medical care.

末梢静脈内カテーテル留置法では，対象静脈が目視困難な場合，確実な穿刺，合併症の発生に影響を及ぼす．本研究の目的は目視困難静脈の穿刺技術向上に向け，目視の可否による血管径 ・ 深さ，動脈との位置関係を超音波診断装置で，皮膚色を色差計で計測し違いを明らかにすることである．研究デザインは実態調査型研究である．対象者は健常若年女性 20名，計測静脈は 58本，計測動脈は 18本であった．その結果，目視の可否に有意差があったのは深さのみで，血管径，動脈との位置関係，皮膚色は同等であることが明らかになった．静脈の深さの平均 (SD) は，目視可能静脈が2.7 (0.7) mm，目視困難静脈が4.6 (1.8) mmであった (p=.0001)．目視の可否の分離値は 3.0mm (AUC=0.919，95％CI 0.84－0.99)で，深さ3mm以上の留置カテーテル用末梢静脈は目視困難になることが明らかとなった．したがって，目視困難な静脈は深さ3mm以上の穿刺技術が，動脈穿刺の防止は，目視の可否に関わらない穿刺技術の必要性が示唆された．

Objective: To develop an equation for the estimation of exudate volume in millilitres, for fullthickness pressure ulcers, according to wound characteristics. Method: In a cross-sectional study, 41 patients aged ≤ 60 years with 58 full-thickness pressure ulcers were evaluated. Exudate was collected by covering each wound with a transparent occlusive dressing and the accumulated volume was measured to estimate volume per day. The overall severity of each wound was evaluated by the DESIGN-R tool; a model was then developed to estimate the volume of exudate based on these experimental values. Linear regression analyses were performed to evaluate the precision and accuracy of the model. Results: The model, including exudate score, size score, and total score, showed a higher adjusted coefficient of determination (R2=0.66) than the model with only a traditional exudate score (R2=0.57). After adjustment for age, inclusion of interaction terms, and modification of bias, a model with continuous parameters was finally developed: exudate volume per day (ml/day) = exp([0.86×exudate score]+ [0.21×size score]+[0. 12×total score]-[0.013×size score×total score]-[0. 04×age]-3.60). Furthermore, a categorical model was developed for clinical simplicity of use. The adjusted R2was increased to 0.73 for the continuous model and to 0.77 for the categorical model. There were no apparent biases (p > 0.05) and no correlations between residuals and measured value (p > 0.05) in these models. Conclusion: The equation, including the exudate score, size score and total score of DESIGN-R, as well as age, is called the ESTimation method. It will be useful for clinicians to predict the absolute volume of exudate and to select appropriate dressings for full-thickness pressure ulcers. l Declaration of interest: The authors have nothing to declare.

AIM: To investigate the characteristics of elderly Japanese people sitting in a wheelchair using pressure mapping and an objective method to classify sitting patterns. METHOD: This descriptive observational study was conducted in a senior care facility and a geriatric hospital, with 107 elderly subjects (37 group A (house-bound), 34 group B (chair-bound) and 36 group C (bed-bound)) and 36 able-bodied. Maximum pressure, total support area, distance from backrest to coccyx and sitting pattern were collected by using a pressure mapping system. RESULTS: Maximum pressure was significantly lower for able-bodied than groups B and C (p < 0.001 and p = 0.024, respectively). Total support area was significantly larger for able-bodied than each elderly group (group A p = 0.014, group B p = 0.021, and group C p < 0.001). Distance from backrest to coccyx was significantly longer for group C than able-bodied (p < 0.001). The occurrence of proper sitting pattern significantly decreased as the degree of independence reduced (p < 0.001). CONCLUSION: Elderly people with disabilities have high interface pressure on a small support area, malposition, which is confirmed by longitudinal and lateral supporting balance indices, and imbalance in a wheelchair. The following concepts for developing cushions should be considered: low interface pressure with large support area, individual adjustment of sitting position and stability of body trunk.

Incontinence-associated dermatitis (IAD) is a common problem in elderly incontinent people. A comparative cross-sectional study was conducted to examine and compare properties of intact skin on the buttocks and subumbilicus area in elderly people wearing absorbent products and to identify pad environment factors that affect skin properties. Study participants included 45 elderly (age range: 68 to 103 years) female residents of one nursing home who were incontinent of feces and urine (dual incontinence group--DIG, n = 35) or feces only (fecal incontinence group--FIG, n= 10). Skin pH and hydration were measured and factors believed to affect the perineal environment and contribute to the development of IAD were assessed. In both DIG and FIG, skin hydration levels and pH were higher in the coccygeal than in the subumbilical area. Skin hydration of the sacral region in the DIG was significantly higher than in the FIG (P = 0.019) and skin pH on the coccygeal region and sacral region in the DIG was significantly higher than in the FIG (coccygeal region, P = 0.013; sacral region, P = 0.023). Absorbent pad surface pH (P &0.01) and excessive sweating (P = 0.006) were significantly related to skin pH. Results show that properties of perineal skin in elderly women with incontinence are affected by occlusion with pads, increasing the risk of IAD. Studies comparing the effect of various types of pads and pad-change frequencies on skin properties are needed.