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Amyotrophic lateral sclerosis

Patients with sporadic amyotrophic lateral sclerosis (ALS) show disorganised collagen and elastin of the dermis. We looked for inflammatory alterations to cutaneous blood vessels.

Seven patients with sporadic ALS were investigated; five were confined to bed, but none had bedsores.

The skin in ALS is characterised by a distinctive pattern of alterations of connective tissue and blood vessels. Examination of skin in an additional and easily accessible investigation which may help elucidate the pathogenesis of ALS.

Kolde G et al., Skin involvement in amyotrophic lateral sclerosis. Lancet, 1996 May 4, 347:9010, 1226-7.

Analysis of Metabolites

Sweat was collected from tissues subjected to external load (sacrum, ischium, forearm, calf) and 6 metabolites analysed: chloride, lactate, urea, urate, sodium, potassium. Sweat rates were greater at the sacrum and ischium. There were differences in the concentrations of lactate and urea between sites but these were smaller when expressed as amount secreted. This technique has potential clinical application to the investigation of suceptibility to pressure sores.

"The analysis of metabolites in human sweat: analystical methods and potential application to investigation of pressure ischemia of soft tissues." Taylor, R.P.; Pollack, A.A.; Bader, D.L. Ann. Clin. Biochem. 1994 Jan; 31(Pt 1): 18-24.


In an effort to reduce the incidence of decubitus ulcers among wheelchair users, current work in cushion design concentrates on minimizing the pressure at the buttock-cushion interface. Finite element analysis can show the stress levels throughout the soft tissue between the cushion and the ischial tuberosity and give designers a better indication of the effects of a particular cushion.

Finite element models were generated of the tissues around the ischial tuberosities of male and female subjects. Linear three-dimensional models were generated using a 386 computer and solved with infinitesimal deflection theory.
The resulting minimal principal stresses were 17 kPa and 15 kPa at the buttock-cushion interface for seated male and female subjects, respectively. Computational results were verified experimentally with magnetic resonance imaging and interface pressure measurements.

Three-dimensional computer model of the human buttocks, in vivo. Todd-BA; Thacker-JG. J-Rehabil-Res-Dev. 1994; 31(2): 111-9.

Care Unit

Care Unit Management

A systematic approach to intensive care unit management of acute spinal cord injury

Anticipation, prevention, and treatment of sequelae of spinal cord injury are stressed in sections on respiratory, cardiovascular, venous thrombosis, and gastrointestinal issues, as well as in sections on nutritional, genitourinary, and skin problems associated with spinal cord injury.

Intensive care of patients with spinal trauma. McBride-DQ; Rodts-GE. Neurosurg-Clin-N-Am. 1994 Oct; 5(4): 755-66.

Cervical collars

Cervical collars play a role in the long-term treatment of cervical spine injuries. Pressure ulcers are one of the potential complications.

The Stifneck collar exceeds capillary closing pressure (CCP) for most contact points. The Philadelphia collar exposes the wearer to high pressures when supine compared with the upright position. The Newport and Miami J collars exerted pressure well below CCP. The subjective comfort (scale from 0 (poor) to 5 (best)) ratings were: Stifneck = 0.85, Philadelphia = 3.00, Newport = 3.80, and Miami J = 3.45.
Recommend use of "patient-friendly" collars such as the Newport or Miami J. These collars should potentially reduce the incidence of soft-tissue complications and improve patient compliance.

Prospective evaluation of craniofacial pressure in four different cervical orthoses. Plaisier-B; Gabram-SG; Schwartz-RJ; Jacobs-LM. J-Trauma. 1994 Nov; 37(5): 714-20.


Clinical indicators

To monitor adults older than 65 years living in nursing facilities and who experience unintentional weight loss of more than 10% of actual body weight in 6 months or more than 5% in 1 month or who have stage II, III, or IV pressure ulcers.

Of the 24 indicators for unintentional weight loss, the 6 indicators present most often, in descending order, were:
reduced functional ability,
intake of 50% or less of food served for the past 3 consecutive days,
chewing problems,
serum albumin level less than 35 g/l with normal hydration status,
cholesterol level less than 4.1 mmol/L, and
refusal of 50% or more of food replacement for the past 7 days.

For the residents with pressure ulcers, the indicator present most often was serum albumin level less than 35 g/L with normal hydration status.

The three highest intervention indicators were:

receives 1.2 g protein per kilogram of actual body weight,
receives 120 mg or more of vitamin C daily, and
receives 1 1/2 times the energy required based on goal body weight.

When serum albumin level was documented in the medical record, it was a valid indicator for both diagnoses.

Inappropriate dietary intake, disease, and disability place residents in nursing facilities at risk for malnutrition. Thus, it is important to obtain laboratory values when assessing elderly residents and determining their nutritional status.

Gilmore SA et al., Clinical indicators associated with unintentional weight loss and pressure ulcers in elderly residents of nursing facilities. J Am Diet Assoc, 1995 Sep, 95:9, 984-92.

Clinical Practice Guideline

This Quick Reference Guide for Clinicians (highlights from the Clinical Practice Guideline of Treatment of Pressure Ulcers).

Topics covered include: assessment of the patient and pressure ulcer(s), tissue load management, ulcer care, management of bacterial colonization and infection, operative repair of the pressure ulcer, and education and quality improvement.

Tables and forms are included as aids for assessing the pressure ulcer and the patient's nutritional status.

Pressure ulcer treatment. Agency for Health Care Policy and Research. Clin-Pract-Guidel-Quick-Ref-Guide-Clin. 1994 Dec(15): 1-25.


Complications (England)

The initial admission of patients to other hospitals has inevitably led to delays in transfer to spinal injuries units. Complications were more frequent in patients undergoing spinal surgery before transfer to the center. Furthermore, the longer the delay in transfer, the higher the incidence of pressure sores. Suggestions are made as to how complications can be avoided in future.

"Complications of spinal surgery in acute spinal cord injury." Carvell, J.E. & Grundy, D.J. Paraplegia. 1994 Jun; 32(6): 389-95.


Diapulse treatment

Investigated the effect of pulsed high peak power electromagnetic field (Diapulse) on treatment of pressure ulcers

Bulge healing rate was: 85% excellent and 15% very good healing under Diapulse therapy; in the placebo group, 80% patients show no improvement and 20% poor improvement

Strongly advise Diapulse treatment.

The effect of diapulse therapy on the healing of decubitus ulcer. Comorosan-S; Vasilco-R; Arghiropol-M; Paslaru-L; Jieanu-V; Stelea-S. Rom-J-Physiol. 1993 Jan-Jun; 30(1-2): 41-5.


Compares the clinical effectiveness and wound management properties of a copolymer membrane, Inerpan (Synthelabo), and a hydrocolloid dressing, Comfeel (Coloplast), in the treatment of decubitus ulcers in the elderly.

Inerpan is easy to use, safeguards the healing process and is of particular value in the management of pressure sores.

Local treatment of pressure sores in the elderly: amino acid copolymer membrane versus hydrocolloid dressing. Honde-C; Derks-C; Tudor-D. J-Am-Geriatr-Soc. 1994 Nov; 42(11): 1180-3.


Reviewed cases with myelomeningocele and congenital kyphosis. Ten patients underwent kyphectomy with wire fixation and spinal fusion for severe-curve progression and problems with decubiti ulcers.

Two of these patients continue to have problems with skin breakdown. Kyphectomy enables patients to sit straighter and is the proper treatment for these patients. If operative treatment is prohibitive or denied for some reason, then suitable wheelchair modifications can enable these patients to function with reasonable comfort.

Congenital kyphosis in myelomeningocele: results following operative and nonoperative treatment. Martin-J Jr; Kumar-SJ; Guille-JT; Ger-D; Gibbs-M J-Pediatr-Orthop. 1994 May-Jun; 14(3): 323-8.


Malnutrition (1)

Malnutrition has received little attention in acute stroke, although it represents a risk of decreased immunity and nosocomial infections.

Protein-energy malnutrition was observed in 16.3% of patients at inclusion and in 26.4% after the first week, with a significant decrease in fat and visceral protein compartments.

Malnourished patients showed higher stress reaction and increased frequency of infections and bedsores in comparison with the appropriately nourished group.

Protein-energy malnutrition after acute stroke is a risk factor for poor outcome. Early appropriate enteral caloric feeding did not prevent malnutrition during the first week of hospitalization.

Davalos A et al., Effect of malnutrition after acute stroke on clinical outcome. Stroke, 1996 Jun, 27:6, 1028-32.

Malnutrition (2)

The association between protein-calorie malnutrition and pressure ulcers is well established.

Measurements of nutritional status are frequently included in the routine clinical assessment of patients with pressure ulcers. This paper reviews the associations between these measurements and the presence, severity and healing of pressure ulcers.

Strauss EA & Margolis DJ: Malnutrition in patients with pressure ulcers: morbidity, mortality, and clinically practical assessments. Adv Wound Care, 1996 Sep-Oct, 9:5, 37-40.



Micronutrient supplements
Nutritional Risk Factors
Nutritional support
Nutritional supplements

Micronutrient supplements

To estimate the intakes of essential nutrients by eating-dependent nursing home residents (EDR).

Seventy percent (24/34) residents in the study group were underweight (body mass index < 23 kg/m2), 26% were hypoalbuminemic (serum level < 3.5 g/dl), 50% were anemic (hematocrit < 37%); and 38% had pressure ulcers.

In 88% EDR, the dietary intakes of three or more essential nutrients were below 50% of the RDA. Most frequent and severely deficient were zinc, copper, and vitamin B6. Despite the inadequate essential micronutrient intakes in the majority of EDR, only 35% received a multivitamin supplement and only 3% received a trace mineral supplement.

A survey of 30 other VA nursing homes indicated generally similar findings to those in the Milwaukee facility with regard to the high frequency for eating-dependence, and the low frequency for administration of multivitamin and trace mineral supplements.

Despite eating supervision and assistance, the majority of EDR have inadequate intakes of numerous essential macro- and micronutrients. The deficient micronutrient intakes could be normalized by administration of a multivitamin/trace mineral supplement daily. Nevertheless, only a minority of EDR in VA nursing homes currently receive such a supplement.

Rudman D et al., Nutrient intakes of eating-dependent nursing home residents: underutilization of micronutrient supplements [see comments]. J Am Coll Nutr, 1995 Dec, 14:6, 604-13.


Among the many risk factors for pressure ulcers, malnutrition is potentially reversible. This article examines the relationship of malnutrition to the prevention and healing of pressure ulcers. Evidence for nutrition in preventing and healing pressure ulcers is presented. Specific nutrients, including some amino acids, vitamins, and minerals, have been evaluated for their effects on wound healing.

Thomas DR: The role of nutrition in prevention and healing of pressure ulcers. Clin Geriatr Med, 1997 Aug, 13:3, 497-511.

Nutritional Risk Factors

This article focuses on nutritional risk factors that predict the development of pressure ulcers in hospital and nursing home patients.

Cross-sectional studies associate inadequate energy and protein intake; underweight; low triceps skinfold measurement; and low serum albumin, serum cholesterol, and hemoglobin levels with pressure ulcers.

Nutritionists should provide a high-energy, high-protein diet for patients at risk of development of pressure ulcers to improve their dietary intake and nutritional status.

Nutritional prediction of pressure ulcers. Breslow-RA; Bergstrom-N. J-Am-Diet-Assoc. 1994 Nov; 94(11): 1301-4; quiz 1305-6.

Nutritional support

Malnutrition is a common problem in older persons, and in the presence of disease, is accompanied by increased morbidity and mortality. This article provides a rational approach to the nutritional care of the common nutritional problems that occur in the elderly. These problems include obesity, a condition that occurs with some prevalence in older persons, weight loss and being significantly underweight, and hypoalbuminemic malnutrition. An approach to the nutritional management of patients with pressure ulcers is also discussed.

Lipschitz DA: Approaches to the nutritional support of the older patient. Clin Geriatr Med, 1995 Nov, 11:4, 715-24.

Nutritional supplements

Because a pressure ulcer may be related to malnutrition, clinicians should assess patients' nutritional status and ensure that patients receive adequate nutrition to support healing.

The Agency for Health Care Policy and Research's guideline Treatment of Pressure Ulcers outlines recommended calorie and protein levels for patients at risk for pressure ulcers and with pressure ulcers. This article focuses on practical aspects of providing adequate nutrition to patients with pressure ulcers, using a variety of products available for oral supplementation.

Himes D: Nutritional supplements in the treatment of pressure ulcers: practical perspectives. Adv Wound Care, 1997 Jan-Feb, 10:1, 30-1.

Pressure ulcers

Pressure ulcers: a review

This article reviews the etiology, pathology, description, risk factors, prevention, medical and surgical management, and complications of pressure sores. Pressure ulcers, which develop primarily from pressure and shear, are also known as decubitus ulcers, bed sores, and pressure sores. They continue to occur in hospitals, nursing homes, and among disabled persons in the community. Estimates of the prevalence of pressure ulcers in hospitalized patients range from 3% to 14% and up to 25% in nursing homes. Persons with spinal cord injury and the elderly are two groups at high risk. The most common sites of development are the sacrum, ischium, trochanters, and about the ankles and heels. Areas of ongoing research such as electrical stimulation nd growth factors are discussed.

"Pressure ulcers: a review." Yarkony, G.M. Arch.Phys.Med.Rehabil. 1994 Aug; 75(8): 908-17.

Risk assessment

Risk assessment (England)

Hospital-acquired pressure sores are a costly and often avoidable drain on both the patient and hospital resources. This article describes the process and rationale behind a multidisciplinary attempt to develop and effective risk assessment tool for use in a specialist neurosciences setting.

"Pressure area risk assessment in a neurological setting." Johnson, J. Br. J. Nurs. 1994 Oct 13-26; 3(18): 926-8, 930-1,933-5.


In twenty-one children with myelomeningocele and progressive scoliosis, treatment of scoliosis was attempted with a Boston type underarm brace.

The brace caused decubitus ulcer in one patient, and two patients developed increased pressure of the urinary tract.

Brace treatment of scoliosis in children with myelomeningocele. Muller-EB; Nordwall-A. Spine. 1994 Jan 15; 19(2): 151-5.


The Agency for Health Care Policy and Research supported the development of guidelines for the prediction and prevention of pressure ulcers.

Based on the best available scientific evidence, the guidelines recommend that individuals who are bed- or chair-bound should be assessed further for risk and receive care according to the risk factors.

Appropriate actions include managing tissue loads, reducing exposure to moisture, managing incontinence, and assuring adequate nutrition. The guidelines are presented, research supporting the guidelines is summarized, and relevant articles published since the release of the guidelines are reviewed.

Bergstrom NI: Strategies for preventing pressure ulcers. Clin Geriatr Med, 1997 Aug, 13:3, 437-54.


In the 1993 survey, the prevalence of pressure ulcers was 11.1% in 177 hospitals. This is higher than the 9.2 prevalence rate Meehan found in 1989. The sacrum, with 38% (n = 2,168) of all reported ulcers, remains the most common site for pressure ulcer occurrence.

Patients between the ages of 70 and 89 years of age had 54% of the ulcers found. The average number of ulcers per patient was 1.73. Dark-skinned, African-American patients again were found to have the majority of Stage IV ulcers. There were 1,024 ulcers reported in this stage group, and of these, they had 16% (n = 164). Of patients with ulcers, 22% were on some form of air or foam overlay support system; however, standard mattresses and mattress replacements were used for 31% of all patients with pressure ulcers.

National pressure ulcer prevalence survey. Meehan-M. Adv-Wound-Care. 1994 May; 7(3): 27-30, 34, 36-8.

Thermal changes

Elderly subjects are prone to develop pressure sores over the sacrum area mainly due to external pressure and shear effects which negatively affect the skin microcirculation.

The total microcirculatory blood flow increased over 16 times and the nutritive transport approximately 5 times compared to the reference value, and the calculated blood flow of subpapillary tissue layers increased 17-19 times. However, the skin temperatures in damaged and undamaged skin did not differ significantly. These results show an increased skin microcirculation in the early stage of pressure sores but no increase in skin temperature. The more strongly increased skin blood flow in subpapillary layers effectively conducts away the heat caused by the damage and the increased metabolite activity.

"Skin microcirculatory and thermal changes in elderly subjects with early stage of pressure sores." Schubert, V; Perbeck, L; Schubert, P.A. Clin. Physiol. 1994 Jan; 14(1): 1-13.

Topical EFAs

Topical essential fatty acids (EFA)

Investigated whether the topical application of essential fatty acids improves hydration and elasticity and helps prevent skin breakdown in individuals with poor nutritional status.

Every 8 hours, approximately 20 ml of solution A (1.6 gr EFA with linoleic acid extracted from sunflower oil, 112 UI vitamin A, and 5 UI Vitamin E) or B (1.6 gr mineral oil, 112 UI Vitamin A, and 5 UI Vitamin E) was applied all over the body inclusive of all potential wound sites for a mean of 21 days.

Essential fatty acids really do make a difference in the skin.

Declair V: The usefulness of topical application of essential fatty acids (EFA) to prevent pressure ulcers. Ostomy Wound Manage, 1997 Jun, 43:5, 48-52, 54.