須釜 淳子

This study aims to clarify (i) the incidence of pressure ulcers in neonates admitted to the neonatal intensive care units (NICUs) and (ii) risk factors of pressure ulcer development. All infants admitted to the NICU and kept in incubators from seven hospitals during the study period were recruited to the study. Each infant was given skin examination every day by nurses, and risk factors were collected three times a week by one researcher. The incidence of the pressure ulcers was calculated, and the risk factors for pressure ulcers were determined by using univariate and multivariate analysis. Eighty-one infants were involved in the study. A total of 14 pressure ulcers occurred in 13 infants during the 11-month study period, the incidence was 0.01 persons per day and cumulative incidence rate was 16.0%. Seven (50.0%) of 14 pressure ulcers were located on the nose. Multivariate analysis identified the following risk factors: skin texture (Dubowitz neonatal maturation assessment scale: skin texture score of 1 point or lower) [odds ratio 7.6; 95% confidence interval (CI) 1.58-36.71, P = 0.012] and endotracheal intubation usage (odds ratio 4.0; 95% CI 1.04-15.42, P = 0.042).

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: The present study investigated whether vibration therapy using a vibrator could facilitate the healing of Stage I pressure ulcers (PrUs) in older adults. METHODS: The study had a nonrandomized, blinded, controlled design. The subjects were hospital patients in long-term-care facilities with Stage I PrUs. In the experimental group, a vibrator (RelaWave; Matsuda Micronics Corp, Chiba, Japan) was used to apply vibration (frequency: 47 Hz; time: 10 seconds; amplitude modulation cycle: 15 seconds) for 15 minutes 3 times a day for up to 7 days, until Stage I PrUs healed. Apart from the vibration therapy, the experimental and control groups received the same care, which was provided according to PrU care guidelines. The number of healed ulcers was compared between 2 groups. RESULTS: The experimental group consisted of 16 patients with 20 Stage I PrUs; the control group consisted of 15 patients with 21 Stage I PrUs. In the experimental group, 8 (40.0%) PrUs healed; in the control group, 2 (9.5%) PrUs healed. The number of healed ulcers was significantly higher in the experimental group than in the control group (P = .033). The healing rate during the study period was significantly higher in the experimental group than in the control group (P = .018, logrank test). The hazard ratio adjusted for baseline risk factors was 0.031 (95% confidence intervals: 0.002-0.594, P = .021). The mean relative changes per day in wound area and intensity of redness were significantly greater in the experimental group than in the control group (P = .007, and P = .023, respectively). CONCLUSION: Based on these results, the use of the vibrator may facilitate the healing of Stage I PrUs.

第3期日本褥瘡学会学術教育委員会では、DESIGN-R下位項目の重み付けに続き、合計点の予測妥当性について、以下の「褥瘡治癒との関係」「褥瘡期間内治癒に対するカットオフポイント」の項目を検証した。治癒まで追跡できた1822症例を対象に解析した結果、DESIGN-Rの予測妥当性は深さ等の他の変数とは独立していた。DESIGN-R合計点は9点以下であれば、約8割の褥瘡が1ヵ月未満に治癒し、18点以下であれは約6割が1〜3ヵ月未満に治癒していた。更に19点以上であれば約8割は3ヵ月では治癒しないことが予想された。一方、DESIGN-R合計点を臨床で使用する際の注意事項として、1)合計点が極端に高い褥瘡における予後予測の不明瞭さ、2)他の患者・褥瘡要因を考慮する必要性、3)3ヵ月以後の治癒を予測することが困難であること、4)精度として2〜3割の予測誤差があることが示唆された。

著者らは共同開発した振動器を用いて、加振した場合に壊死組織を有する褥瘡の治癒が促進するかを検討した。対象は創の50%以上が黄色壊死組織または黒色壊死組織に覆われた褥瘡入院患者で、加振した13例(実験群、平均年齢81歳)と非加振11例(対照群、平均年齢81歳)にID番号の偶数奇数で分け、実験群には振動周波数47Hz、振動加速度1.78m/(s)2の加振を1日3回15分間5週間施行した。そして、治癒過程は壊死組織の割合と創面積の相対値で評価した。その結果、1)両群とも脳血管系の疾患が半数以上を占めており、両群の褥瘡の概要、交絡変数には有意差はなかった。2)実験群の壊死組織の割合は対照群に比べて2週目、3週目、4週目に有意に減少していた。3)創面積の相対値には有意差はなく、加振による有害事象も認められなかった。4)加振という阻血を改善する血行促進ケアを実施したことで、新たな壊死組織の産生が抑制され、実験群の方が速く壊死組織の割合が減少したと考えられた。

We prepared full thickness skin defects in rats fed on a protein-free diet as a hypoproteinaemia model, then switched the animals to a diet containing a normal protein level 1, 6 or 12 days after wounding (inflammatory, granulation and rearrangement phases of the wound healing process) to examine whether improvement in the low-protein state promotes subsequent wound healing. The interval until wound healing in rats fed on a normal protein diet was significantly shorter, whereas that in rats continuously fed on a protein-free diet was significantly longer than those of other groups. Early correction tended to accelerate wound healing. Although wound contraction in groups receiving a protein-corrected or protein-free diet remained similar until 15 days after wounding, thereafter the duration of the rearrangement phase was significantly longer in the protein-free group than in the other groups. The collagen level per unit of granulation tissue area during wound healing was significantly lower in the protein-free group than in the other groups. These findings indicate that protein correction at any time after wounding accelerates wound healing, although early correction is more effective, and reduces the duration of the rearrangement phase more than those of the inflammatory and granulation phases because of the deposit of collagen.

AIM AND OBJECTIVES: This study was designed to investigate the status of skin injuries in older individuals caused by adhesive tape and the associated factors for skin injury. BACKGROUND: Older individuals are susceptible to skin injuries caused by medical adhesive tape. However, the current status of such skin injuries and the associated factors involved has not been clearly elucidated. DESIGN: Prospective cohort design, using comparative and descriptive statistical tests. METHODS: The subjects were 155 patients aged 65 or older who were admitted to a long-term care facility and required the use of medical adhesive tape. Patients who showed no skin injuries were selected and the incidence rate and status of skin injuries that occurred during the eight-week study period were investigated. The skin injuries observed were classified by a dermatologist. The associated factors were examined statistically. Informed consent was obtained from all patients. RESULTS: Skin injuries developed at 34 sites in 24 subjects. The cumulative incidence rate was 15.5%, and the incidence density was 38.0/1000 person-days. Many of the skin injuries occurred around pressure ulcers and intravenous hyperalimentation sites. Other prevalent areas included the buttocks and back, where tape is commonly used. The skin injuries were classified as contact dermatitis (70.6%), trauma (20.6%) and infection (8.8%). The ratio of skin contamination and skin mobility in patients with contact dermatitis was significantly higher than in patients without skin injury. CONCLUSION: The highest incidence rate was observed in the buttock area of patients with pressure ulcers. The incidence rate of contact dermatitis was the highest. RELEVANCE TO CLINICAL PRACTICE: Skin care to minimise contamination and more effective ways of applying medical adhesive tape may be needed to prevent contact dermatitis.

Suspected deep tissue injury (DTI) is a new category of pressure ulcer (PU), and defined as an ulcer that developed from a deep tissue (subcutaneous tissue) region and deteriorates towards the superficial skin. DTI is a serious clinical problem because it cannot be detected at an early stage and rapidly deteriorates to a deep PU. Consequently, there is a requirement for the identification of novel biomarkers to detect damage to the deep tissue including deep muscle tissue. For this purpose, it is essential to understand the molecular and cellular mechanisms of DTI formation and deterioration. This article reviews the recent progress in studies on the hypoxia-related mechanisms of DTI, and introduces our attempts to establish novel biomarkers for detecting deep muscle damage. Hypoxia-inducible factor 1 alpha subunit (HIF1-alpha) is a widely used marker for hypoxic conditions. We detected increased expression and localization of HIF1-alpha in the deep muscle tissue of PU model rats, indicating that HIF1alpha is a key molecule in DTI and a valuable biomarker for hypoxia in DTI in the research field. From the biochemical aspect, we focused on creatine phosphokinase (CPK). CPK is an intracellular enzyme related to energy metabolism, and its level in serum has been extensively used as a diagnostic marker for muscle injury. We attempted to estimate muscle injury from the CPK levels in exudates, which can be collected non-invasively and reflect the microenvironmental conditions. Our results using PU model rats suggested that exudate CPK could be a more sensitive biomarker than serum CPK for deep muscle tissue injury, and could be applicable for clinical diagnosis of DTI.

Background & aims: To investigate the impact of nutritional status and nutrition-related factors on the development and severity of pressure ulcers acquired in the home care setting. Methods: Two hundred and seven home care offices in Japan were selected at random and 290 patients with home-acquired pressure ulcers and 456 patients without pressure ulcers were analyzed. Data on nutritional status, caregiver knowledge, and health professional&apos;s nutritional management were collected. Pressure ulcers were categorized as superficial or full-thickness. Results: Malnutrition was significantly and most strongly associated with higher rate of the pressure ulcer after adjusting for other risk factors (OR, 2.29; 95% CI, 1.53-3.44). Assessment of the patient&apos;s nutritional status and adequate dietary intake by a health professional were significantly associated with lower odds for developing pressure ulcers (OR, 0.43, 0.47; 95% CI, 0.27-0.68, 0.28-0.79, respectively). Malnutrition was also significantly and most strongly associated with more severe pressure ulcers (OR, 1.88: 95% CI, 1.03-3.45). Assessment of a caregiver&apos;s nutritional knowledge by a health professional was a significant preventive factor for severe pressure ulcers. Conclusion: The quality of home care for risk factors such as pressure redistribution has improved, making nutritional management a more crucial factor in pressure ulcer prevention. (C) 2009 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

女性入院高齢者における体温の概日リズムの特徴とその対象者の特性を明らかにするために、対象者の活動を記録しながら24時間継続して深部温を測定した。対象者は日常生活自立度がA〜Cで、療養型医療施設に入院している70歳以上の女性高齢者12名である。深部体温は非加熱型深部体温計測装置を腹部に貼付して測定し、研究者らが作成した条件の該当数によって健常・境界・逸脱の3グループに分類した。さらに、概日リズムに影響を及ぼす特性をみるために、基礎情報、環境、エネルギー代謝を調査し、グループ間で比較して特徴を抽出した。その結果、深部温の概日リズムは特徴ごとに健常3名、境界7名、逸脱2名に分類され、概日リズムの振幅平均1.1±0.3℃であった。概日リズムを崩れやすくする特性としては「日常生活自立度が低い」、「主な栄養摂取経路が経口以外」、「意識レベルが低い」が抽出された。以上より、女性入院高齢者では深部温が昼夜問わず不規則に変動し、概日リズムのない逸脱グループがあることが明らかとなった。そのため、概日リズムを整えるためには、まず24時間深部温をモニタリングし、これらの特性に合ったケアを行なうことが重要であると示唆された。(著者抄録)

We considered the relationship among exudate, wound area, angiogenesis, lymphangiogenesis, and reepithelialization during wound healing. Full-thickness wounds were made on the dorsum of mice. The weight of exudate absorbed into the dressing as well as the wound area was determined daily. Sections of the wounds were stained with anti-LYVE-1 and CD31 antibodies. Indian ink was injected into the wound for observing the movement of the exudate on days 3, 5, and 7 after wounding. New epithelium completely covered the wound on day 11. The quantity of exudate peaked on day 1, and then rapidly decreased until it was undetectable on day 11. Most of the Indian ink injected into the wound was retained within the wound and did not flow into the surrounding tissue. New blood vessels showed a uniform distribution in the granulation tissue on day 5. New lymphatics appeared in the granulation tissue approximately 2 days later than the blood vessels and they were distributed toward the center of the granulation tissue on day 11. Thus, reduction of exudate from the wound appears to be related to blood vessels, not lymphatics. However, increasing lymphatics may play a role in the late phase of the wound-healing process.

AIM: The aim of this study is to identify the related factors of skin lesions found in the surrounding environment of absorbent pads by clinical investigation. BACKGROUND: Most older patients with incontinence use absorbent products, therefore causing many patients to have skin lesion in the absorbent pad area. To prevent these skin lesions from occurring, it is necessary to examine the absorbent pad environment of clinical patients since there are many contributing factors that complicate the pathophysiology in this area. DESIGN: A cross-sectional design was used. METHODS: One hundred older Japanese patients with faecal and/or urinary incontinence using diapers and absorbent pads participated. Excluding blanchable erythema, the presence of skin lesions in the absorbent pad area was confirmed. Skin pH, hydration level and bacterial cultures were used to assess the skin property. Absorbent pad environment and patient demographics were also investigated. RESULTS: The overall prevalence of skin lesions was 36%. Forty percent of the skin lesions were contact dermatitis. Multivariate logistic regression analysis revealed that only the presence of diarrhoea independently affected contact dermatitis. CONCLUSION: There was a significant relationship between contact dermatitis and the use of absorbent pads when the patient had diarrhoea. Although the factors related to skin lesions in the absorbent pad area are complexly intertwined, this study was the first to be able to determine diarrhoea as one specific factor in clinical setting. RELEVANCE TO CLINICAL PRACTICE: This finding suggests that the presence of diarrhoea is significantly related with contact dermatitis. Therefore, when a patient has diarrhoea, health-care professionals should immediately implement a preventative care program which includes careful skin observation and improved skin care. It is also necessary to develop a more effective absorbent pad to protect the skin of incontinent patients who suffer from the irritating effects of liquid stool.

AIM: This paper is a report of a study conducted to examine whether continuous interface pressure monitoring of postoperative patients in an intensive care unit is feasible in clinical practice. BACKGROUND: The interface pressure between skin and surfaces is generally evaluated for pressure ulcer prevention. However, the intensity and duration of interface pressure necessary for pressure ulcer development remains unclear because the conventional interface pressure sensors are unsuitable for continuous monitoring in clinical settings. METHODS: A total of 30 postoperative patients in an intensive care unit participated in this study in 2006-2007. A sensor was built into a thermoelastic polymer mattress. The whole-body interface pressure was recorded for up to 48 hours. Pressure ulcer development was observed during the morning bed-bath. For analysis, the intensity and duration of the maximal interface pressure was evaluated. FINDINGS: The mean age of the study group was 62.0 +/- 15.4 years. Two participants developed stage I pressure ulcer and blanchable redness at the sacrum. The longest duration of pressures greater than 100 mmHg were 487.0, 273.5 and 275.7 minutes in the pressure ulcer, blanchable redness and no redness groups respectively. CONCLUSION: Continuous monitoring of the intensity and duration of whole-body interface pressure using the KINOTEX sensor is feasible in intensive care patients.

Deep tissue injury (DTI) is a pressure-related injury to subcutaneous tissues under intact skin. DTI has recently been a focus of enthusiastic debates among wound care specialists, particularly regarding how DTI should be categorized into the conventional pressure ulcer (PU) classification. Pathophysiologically, DTI is regarded as an antithesis (bottom-up) of the conventional understanding of PU formation (top-down), and some researchers have suggested that all deep PUs are derived from DTI. On the other hand, the concept DTI can be applied to several specific conditions characterized by subcutaneous tissue damage, some of which were not originally recognized as PUs. In the first part of this chapter, we discuss the novelty and conceptual confusion of DTI from the clinical standpoint, and briefly review several specific types of DTI, as found in immobilized patients, in Asian patients with excess bony prominences, and in patients with spinal cord injury. In the second part of this chapter, we review the molecular aspects of DTI pathophysiology. Damage to subcutaneous tissues such as muscle and adipose tissue is predominantly repaired by the conventional wound healing process with granulation and scar formation. However, there may also be endogenous regenerative reactions in these tissues, such as myogenesis, possibly adipogenesis, and angiogenesis, which will be reviewed at the molecular level later in this chapter. Furthermore, we have established a rat model of DTI. We will present our own experimental results of muscle damage in the DTI model, and the elevation of biochemical and molecular markers indicating muscle damage and regeneration, including creatine phosphokinase (CPK), hypoxia-inducible factor-1 (HIF-1), and Hedgehog (Hh) signaling molecules.

本研究の目的は, 血液透析療法中患者に加える振動の効果を循環動態の指標から明らかにすることであり, 全身への影響と下肢循環への影響を測定し, 安全性を確認した. 対象者は成人透析患者8 名. 研究デザインは準実験 ･ 比較研究で, 実験的操作は血液透析中に加える下肢振動であり, コントロールは同一対象者の通常の血液透析療法 (振動付加なし) であった. 循環動態は上肢血圧 (BP), 下肢末梢循環は足背部経皮酸素分圧 (TcPO₂) を指標とし, それぞれ変化量 (&Delta;) を比較した. &Delta;BP は振動群のほうが変動は少なかったが, 有意差はなかった. 足背部 &Delta;TcPO₂(平均 ±SD) は, 振動終了直後/30 分後 /60 分後において振動群 8.2±9.0/8.3±11.3/6.9±13.2 mmHg, コントロール群 3.0±7.2/1.0±7.6/- 1.2±11.4 mmHg であり, いずれも振動群が上昇していた. 振動終了後少なくとも 60 分は効果が持続すると考えられ, 振動の血液透析患者への下肢末梢循環促進法としての安全性と有効性が示唆された.

This study objectively evaluated the degree of comfort in bedridden older adults using an air-cell mattress with an automated turning mechanism. The sample included 10 bedridden women with verbal communication difficulties. The high frequency (HF) components of heart rate variability, which reflect parasympathetic nervous activity, were compared for the manual and automated turning periods. No significant differences in the HF component were observed in 5 of the participants. Significant increases in the HF component associated with automated turning were observed in 3 participants; however, the two participants with the lowest body mass index values exhibited a significant reduction in the HF component during the automated turning period. The results revealed that comfort might not be disturbed during the automated turning period.

Deep tissue injury (DTI) is difficult to detect in the early phase. Creatine phosphokinase (CPK) as a muscle enzyme could represent a promising indicator of DTI. However, serum CPK levels reflect the systemic condition rather than the local wound environment. Wound exudates can be indicative of the local wound environment. This study aimed to investigate the usefulness of CPK levels in wound exudates as an indicator of DTI. Rats were divided into control, 6 hours 10-kg and 6 hours 20-kg loading groups. Serum samples were obtained before wounding, and at 8 and 12 hours, and 1, 2 and 3 days after wounding, while exudate samples were obtained on days 2 and 3. Serum CPK levels were markedly increased in the 10-kg and 20-kg groups at 8 and 12 hours after loading compared with the baseline value and control group, but decreased to the normal level on day 1. In both loading groups, exudate CPK levels were high on day 2 and decreased on day 3. Muscle necrosis was more severe in the 20-kg group than in the 10-kg group by histological examination. This is the first study to indicate the potential of CPK in wound exudates as an indicator of DTI.

The formation of pressure ulcers is dependent on multiple factors including ischemia-reperfusion (IR). This study assessed the mechanism of a previously reported murine model of cutaneous IR injury. Three cycles of IR (days 1-3) by external application of two magnetic plates were performed to induce pressure ulcer formation. Increased infiltration of neutrophils and macrophages, and augmented expression of proinflammatory cytokines and inducible nitric oxide synthase (iNOS), were observed during IR cycles. In this model, monocyte chemoattractant protein-1 (MCP-1) was remarkably increased at day 1 in the skin followed by inflammatory cell infiltration. Therefore, IR cycles were performed in MCP-1-deficient (MCP-1-/-) mice to evaluate the role of this chemokine in pressure ulcer development. MCP-1-/- mice showed reduced macrophage infiltration and expression of tumor-necrosis factor-α (TNF)-α and iNOS during IR cycles leading to attenuated apoptosis and skin injury. Importantly, MCP-1 played a role in apoptosis and injury via inducing iNOS during the reperfusion rather than the ischemic period. These findings indicate that MCP-1 may be a critical factor for macrophage recruitment and subsequent skin inflammation and injury during IR cycles. We propose that this is a useful model for investigating the mechanism of pressure ulcer formation using various transgenic mice. © 2008 The Society for Investigative Dermatology.

This study aimed to determine the predictive accuracy and factors deteriorating blanchable erythema. A prospective cohort study was conducted in a 832-bed university hospital in Japan. Skin condition, risk factors, care plans and practices were measured everyday for 4 weeks by direct assessments and chart review by research staff. Blanchable erythema developed in 62 (24.9%) and a pressure ulcer in 8 (3.2%) patients. Six of the 62 blanchable erythema patients worsened to pressure ulcer of either stage I or II. Calculating the accuracy of blanchable erythema for predicting pressure ulcer development, sensitivity was 75%, specificity 77% and positive likelihood ratio 3.26. The factors found to deteriorate blanchable erythema were K-scale &apos;pressure&apos; and inadequate support surface management to a patient whose condition was deteriorating. These results suggested that the value of positive likelihood ratio means small effect to the clinical use. However, if adequate support surface management were implemented to blanchable erythema patients, the incidence of pressure ulcer would probably fall to 0.8%.

1% chitooligosaccharide injected intraperitoneally for 14 days after full-thickness skin wounds were made. Although the effect of chitooligosaccharide on the process of skin wound healing was almost not observed, the wound size in the experimental group on day 14 was significantly smaller than that of in the group injected saline. Thus, we invested whether 1% chitooligosaccharide injected intraperitoneally per day 14 days before and after wounding promoted the healing process of the skin wound. 1% chitooligosaccharide injected intraperitoneally doesn't promote the healing process of the full-thickness skin wound but induces aseptic peritonitis with lacteous lumps on the peritoneal surface consisted inflammatory cells phagocytosing chitooligosaccharide. 先にマウスに皮膚全層欠損創を作製し、連日1% キトサンオリゴ糖を腹腔内投与する実験を行ったところ、治癒促進の効果はほとんどみられなかった。しかし投与14 日目に生食投与群との間に創面積の有意な縮小が見られたため、今回は投与期間を延長し、創作製前からキトサンオリゴ糖投与をすることで創傷治癒過程が促進されるかを検討した。その結果、治癒は促進されることなく、さらには無菌性の腹水が貯留する腹膜炎を起こした。また、横隔膜の腹膜面においてキトサンオリゴ糖を貪食したと思われる炎症細胞の塊が形成されているのが観察された。