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Intertrigo is a common inflammatory skin disorder caused by skin-on-skin friction in skin folds, due to moisture becoming trapped because of poor air circulation. This can occur in any area of the body where two skin surfaces are in close contact with each other. The aim of this scoping review was to systematically map, review and synthesise evidence on intertrigo in adults. We identified a wide range of evidence and performed a narrative integration of this related to the diagnosis, management and prevention of intertrigo. A literature search was conducted within the following databases: Cochrane Library, MEDLINE, CINAHL, PubMed and EMBASE. After reviewing articles for duplicates and relevance, 55 articles were included. The incorporation of intertrigo in the ICD-11 provides a clear definition and should improve the accuracy of estimates. With regards to the diagnosis, prevention and management of intertrigo, the literature demonstrates consensus among health professionals in approach and this forms the basis for the recommendations of this review: identify predisposing factors and educate patient in reducing these; educate patients in skin fold management and adopt structured skin care routine; treat secondary infection with appropriate topical agent; consider using moisture-wicking textiles within skin folds to reduce skin-on-skin friction, wick away moisture and reduce secondary infection. Overall, the quality of evidence on which to determine the strength of any recommendations for practice remains low. There remains the need for well-designed studies to test proposed interventions and build a robust evidence base.

Chronic wounds fail to progress through the normal stages of healing, with the largest remediable cause of chronicity being presence of a multi-species biofilm. Removal of biofilm from the wound environment is central to wound care. A device for mechanically removing biofilms from wounds has been devised. The removal is caused by small-scale liquid currents and shear, generated by acoustically activated microscopic air bubbles. These bubbles and acoustic waves are delivered onto the wound by a gentle liquid stream, allowing cleaning in situ and removal of debris in the run-off liquid. We have investigated if this liquid acoustic wound stream (LAWS) can remove bacterial biofilm from soft biological wound models and studied the effect of LAWS on the cellular tissues of the substrate. LAWS will efficiently remove early Pseudomonas aeruginosa biofilm from an artificial wound in a pig's trotter, 24 hours-mature biofilm of P. aeruginosa from a pre-wounded human full thickness skin model (EpiDerm FT), and 3-day mature biofilm of P. aeruginosa or Staphylococcus aureus from a porcine skin explant. Histological examinations of uninfected EpiDerm models that had been treated by LAWS and then stained with Haematoxylin and Eosin, demonstrated no damage to the human tissue, and wound diameter was smaller in the treated skin models compared with untreated samples. Immunofluorescence staining for cytokeratin 14 showed that keratinocytes had migrated further across the wound in the uninfected samples treated by LAWS. We discuss the implications for wound healing and propose further laboratory and clinical studies to demonstrate the removal of biofilm from patients with chronic leg ulcers and the impact on healing., (© 2022 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Background: Vitamin D is associated not only with effects on calcium and bone metabolisms but also with many chronic diseases. Low vitamin D levels in patients with Alzheimer's disease have been widely reported in the literature., Aim: The purpose of this study was to critically review the potential benefit of vitamin D supplementation in individuals with Alzheimer's disease living in the community., Methods: A systematic literature search was conducted in PubMed, CINAHL, EMBASE and the Cochrane Library for papers published 2011-2018., Results: Seven papers were selected, consisting of one clinical trial, five cohort studies and one systematic review. Studies showed an association only between vitamin D deficiency and lower attention in older people. None of the reviewed studies provided evidence of a positive impact of vitamin D supplementation on cognitive function in older people with Alzheimer's disease., Conclusion: There was no evidence that vitamin D supplementation has a direct benefit for Alzheimer's disease. The review synthesised the existing body of knowledge and concluded that optimum levels of vitamin D (neither too low nor too high) do appear to have positive effects on patient outcomes and quality of life. It is still unclear why vitamin D intake is inadequate as people age. Further research is needed to clarify vitamin-D-related aspects of Alzheimer's disease.

Background: Incontinence-associated dermatitis (IAD) develops from prolonged exposure of skin to urine and/or stool and represents a common complication in older adults, reducing the quality of life. Increased pH is an important etiologic factor of IAD; however, the relationship between urinary pH and skin barrier disruption remains unclear., Objective: The aim of this study is to examine the effects of synthetic urine (s-urine) at various pHs on transepidermal water loss (TEWL), stratum corneum hydration (SCH), and skin surface pH., Methods: S-urine solutions (pH 5.0-9.0) were applied to the volar forearms of 15 healthy participants for 2 h, with another site serving as the untreated control. Measurements of TEWL, SCH, and skin surface pH were obtained at baseline (BL) and after each challenge. Skin buffering capacity was also examined in 5 volunteers by recording skin pH at BL, after 2 h exposure and every 5 min for 40 min., Results: TEWL and SCH were increased following exposure to s-urine compared to BL values. Although there was a tendency for pH to increase after exposure, further investigation showed that changes are only temporal as pH value is restored to BL within 5 mins. There were no significant differences between solutions., Conclusions: This study revealed that urine disrupts healthy skin integrity; however, its effects are not pH dependent. Transient changes were observed on the acid mantle of the skin due to its innate buffering capacity. Future studies need to examine the effects of urine combined with bacteria responsible for pH elevation in patients with urinary incontinence., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Objective: To identify the factors associated with pressure injury (PI) development in older adult patients who underwent elective total hip arthroplasty (THA)., Methods: A nonexperimental longitudinal prospective study was conducted with a sample of 40 patients undergoing elective THA. Patients were evaluated for PI at hospital admission, 24 hours postsurgery, at discharge, and 1 month after surgery., Results: The incidence of PIs (category 1 or category 2) in this study was 7.9% 24 hours after surgery and 24.3% at discharge. The most common PI location was the sacrum/coccyx or the ischial tuberosity. This study found significant relationships between PIs and female sex (odds ratio [OR], 8.75), body fat mass percentage (OR, 1.15), and the motor score from a Functional Independence Measure scale (OR, 0.89). Finally, the following variables were also associated with PIs (P < .1): skeletal muscle mass (OR, 0.82), lower limb with osteoarthritis weight (OR, 0.61), lower limb without osteoarthritis weight (OR, 0.62), and geriatric depression scale (OR, 1.12)., Conclusions: This work identifies those patients at higher risk of PI, enabling targeted prevention and treatment in the population of patients undergoing elective THA. The findings of this study are in line with extant literature and suggest that women with a higher percentage of body fat and less mobility had a higher risk of PI., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Peristomal skin complications (PSCs) impair life for people with an ostomy. Visual signs of PSCs include discolouration, but sensation symptoms like pain, itching, and burning are equally important and underreported., Aim: To provide improved understanding of PSC prevalence and associated challenges in the communities of ostomy patients and ostomy care nurses., Methods: The Ostomy Life Study 2019 encompassed a patient survey (completed by 5187 people with an ostomy) and a nurse survey (completed by 328 ostomy care nurses)., Findings: In total, 88% of patients experienced PSCs and 75% experienced PSC symptoms in the absence of discolouration. Eighty per cent of nurses considered ostomy-related issues to be the main reason for PSCs, and a correlation between PSC severity and number of nurse consultations was demonstrated., Conclusion: This study revealed a remarkably high PSC incidence in the absence of discolouration and highlighted direct consequences of having compromised skin and the health-economic consequences.

Disruption to the integrity of the skin can reduce patient wellbeing and quality of life. A major cause of skin breakdown is prolonged exposure to moisture, but this is often overlooked. When skin is wet, it becomes more susceptible to damage from friction and shearing forces, and skin flora can penetrate the disrupted barrier, causing further irritation and inflammation. If untreated, moisture-associated skin damage (MASD) can rapidly lead to excoriation and skin breakdown. MASD includes incontinence-associated dermatitis (IAD), which is caused by prolonged skin exposure to urine and stool, particularly liquid stool. For patients at a high risk of developing IAD, preventive measures should be instituted as soon as possible. The main one is to prevent excessive contact of the skin with moisture. Optimal skin care should be provided to patients with any form of MASD. It should be based on a structured regimen and include the use of a gentle skin cleanser, a barrier product and moisturiser. Derma Protective Plus is a liquid barrier that gives long-lasting protection against chafing or ingress of urine and stool into the skin. This product is less greasy than others, and provides a barrier and a healing environment, with resistance to further maceration from IAD or persistent loose stools.

Incontinence-associated dermatitis (IAD) is a painful complication in elderly patients, leading to reduced quality of life. Despite recent attention, its underlying inflammatory mechanisms remain poorly understood. This study was designed to quantify the release of inflammatory cytokines in a human model of IAD. The left volar forearm of ten healthy volunteers was exposed to synthetic urine and synthetic faeces for 2 h, simulating the effects of urinary and faecal incontinence, respectively, and the subsequent cytokine response compared to that of an untreated control site. Inflammatory cytokines were collected using both the Sebutape® absorption method and dermal microdialysis and quantified using immunoassays. Results from the former demonstrated an upregulation in IL-1α, IL-1RA and TNF-α. Synthetic urine caused a higher median increase in IL-1α from baseline compared to synthetic faeces, whereas synthetic faeces were associated with significantly higher median TNF-α levels compared to synthetic urine (p = 0.01). An increase in IL-1α/IL-1RA ratio was also observed with significant differences evident following exposure to synthetic urine (p = 0.047). Additionally, microdialysis revealed a time-dependent increase in IL-1β and IL-8 following exposure of up to 120 min to synthetic urine and synthetic faeces, respectively. This study demonstrated the suitability of both sampling approaches to recover quantifiable cytokine levels in biofluids for the assessment of skin status following exposure to synthetic fluids associated with incontinence. Findings suggest some differences in the inflammatory mechanisms of IAD, depending on moisture source, and the potential of the cytokines, IL-1α and TNF-α, as responsive markers of early skin damage caused by incontinence., (Copyright © 2021 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Purpose: The aim of this study was to investigate the permeability of the skin following cleansing activities and its susceptibility to synthetic urine penetration., Subjects and Setting: Ten healthy volunteers (aged 22-58 years) participated in the study, which was conducted in a university bioengineering laboratory., Methods: Tape stripping and sodium lauryl sulfate were used to simulate the physical and chemical irritation exacerbated by frequent cleansing activities, respectively. An untreated site also was selected to evaluate responses of intact skin. Synthetic urine was then applied for a period of 2 hours. Measurements of transepidermal water loss and skin pH were taken at baseline and after each challenge. To quantify the permeability of the skin following exposure, desorption curves of transepidermal water loss were measured and skin surface water loss was calculated., Results: Chemically irritated skin, characterized by increased pH (7.34 ± 0.22), demonstrated an increased permeability to urine, as reflected by a significant increase in mean skin surface water loss (46,209 ± 15,596 g/m2) compared to both the intact (14,631 ± 6164 g/m2) and physically irritated (14,545 ± 4051 g/m2) skin (P = .005 in both cases). In contrast, the differences between the intact and physically irritated skin were not significant (P = .88)., Conclusion: Permeability of the skin to irritants is influenced by the status of the skin and its acid mantle. These highlight the need to reevaluate the frequency of cleansing activities, along with the choice of product in clinical settings, favoring the use of pH-balanced cleansers., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 by the Wound, Ostomy and Continence Nurses Society.)

Purpose: The main aims of this study were to describe the effects of incontinence pad composition on skin wetness, the skin/pad microclimate, and skin barrier function. We also evaluated the potential utility of our methods for future clinical investigation of absorbent pad design., Design: Single-blind, quasi-experimental, open cohort design., Subjects and Setting: Twenty healthy older volunteers (mean age = 72.8 years, SD = 5.8 years; 8 male and 12 female) tested 2 absorbent pad types, with acquisition layers of different compositions (A and B) applied to different sites on the volar aspect of the forearms. One type A pad served as control (A dry) versus 3 pad samples wetted with 3 volumes of saline (A 15 mL, A 35 mL, and B 15 mL). The study was conducted within the clinical laboratory of a university nursing research group in the United Kingdom., Methods: Skin barrier function was assessed by measuring transepidermal water loss (TEWL), stratum corneum (SC) hydration by corneometry, and skin surface pH using a standard skin pH electrode. Skin water loading (excess water penetration into the skin) was quantified by measuring TEWL and creating a desorption curve of the water vapor flux density. Calculating the area under the curve of the desorption curve to give skin surface water loss reflected excess water penetration into the skin. In a subgroup of the sample, the temperature and relative humidity (microclimate) at the interface between the skin and test pads were measured using a wafer-thin sensor placed between the skin and pad sample. Proinflammatory cytokine release from the SC was assessed using a noninvasive lipophilic film. The main outcome measures in this study were the differences in biophysical measurements of skin barrier function (TEWL, corneometer, and pH) before and after the application of the different pads., Results: Mean ± SD baseline TEWL across all test sites was 10.4 ± 4.4 g/h/m. This increased to 10.6 ± 3.8 g/h/m at the control site, 15.3 ± 6.3 g/h/m for the A 15-mL pad, 15.3 ± 3.9 g/h/m for the A 35-mL pad, and 15.6 ± 3.2 g/h/m for the B 15-mL pad. The mean baseline skin surface pH was 5.9 ± 0.04; cutaneous pH increased to a mean of 6.1 ± 0.06 following all pad applications (P = .16). Mean SC hydration remained unchanged at the control site (A dry). In contrast, SC hydration increased following the application of all wetted pads. Target cytokines were detected in all samples we analyzed. The IL-1RA/IL-1α ratio increased following pad application, except for the wettest pad., Conclusion: Study findings suggest that absorbent pad design and composition, particularly the acquisition layer, affect performance and may influence skin health. Based on our experience with this study, we believe the methods we used provide a simple and objective means to evaluate product performance that could be used to guide the future development of products and applied to clinical settings.

Purpose: Incontinence-associated dermatitis (IAD) due to the prolonged exposure of the skin to urinary, fecal, or double incontinence represents a major clinical practice challenge. The aim of this review was to identify and critically appraise the results of published studies on the etiology and pathophysiology of IAD and highlight the current gaps in empirical evidence., Methods: Scoping literature review., Search Strategy: The electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, and Embase were searched for relevant articles published from 1996 to April 2018. Thirteen studies and review articles related to the etiology and pathophysiology of IAD were identified in our initial review, and 3 studies published subsequent to our initial review were evaluated and included in our final review., Findings: These studies suggest that several etiologic factors contribute to the development of IAD including exposure to urine, stool, or a combination of these substances (dual incontinence), the duration and frequency of exposure, frequent cleaning, and inflammatory responses. Results from the current scoping review showed that despite the increasing interest in IAD, evidence related to the underlying mechanisms causing IAD remains sparse. This paucity represents a clear gap in knowledge and indicates a need for additional research., Implications: Future studies should aim at elucidating: (1) the role of urine and its inherent pH on skin integrity, (2) the role of stool, specific digestive enzymes, and fecal bacteria on skin integrity, (3) the permeability and susceptibility of the skin to damage following frequent cleansing activities and occlusion, and (4) the specific inflammatory response triggered following exposure to urine and fecal matter.

Intertrigo, also known as intertriginous dermatitis, is one of the four separate conditions that fall under the umbrella term of moisture-associated skin damage (MASD). It can affect individuals of all ages. Intertrigo is a common inflammatory skin disorder caused by skin-on-skin friction within skin folds, as a result of moisture becoming trapped because of poor air circulation. It can occur in any area of the body where two skin surfaces are in close contact with each other, such as the axillary, inframammary, umbilical and inguinal areas, and is strongly associated with obesity. Consensus clinical expert opinion suggests that investment in the development and adoption of clear skin care and skin fold management protocols can lead to improvements in the patient experience and better clinical outcomes.

Aim: To examine the inter-practitioner variability of repositioning for pressure ulcer prevention, the effectiveness of the intervention, and whether the provision of written guidance influenced the repositioning technique., Methods: A pre-test post-test study design was utilised. Descriptive data regarding the work history of participants was collected. Participants were invited to reposition a healthy volunteer before and after reviewing guidance detailing the 30° side-lying technique. The researchers measured the resulting turn angles and assessed offloading of bony prominences., Results: The repositioning technique varied considerably in the sample of nurse participants. Turn angles decreased following the guidance, but offloading of body sites vulnerable to pressure damage remained sporadic., Conclusion: Pressure ulcer prevention training should include practical demonstrations of repositioning. Clear guidance regarding the optimal repositioning technique for pressure ulcer prevention is needed., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: The aims of this study were to evaluate the relationship between sociodemographic information, anthropometric values, clinical and presurgery factors, and length of stay (LOS) in older adult patients undergoing total hip arthroplasty (THA) and to predict which factors can delay the start of the rehabilitation program and increase the corresponding LOS., Methods: A prospective cohort study was conducted in an orthopedic inpatient unit with 40 patients undergoing THA., Findings: The Morse Fall Scale scores and pain intensity scores delayed the commencement of the rehabilitation program. Gender and social support were important determinants of LOS and rehabilitation outcome following THA. The weight of the lower limb without osteoarthritis followed by pain intensity and overweight patients also influenced LOS., Conclusions/clinical Relevance: Functional outcomes after THA are variable, and the rehabilitation process is an important factor to regain their normal level of physical functioning. This factor can have an impact in the discharge of patients, in resource allocation and in health care of older adult patients.

Knowing how biomarker levels vary within biological fluids over time can produce valuable insight into tissue physiology and pathology, and could inform personalised clinical treatment. We describe here a wearable sensor for monitoring biomolecule levels that combines continuous fluid sampling with in situ analysis using wet-chemical assays (with the specific assay interchangeable depending on the target biomolecule). The microfluidic device employs a droplet flow regime to maximise the temporal response of the device, using a screw-driven push-pull peristaltic micropump to robustly produce nanolitre-sized droplets. The fully integrated sensor is contained within a small (palm-sized) footprint, is fully autonomous, and features high measurement frequency (a measurement every few seconds) meaning deviations from steady-state levels are quickly detected. We demonstrate how the sensor can track perturbed glucose and lactate levels in dermal tissue with results in close agreement with standard off-line analysis and consistent with changes in peripheral blood levels.

The harmful effects of excessive moisture on a patient's skin are well known. While traditionally considered an issue only encountered in continence care and older people, it is now recognised that the harmful effects of excessive moisture can occur across the lifespan and in various patient groups. The term 'moisture-associated skin damage' describes the spectrum of inflammatory damage that occurs in response to the prolonged exposure of a patient's skin to perspiration, urine, faeces or wound exudate. It is generally accepted that moisture-associated skin damage consists of four conditions: incontinence-associated dermatitis, intertrigo, peristomal moisture-associated dermatitis, and periwound moisture-associated dermatitis. This article describes the aetiologies of each of the different types of moisture-associated skin damage, and outlines the nursing interventions required for their prevention and management., Competing Interests: None declared, (© 2019 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Background: The use of noninvasive ventilation masks is known to cause damage to facial skin tissue, which affects both the efficacy of the intervention and the patient's quality of life. The use of humidification with noninvasive ventilation is a common practice, but its relative role in the development of facial pressure ulcers has not been fully studied., Methods: A crossover cohort design was used in this study, with 15 healthy volunteers. Each volunteer randomly received both 10 cm H 2 O of CPAP with and without humidification through an oronasal mask. Skin integrity was evaluated by measuring transepidermal water loss, skin hydration, and skin pH at the bridge of the nose. Device-skin interface conditions (pressure and microclimate) were recorded at the bridge of the nose and both cheeks. The pro-inflammatory cytokine interleukin-1α was collected from the nose bridge before and after CPAP application by using a skin analysis tape. Nasal symptoms were collected by using a validated 6-point score., Results: Humidified CPAP significantly increased transepidermal water loss ( P < .001) and skin humidity ( P = .02) compared with non-humidified CPAP. There were no significant differences in skin hydration, skin pH, skin temperature, and cytokine expression between both conditions. However, there was a trend of increased median ratios of interleukin-1α concentrations in the humidified CPAP. There was a significant increase in the interface pressure at the bridge of the nose after CPAP application ( P = .02), with higher interface pressure values at the nose bridge compared with both left ( P = .002) and right ( P = .003) cheeks. The participants reported elevated nasal discomfort during non-humidified CPAP., Conclusions: These findings indicated that noninvasive ventilation with humidification had a potential disrupting effect on the barrier function of facial skin, associated with changes in skin microclimate and function. Further research is required to establish the cause of mask-related skin damage and to evaluate the effects of mask design, application techniques, and air flow and humidity settings., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2018 by Daedalus Enterprises.)

Aims: To identify the presence and geographical distribution of mast cell (MC) subtypes: MC T (tryptase positive-chymase negative) and MC TC (tryptase positive-chymase positive) in bladder tissue., Methods: Bladder tissue was obtained from patients with painful bladder syndrome/interstitial cystitis (n=14) and normal histology from University Hospital Southampton tissue bank. Sequential tissue slices were immunohistochemically stained for MC subtypes using anti-MC tryptase (for MC T and MC TC ) and anti-MC chymase (for MC TC ). Stained sections were photographed, and positively stained MCs were quantified using ImageJ. Data were analysed using descriptive statistics and individual paired t-tests., Results: There was a significant difference in the density of MCs between each layer of the disease bladder, with the greatest accumulation within the detrusor (p<0.001). There was a significant increase in MC TC subtype in the lamina (p=0.009) in painful bladder syndrome/interstitial cystitis., Conclusions: Our results suggest that mastocytosis is present within all layers of disease bladder, especially the muscle layer. The varying increase in MC subtypes in the lamina and mucosa may explain the variability in painful bladder syndrome/interstitial cystitis symptoms. A high influx of MC TC in the mucosa of individuals who also had ulceration noted within their diagnostic notes may be of the Hunner's ulcer subclassification. These findings suggest a relationship between the pathogenesis of MC subtypes and the clinical presentation of painful bladder syndrome/interstitial cystitis. A cohort study would further elucidate the diagnostic and/or therapeutic potential of MCs in patients with painful bladder syndrome/interstitial cystitis., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Permissive hypotensive resuscitation (PHR) is an advancing concept aiming towards deliberative balanced resuscitation whilst treating severely injured patients, and its effectiveness on the survival rate remains unexplored. This detailed systematic review aims to critically evaluate the available literature that investigates the effects of PHR on survival rate., Methods: A systematic review design searched for comparative and non-comparative studies using EMBASE, MEDLINE, PubMed, Web-of-Science and CENTRAL. Full-text articles on adult trauma patients with low blood pressure were considered for inclusion. The risk of bias and a critical appraisal of the identified articles were performed to assess the quality of the selected studies. Included studies were sorted into comparative and non-comparative studies to ease the process of analysis. Mortality rates of PHR were calculated for both groups of studies., Results: From the 869 articles that were initially identified, ten studies were selected for review, including randomised control trials (RCTs) and cohort studies. By applying the risk of bias assessment and critique tools, the methodologies of the selected articles ranged from moderate to high quality. The mortality rates among patients resuscitated with low volume and large volume in the selected RCTs were 21.5% (123/570) and 28.6% (168/587) respectively, whilst the total mortality rate of the patients enrolled in three non-comparative studies was 9.97% (279/2797)., Conclusions: The death rate amongst post-trauma patients managed with conservative resuscitation was lower than standard aggressive resuscitation, which indicates that PHR can create better survival rate among traumatised patients. Therefore, PHR is a feasible and safely practiced fluid resuscitative strategy to manage haemorrhagic shock in pre-hospital and in-hospital settings. Further trials on PHR are required to assess its effectiveness on the survival rate., Level of Evidence: Systematic review, level III.

David Voegeli, Associate Professor of Nursing, Skin Health Research Group, Faculty of Health Sciences, University of Southampton, discusses the care of patients with incontinence-associated dermatitis and how to distinguish this condition from pressure ulcers.

Background: Cardiopulmonary bypass is thought to propagate a global systemic response through contact with the non-physiological surfaces of the extracorporeal circuit, leading to the stimulation of leukocytes, their adherence to endothelial cells and the release of cytotoxic molecules. This, in turn, has been shown to accelerate pulmonary injury. This study tested a new leukocyte-filtration system (RemoweLL) against a conventional system with no leukocyte-depleting capacity to determine the efficacy of the filtration system and its effects on pulmonary function., Methods: Thirty patients underwent coronary artery bypass graft surgery using either the RemoweLL filtration system (15 patients) or a conventional cardiopulmonary bypass circuit (15 patients). Data were collected on the total number of leukocytes, their differentiation and activation, using the leukocyte adhesion integrin CD11b as a surrogate marker. Pulmonary function was assessed using the Alveolar-arterial Oxygenation Index (AaOI) and patients were categorized using the Berlin definition of acute respiratory distress syndrome (ARDS)., Results: Both groups showed significant increases in leukocyte numbers during CPB (p<0.001), with no differences noted between the groups. CD11b showed a significant increase in both groups, with peak activation occurring at the end of CPB, but no difference between the groups (p=0.8). There was a trend towards lower AaOI increases in the filtration group, but this did not reach significance (p=0.075) and there was no difference in ARDS definitions (p=0.33)., Conclusions: Leukocyte filtration of cardiotomy suction did not influence total leukocyte counts or activation as measured by CD11b upregulation. Furthermore, no evidence could be found to suggest improved pulmonary function.

Background: Lipid microemboli (LME) are formed in pericardial suction blood which, when returned to the cardiopulmonary bypass (CPB) circuit, can pass through filter materials and are returned to the arterial cannula. LME have been observed to enter all major organs and have been associated with small capillary arteriolar dilatations in the brains of patients who have died after CPB. However, a causal relationship showing correlation between LME and organ dysfunction has not been demonstrated, or whether removal of LME results in improved organ function., Methods: A prospective, single center, randomized controlled trial examined 30 patients (15 per group) undergoing coronary artery bypass grafting using CPB with or without a lipid-depleting filter. The effects of LME filtration on neurocognitive injury were assessed using neuron-specific enolase (NSE)., Results: The study group showed a significant reduction in LME after filtration of the pericardial suction blood (p < 0.001), whereas the control group exhibited a significant rise in LME (p < 0.001). There was a significant reduction in peak NSE release (p = 0.013) and significant attenuation throughout the postoperative period (p = 0.002). Correlation and regression analyses showed a significant relationship between the number of LME post-CPB and peak NSE release (r = 0.42, p = 0.02)., Conclusions: Several methods of LME filtration have been proposed, but none provided a suitable, efficacious method for use within the clinical setting. The RemoweLL CPB system removes significant numbers of LME from the cardiotomy suction. Furthermore, LME correlate to the release of a known marker of neurologic injury., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Acute kidney injury (AKI) following cardiopulmonary bypass affects 5% of patients, representing significant postoperative morbidity and mortality. Animal models have shown an increased uptake of lipid microemboli (LME) into the renal vasculature, potentially indicating ischaemic causation. This study tested a new lipid filtration system (RemoweLL) against a conventional system with no lipid-depleting capacity to determine the efficacy of the filtration system and its effects on renal function., Methods: Thirty consecutive patients underwent coronary artery bypass graft surgery using either the RemoweLL filtration system (15 patients) or a conventional cardiopulmonary bypass circuit (15 patients). Renal function was assessed using cystatin C concentrations as a surrogate marker of glomerular injury, as well as perioperative glomerular filtration rate (GFR) and serum creatinine concentrations. Patients were defined as having acute renal injury if there was an increase in absolute serum creatinine ⩾3 mg/dL (26.4 µmol/L) or 1.5-fold increase from baseline as categorised using the AKIN criteria., Results: Postoperative differences in LME count between the two groups were highly significant [p<0.001]. Analysis of peak cystatin C concentrations showed significantly lower levels in the LME filtration group on the 2 nd postoperative morning [p=0.04]. Two-factor ANOVA revealed a trend towards interaction, but this failed to reach significance [p=0.06]. There were no differences throughout the study period in serum creatinine or GFR [p>0.05]. There were no differences in any of the serum or urinary electrolytes., Conclusions: This study has shown a trend towards improved cystatin C removal with LME filtration; with significantly lower peak concentrations, although no further evidence of renoprotection could be demonstrated. Further research is warranted to establish possible renal benefits of LME filtration in patients undergoing cardiac surgery.

Introduction: The assessment and treatment of children with major injury is fraught with difficulty - differences in anatomy and physiology mean that children that have suffered trauma can be over or under assessed. In recent years, there has been an increase in the use of biochemical markers, such as haematocrit, to assist the clinician in determining severity of injury. This paper examines the evidence surrounding lactate as a marker in paediatric trauma., Method: A literature search was completed on Medline, CINAHL, Ovid and Science. 63 papers were initially identified - 41 papers were rejected after reading the abstracts. Of the 22 remaining papers - 6 had a paediatric focus, 16 were adult - of these 12 were rejected as not primary studies. Ten papers were fully critically reviewed - of these only one article related to paediatric patients and trauma., Results: The literature shows that an elevated lactate in a trauma patient is strongly correlated to severity of injury, length of stay and morbidity and mortality. However, one elevated lactate may be misleading and lactate clearance - that is the time when lactate levels return to normal, is just as important in the assessment of the severely injured. However, from this literature review it is clear that there is very little evidence for the relationship between lactate levels and trauma in children and that more studies are required., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Incontinence-associated dermatitis (IAD) is a common skin disorder seen in patients with incontinence. Typically IAD presents as inflammation of the skin surface characterised by redness, and in extreme cases, swelling and blister formation. If untreated this usually rapidly leads to excoriation and skin breakdown, which may subsequently become infected by the skin flora. While this is a common condition encountered in all areas of nursing practice, gaps remain in our understanding of the many contributing factors. A lack of standardised definitions of IAD, differences in terminology, and a bewildering increase in products available to prevent and manage IAD, makes it difficult for nurses to deliver evidence-based care. However, it is an area where nursing research has made a considerable contribution over the past few years. This article explores the current thinking on IAD and the implications for nursing practice.

Objective: Impaired lymph formation and clearance has previously been proposed as a contributory factor in the development of pressure ulcers. The present study has been designed to trial fluorescence lymphangiography for establishing how lymphatic function is altered under a clinically relevant form of mechanical loading., Methods: Lymph formation and clearance was traced in both forearms by an intradermal injection of indocyanine green (ICG) (50 μl, 0.05%w/v), imaged using a commercial near-infrared fluorescence imaging unit (Fluobeam(®) 800). External uniaxial loading equivalent to a pressure of 60 mmHg was applied for 45 min in one arm using a custom-built indenter., Results: Loading was associated with a decreased frequency of normal directional drainage (DD) of ICG within delineated vessels, both immediately after loading and 45 min thereafter. Loading was also associated with non-directional drainage (NDD) of ICG within the interstitium. Signal intensity within NDD was often greatest at areas of stress concentration, producing a 'halo pattern', corresponding to the rounded edges of the indenter., Conclusions: These results suggest that loading skin with a clinically relevant magnitude of pressure alters both lymph formation and clearance. Further work to quantify impaired clearance under mechanical loading could provide valuable insight into their involvement in the development of pressure ulcers., (Copyright © 2016 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Background: Individuals who have reduced mobility are at risk of developing pressure ulcers if they are subjected to sustained static postures. To reduce this risk, clinical guidelines advocate healthcare professionals reposition patients regularly. Automated tilting mechanisms have recently been introduced to provide periodic repositioning. This study compared the performance of such a prototype mattress to conventional manual repositioning., Methods: Ten healthy participants (7 male and 3 female, aged 23-66 years) were recruited to compare the effects of an automated tilting mattress to standard manual repositioning, using the 30° tilt. Measures during the tilting protocols (supine, right and left tilt) included comfort and safety scores, interface pressures, inclinometer angles and transcutaneous gas tensions (sacrum and shoulder). Data from these outcomes were compared between each protocol., Findings: Results indicated no significant differences for either interface pressures or transcutaneous gas responses between the two protocols (P>0.05 in both cases). Indeed a small proportion of participants (~30%) exhibited changes in transcutaneous oxygen and carbon dioxide values in the shoulder during a right tilt for both protocols. The tilt angles at the sternum and the pelvis were significantly less in the automated tilt compared to the manual tilt (mean difference=9.4-11.5°, P<0.001). Participants reported similar comfort scores for both protocols, although perceived safety was reduced on the prototype mattress., Interpretation: Although further studies are required to assess its performance in maintaining tissue viability, an automated tilting mattress offers the ability to periodically reposition vulnerable individuals, with potential economic savings to health services., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

We report the Laser Induced Forward Transfer (LIFT) of antibodies from a liquid donor film onto paper receivers for application as point-of-care diagnostic sensors. To minimise the loss of functionality of the active biomolecules during transfer, a dynamic release layer was employed to shield the biomaterial from direct exposure to the pulsed laser source. Cellulose paper was chosen as the ideal receiver because of its inherent bio-compatibility, liquid transport properties, wide availability and low cost, all of which make it an efficient and suitable platform for point-of-care diagnostic sensors. Both enzyme-tagged and untagged IgG antibodies were LIFT-printed and their functionality was confirmed via a colorimetric enzyme-linked immunosorbent assay. Localisation of the printed antibodies was exhibited, which can allow the creation of complex 2-d patterns such as QR codes or letters for use in a final working device. Finally, a calibration curve was determined that related the intensity of the colour obtained to the concentration of active antibodies to enable quantitative assessment of the device performance. The motivation for this work was to implement a laser-based procedure for manufacturing low-cost, point-of-care diagnostic devices on paper.

Emergency hospital admissions for patients with ill-defined conditions International Classification of Diseases-10 R codes (ICD-10 R codes) are rising. Policy literature has suggested that they are attributable to 'social' problems and could potentially be avoided yet there is no research evidence to support this view. Therefore, this study sought to describe patients with ill-defined conditions and determine clinical and demographic factors predicting assignment of such codes. Patients aged over 70 admitted to a hospital acute admissions unit with collapse or falls were recruited in one hospital. Measures of functional status, frailty, depression, routine blood tests, demographic and service use data were collected. 80 patients were recruited, 35 were discharged with ill-defined conditions codes. Functional limitations were common in patients with ill-defined conditions and 77% had frailty. Blood profiles did not indicate acute medical problems. Deprivation was the only significant independent predictor of assignment of ill-defined conditions codes at discharge (OR 0.64, 95% CI: 0.45-0.93). Whilst our data confirm policy suppositions that patients with ill-defined conditions have functional impairment and frailty, it is the social and organisational factors that are important in determining risk of ill-defined conditions rather than clinical indicators., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

The harmful effects of excessive moisture on the skin are well documented. Although traditionally this has been considered as being a specific problem of continence care, it is a common problem encountered in many different patient groups. As a consequence the umbrella term moisture-associated skin damage (MASD) has been introduced to describe the spectrum of damage that occurs in response to the prolonged exposure of a patient's skin to perspiration, urine, faeces or wound exudate etc. It is generally accepted that MASD consists of four distinct conditions, each having slightly different aetiologies, namely: incontinence-associated dermatitis; intertrigo; peristomal moisture-associated dermatitis; and periwound moisture-associated dermatitis. Careful assessment can help distinguish between the four and enable appropriate prevention and management interventions to be implemented. Whatever causes the excessive moisture, effective interventions should consist of the adoption of a structured skin care regime to cleanse and protect, and methods to keep the skin dry, controlling the source of the excessive moisture and treating any secondary infection.

The skin is a complex organ with multiple functions. It undergoes two distinct ageing processes--intrinsic and extrinsic ageing--leading to specific changes in the structure and function of an older person's skin. These changes reduce the effectiveness of the skin barrier and increase the vulnerability of the skin to breakdown. Knowledge of these changes enables a better understanding of the skin care needs of older people and how to promote healthy skin. Nurses are ideally placed to assess older people's skin holistically, and the adoption of skincare protocols comprising cleansing, protection, hydrating and replenishing can have a significant effect on patient outcomes.

The concept of excessive moisture causing damage to the skin is not a new one, and provides a rationale for many fundamental nursing interventions. Although traditionally thought of as a specific problem of continence care, it is a common problem encountered in many different patient groups. As a consequence the umbrella term moisture-associated skin damage (MASD) has been introduced to describe the spectrum of damage that occurs in response to the prolonged exposure of a patient's skin to perspiration, urine, faeces or wound exudate. It is generally accepted that MASD consists of four main separate conditions, each having slightly different aetiologies, all of which will be explored in this paper. Careful assessment can help distinguish between the four and enable appropriate prevention and treatment interventions to be implemented. Whatever causes the excessive moisture, effective interventions should consist of the adoption of a structured skin care regime to cleanse and protect, methods to keep the skin dry, controlling the source of the excessive moisture and treating any secondary infection.

Aims: To translate and adapt the Coma Recovery Scale - Revised to Portuguese using the ICNP® (International Classification of Nursing Practice) terminology and to determine if it can be administered reliably across examiners., Background: Assessment tools for the person in a coma can contribute to the planning, implementation and evaluation of care. It also strengthens the autonomy and responsibility of nurses, contributing to the safety, quality and satisfaction of those who deliver and receive care. This allows the sharing of information amongst healthcare professionals and supports decision-making within a multidisciplinary team., Methods: A convenience sample of 20 patients admitted to an intensive care unit constituted the study participants. The data were collected during 2009. The instrument was administered by the same two raters in all the patients on two consecutive days. The total and subscale score agreement was then examined, using inter-rater and test-retest analyses. The intercorrelation dependencies between the subscales were also analysed., Results: The results of the analyses suggest that the instrument can be used reliably, even when there are some patient fluctuations. The correlation of the subscale scores was high and better than the results presented for the original Coma Recovery Scale - Revised, indicating that this scale is a homogeneous measure of neurobehavioural function., Conclusion: The new instrument can be administered reliably by trained examiners and produces a high degree of reproducibility in scores between raters over repeated assessments. We believe that assessment tools that can assess the communication ability of patients will be relevant to evaluating the continuity of care, and promote the effectiveness of care., (© 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.)

Eczema is one of the most common dermatological diseases, with the number of cases in the UK rising. The use of emollients to maintain skin hydration and help restore barrier function, remains the principal treatment. Unfortunately, many health professionals, and patients themselves, fail to consider emollients an active treatment and may overlook the vital role they play in the maintenance of intact, healthy skin. Despite the overwhelming acceptance of the importance of emollient therapy, there remains a lack of good quality evidence on their effectiveness or whether one is better than another. Even when appropriate emollients are supplied, they are often used incorrectly or accompanied by conflicting/limited advice from health professionals. This article aims to explore normal skin barrier function, the disruption caused by eczema, and some of the contemporary issues surrounding emollient therapy.

Skin care is a fundamental aspect of basic nursing care, with the outcome of these interventions often used to gauge the quality of the care provided. However, possibly as a result of the 'basic' nature of this aspect of care, little attention has been paid to developing a firm evidence base to guide decision-making in this area. This is compounded by the wide variety of products now available, ranging from simple cleansers and moisturizers, to more complex agents that cleanse, moisturize and protect all in one, which can add to the confusion. This article explores the basic principles of skin care, and considers the evidence available to support the nursing interventions used, and the range of products available. Finally, it suggests the adoption of clear skin care protocols, and recommends actions that should form part of these.

During the aging process, remodeling of several body systems occurs, and these changes can have a startling effect upon the immune system. The reduction in sex steroids and growth hormones and declines in vitamin D concentration that accompany the aging process are associated with increases in the baseline levels of inflammatory proteins. At the same time, inflammation arising from atherosclerosis and other chronic diseases further contributes to the inflammatory milieu and effects a state of chronic inflammation. This chronic inflammation, or ''inflammaging'' as it has been termed, seems to be associated with a host of adverse effects contributing to many of the health problems that increase morbidity and decrease both quality of life and the ability to maintain independence in old age. For nurses to be truly informed when caring for older people and to ensure that they have a detailed understanding of the complexities of older people's health needs, they must have a knowledge of the physiological and immunological changes with age. This is the first of a two-part article on inflammatory processes in aging. These age-related changes are presented here, including an examination of the impact of genetic and lifestyle factors. The effect of these changes on the health of the individual and implications for practice are described in Part 2.

Aging is accompanied by declining function and remodeling of body systems. In particular, changes to the immune and endocrine systems have far-reaching effects that cause an increase in cytokine release and decrease in anti-inflammatory feedback systems. The chronic inflammation that ensues has been named ''inflammaging.'' Inflammaging is associated with many detrimental effects that combine to increase morbidity and mortality. The sickness behavior that arises from inflammatory processes and the side effects of chronic diseases lead to a constellation of symptoms that decrease quality of life and affect the well-being of the individual. Part 2 of this two-part article provides an overview of the health effects of inflammaging, addressing the extent to which it contributes to the syndromes of frailty and disability with aging.

The prevention and treatment of pressure ulcers continues to present a challenge across acute and long-term care settings, and costs the NHS up to pound2.64 billion annually. As well as causing a reduced quality of life for sufferers, they can prove to be fatal. The complexity of the exact causes of skin breakdown and accurate risk assessment has proved problematic to fully understanding this common nursing problem, yet despite limited evidence clear guidelines on best practice exist, suggesting that prevention strategies should encompass interventions in three areas: risk assessment; relief of pressure, and education. Evidence exists that where these strategies are adopted at an organizational level, and strong leadership provided, the outcomes can be remarkable. This article outlines effective prevention and risk-reduction strategies, together with interventions that can promote healing.

Purpose: To investigate the relative impacts of age and cigarette smoking on cutaneous blood flow and flow motion., Experimental Design: Skin blood flux was measured before and during the hyperaemic response to thermal warming of the skin to 43 degrees C using laser Doppler fluximetry (LDF) in 28 habitual smokers (5.4 [11.4] (median [IQR]) pack years; pack years = packs/day x duration of smoking habit), aged between 18 and 63 years and their age, sex and body mass index. Flow motion was assessed using Fourier analysis of the LDF signal., Results: Mean and total hyperaemic (area under the flux curve, AUC(10)) response during warming were reduced in smokers compared with their non-smoking controls (P<0.05). Attenuation of the response to warming in smokers was associated with a reduction in relative spectral power around 0.01 Hz, reflecting a reduced endothelial/metabolic activity (P<0.04). In regression modelling with AUC(10) as the outcome, and smoking (yes/no), age, sex and BMI, as explanatory variables, age (P<0.0001) and smoking (P=0.018) were independently associated with the hyperaemic response and together accounted for 31% of the variance in AUC(10)., Conclusions: Age and smoking are associated with approximately one-third of the variance in the endothelium-associated microvascular vasomotor activity in habitual smokers.

The past decade has seen a huge growth in the application of silicone-based products to the healthcare market, with this technology finding its way into diverse areas ranging from the manufacture of disposable contact lenses to urinary catheters, and the development of a new generation of wound and skin care products. However, the current development of topical silicone treatments to protect the skin is not a new idea, but rather a renaissance, with the first of these products being developed in the 1940s as a substance known as 'water glass' or sodium silicate. Although the years have past, the challenges for nursing remain the same, with the need to protect vulnerable areas of the skin and the prevention of skin breakdown forming one of the cornerstones of professional care across all spheres of practice. This article considers the role that silicone-based barrier films, such as CliniMed's LBF, can play in the prevention and management of skin breakdown.

Purpose: The aim of this study was to explore the potential contribution to skin damage caused by standard washing and drying techniques used in nursing., Design: An experimental cohort design was used, with healthy volunteers (n = 15) receiving 6 different washing and drying techniques to the volar aspect of the forearm. Subjects underwent 3 washing and drying techniques on each arm; each technique was repeated twice, separated by a 2-hour rest period., Methods: Skin integrity was assessed by measuring transepidermal water loss (TEWL), skin hydration, skin pH, and erythema. Comparisons were made between washing with soap or water alone, and drying using a towel (rubbing and patting) or evaporation. The significance of any difference was assessed by nonparametric analysis. The study was approved by the local research ethics committee, and all volunteers gave informed consent., Results: TEWL was seen to increase following each type of wash, and increased further following repeated washing. Drying of the skin by patting with a towel increased TEWL to give readings identical to those obtained from wet skin. There was an increase in skin pH with all washing and drying techniques, particularly when soap was used. Erythema also increased with repeated washing, particularly when soap was used. No significant changes were observed in skin hydration as measured by a corneometer, although there was a tendency for the values to decrease with washing., Conclusions: These data suggest that washing with soap and water and towel drying has a significant disrupting effect on the skin's barrier function. There is tentative evidence to suggest that a cumulative effect may exist with damage increasing as washing frequency increases. Drying the skin by patting with a towel offers no advantage to conventional gentle rubbing as it leaves the skin significantly wetter and at greater risk of frictional damage.

Dry skin (xerosis) is a common problem, and ranges from mild dryness through to severe dryness and skin breakdown. The use of emollients continues to be the main therapeutic approach to this problem. However, patients and healthcare professionals do not always appreciate the importance of emollient therapy, and are faced with an overwhelming choice of products. This article aims to review skin barrier function and hydration, the factors causing dry skin and some of the issues that surround the use of emollients.

A series of coordinated enzymatic reactions takes place in the body whenever blood clots. The major physiological initiator of these reactions is a membrane-bound glycoprotein known as tissue factor (TF), which is normally separated from the bloodstream by the vascular endothelium. Bleeding, caused by injury or tissue damage, activates a complex enzyme cascade as TF becomes exposed to the bloodstream. In disease states, leukocytes or the vascular endothelium may abnormally express TF to cause intravascular coagulation. The blood-coagulation cascade is also relevant to diseases such as hemophilia, in which patients are deficient in blood proteins necessary for clotting, and is linked to vascular diseases such as heart attack and stroke, in which clotting can lead to the occlusion of blood vessels. Coagulation is also activated in inflammation and cancer. In this article, we discuss characteristics of TF and review its role in inflammation and cancer.

Students commence nurse education with varying levels of understanding of human anatomy and physiology due to a wide range of previous exposure to the topic. All students, however, are required to attain a broad knowledge of this topic prior to qualification. This paper describes the use of a Virtual Learning Environment (VLE), Blackboard 5, and the associated development of appropriate resources aimed at supporting nursing students undertaking a human anatomy and physiology module at Higher Education Level 1. The VLE was used as part of a blended learning approach. The results suggested that the majority of students utilised the VLE throughout the academic year. Opportunities for independent and self-directed learning were available in that students chose when and where to learn. Students generally commented favourably on ease of use and type of resources available. Frequency of use of the VLE, however, did not correlate strongly with the final examination mark achieved. Overall the VLE and the associated available resources appeared useful in supporting student learning and has been adopted for use in subsequent years.