WHS guidelines for the treatment of pressure ulcers-2023 update.

The major populations at risk for developing pressure ulcers are older adults who have multiple risk factors that increase their vulnerability, people who are critically ill and those with spinal cord injury/disease. The reported prevalence of pressure ulcers in the United States is 2.5 million. However, this estimate is derived from acute care facilities and does not include people who are living at home or in nursing facilities. Despite the implementation of hospital and facility-based preventive measures, the incidence of pressure ulcers has not decreased in decades. In addition to the burden of pain, infection and death, it is estimated that hospital-acquired pressure ulcers cost the health system $26.8 billion annually with over 50% of the cost attributed to treating Stage 3 and 4 pressure injuries. Thus, it is critical to examine the literature and develop guidelines that will improve the outcomes of this complex and costly condition. This guideline update is a compendium of the best available evidence for the treatment of Pressure Ulcers published since the last update in 2015 and includes a new section based on changing demographics entitled 'Palliative wound care for seriously ill patients with pressure ulcers'. The overall goal of the Wound Healing Society Guideline project is to present clear, concise and commercial free guidelines that clinicians can use to guide care, that researchers can use to develop studies that will improve treatment and that both clinicians and researchers can use to understand the gaps in our knowledge base.

The Nursing Home Severity Index and Application to Pressure Injury Risk: Measure Development and Validation Study.

BACKGROUND: An assessment tool is needed to measure the clinical severity of nursing home residents to improve the prediction of outcomes and provide guidance in treatment planning. OBJECTIVE: This study aims to describe the development of the Nursing Home Severity Index, a clinical severity measure targeted for nursing home residents with the potential to be individually tailored to different outcomes, such as pressure injury. METHODS: A retrospective nonexperimental design was used to develop and validate the Nursing Home Severity Index using secondary data from 9 nursing homes participating in the 12-month preintervention period of the Turn Everyone and Move for Ulcer Prevention (TEAM-UP) pragmatic clinical trial. Expert opinion and clinical literature were used to identify indicators, which were grouped into severity dimensions. Index performance and validation to predict risk of pressure injury were accomplished using secondary data from nursing home electronic health records, Minimum Data Sets, and Risk Management Systems. Logistic regression models including a resident's Worst-Braden score with/without severity dimensions generated propensity scores. Goodness of fit for overall models was assessed using C statistic; the significance of improvement of fit after adding severity components to the model was determined using the likelihood ratio chi-square test. The significance of each component was assessed with odds ratios. Validation based on randomly selected 65% training and 35% validation data sets was used to confirm the reliability of the severity measure. Finally, the discriminating ability of models was evaluated using propensity stratification to evaluate which model best discriminated between residents with/without pressure injury. RESULTS: Data from 1015 residents without pressure injuries on admission were used for the Nursing Home Severity Index-Pressure Injury and included laboratory, weights/vitals/pain, underweight, and locomotion severity dimensions. Logistic regression C statistic measuring predictive accuracy increased by 19.3% (from 0.627 to 0.748; P<.001) when adding four severity dimensions to Worst-Braden scores. Significantly higher odds of developing pressure injuries were associated with increasing dimension scores. The use of the three highest propensity deciles predicting the greatest risk of pressure injury improved predictive accuracy by detecting 21 more residents who developed pressure injury (n=58, 65.2% vs n=37, 42.0%) when both severity dimensions and Worst-Braden score were included in prediction modeling. CONCLUSIONS: The clinical Nursing Home Severity Index-Pressure Injury was successfully developed and tested using the outcome of pressure injury. Overall predictive capacity was enhanced when using severity dimensions in combination with Worst-Braden scores. This index has the potential to significantly impact the quality of care decisions aimed at improving individual pressure injury prevention plans. TRIAL REGISTRATION: ClinicalTrials.gov NCT02996331; http://clinicaltrials.gov/ct2/show/NCT02996331.

Factors associated with physician discovery of early melanoma in middle-aged and older men.

OBJECTIVE: To determine factors associated with physician discovery of early melanoma in middle-aged and older men. DESIGN: Survey. SETTING: Three institutional melanoma clinics. PARTICIPANTS: A total of 227 male participants (aged > or =40 years) with invasive melanoma who completed surveys within 3 months of diagnosis. Intervention Survey. MAIN OUTCOME MEASURES: Factors associated with physician-detected thin melanoma. RESULTS: Patients with physician-detected melanoma were older, 57% were 65 years or older compared with 34% for other-detected (odds ratio [OR], 2.57; 95% confidence interval [CI], 1.19-5.55) and 42% for patient-detected melanoma (P = .07). Physician-detected melanoma in the oldest patients (aged > or =65 years) had tumor thickness equal to that of self-detected melanoma or melanoma detected by other means in younger patients. Back lesions composed 46% of all physician-detected melanoma, 57% of those detected by other means, and 16% of self-detected lesions (physician- vs self-detected: OR, 4.25; 95% CI, 1.96-9.23). Ninety-two percent of all physician-detected back-of-the-body melanomas were smaller than 2 mm compared with 63% of self-detected lesions (P = .004) and 76% of lesions detected by other means (P = .07). CONCLUSIONS: Skin screenings of at-risk middle-aged and older American men can be integrated into the routine physical examination, with particular emphasis on hard-to-see areas, such as the back of the body. "Watch your back" professional education campaigns should be promoted by skin cancer advocacy organizations.

Melanoma in middle-aged and older men: a multi-institutional survey study of factors related to tumor thickness.

OBJECTIVES: To identify factors related to the detection of melanoma and to determine those that differ between thinner vs thicker tumors in middle-aged and older men. DESIGN: Survey. SETTING: Three institutional melanoma clinics. PARTICIPANTS: Men 40 years or older who had newly diagnosed invasive melanoma. MAIN OUTCOME MEASURES: Differences in melanoma awareness, skin examination practices, discovery patterns, and social/medical care factors relative to tumor thickness. RESULTS: Two hundred twenty-seven men completed surveys within 3 months of melanoma diagnosis; 57 (25.1%) had thicker tumors (>2.00 mm). Thicker tumors were associated with nodular histologic features (43.9%), a lack of atypical nevi, having less than a high school education, and patient vs physician (dermatologist or nondermatologist) detection. Knowledge of melanoma (P = .007), attention to skin cancer detection information (P = .02), an interest in health topics (P = .003), and knowing the importance of physician skin examination (P = .05) were more common in those with thin tumors. Tumor thickness did not correlate with age, anatomic location, marital/cohabitation status, prior skin cancer, or sun sensitivity. Overall patient awareness of melanoma warning signs, skin self-examination practices, and Internet use were poor (<20%, <50%, and <14%, respectively). CONCLUSIONS: Physician discovery, the patient's higher level of education and detection-promoting awareness and attitudes, and the presence of clinically atypical nevi were related to thinner melanomas. Innovative outreach strategies and novel educational campaigns incorporating these factors, coupled with sharper messages regarding the importance of physician screening, are needed to improve early detection in middle-aged and older men.

Tobacco cessation and prevention practices reported by second and fourth year students at US medical schools.

BACKGROUND: Tobacco dependence counseling is recommended to be included as core curriculum for US medical students. To date, there has been little information on students' self-reported skills and practice opportunities to provide 5A's (Ask, Advise, Assess, Assist, and Arrange) counseling for tobacco cessation. METHODS: We conducted anonymous surveys of second year and fourth year students at multiple US medical schools between February 2004 and March 2005 (overall response rate 70%). We report on the tobacco control practices of the 860 second year and 827 fourth year students completing the survey. MEASUREMENTS AND MAIN RESULTS: Fourth year students reported multiple opportunities to learn tobacco counseling in case-based discussions, simulated patient encounters, and clinical skills courses. They reported more instruction in family medicine (79%) and Internal Medicine (70%) than Pediatrics (54%), Obstetrics/Gynecology (41%), and Surgery clerkships (16%). Compared with asking patients about smoking, advising smokers to quit, and assessing patient willingness to quit, fourth year students were less likely to have multiple practice opportunities to assist the patient with a quit plan and arrange follow-up contact. More than half of second year students reported multiple opportunities for asking patients about smoking but far fewer opportunities for practicing the other 4 As. CONCLUSIONS: By the beginning of their fourth year, most students in this group of medical schools reported multiple opportunities for training and practicing basic 5A counseling, although clear deficits for assisting patients with a quit plan and arranging follow-up care exist. Addressing these deficits and integrating tobacco teaching through tailored specific instruction across all clerkships, particularly in Surgery, Pediatrics, and Obstetrics/Gynecology is a challenge for medical school education.

Study of health outcomes in school children: key challenges and lessons learned from the Framingham Schools' Natural History of Nevi Study.

BACKGROUND: We describe the planning, recruitment, key challenges, and lessons learned in the development of a study of the evolution of nevi (moles) among children in a school setting. METHODS: This population-based study of digital photography and dermoscopy of the child's back (overview, close-up, and dermoscopic images) and genetic specimens took place among fifth graders in the Framingham, Massachusetts School System. Schoolchildren and their parents completed baseline surveys on sun protection practices, sunburns, and past ultraviolet exposures, including summer and vacation experiences. RESULTS: Prestudy outreach was conducted with children, parents, nurses, administrators, and pediatricians. Of the 691 Framingham families with a fifth grader (aged 10-11), 443 consented to complete surveys and undergo digital photography and dermoscopy during the school's routine scoliosis testing. Of the 443 families providing consent, 369 agreed to genetic testing. We identified key factors to consider when implementing school-based studies: (a) pilot studies to demonstrate feasibility, (b) inclusion of school administration and parents, (c) grassroots approach with multiple contacts, and (d) embedding research studies within preexisting school health services. CONCLUSIONS: Launching an observational study within the school environment required an academic/school collaboration across numerous disciplines including dermatology, epidemiology, genetics, medical photography, school health, community health education, and most notably, the need for the presence of a full-time study nurse in the school. A large school system proved to be an excellent resource to conduct this first prospective study on the evolution of moles in US schoolchildren. The key challenges and lessons learned may be applicable to other investigators launching school-based initiatives.

Validating medical students' self-report of smoking-related communication skills and educational experiences.

OBJECTIVE: Pediatric clerkships can be important settings for medical students to learn how to perform smoking assessments and counseling with parents. In evaluating an educational intervention that promotes this skill, we assess whether students' self-report of this counseling skill was a valid measure of actual behavior. METHODS: A trained observer evaluated student smoking assessment and counseling practices during pediatric well-child visits at 5 clinical sites in eastern Massachusetts. The external observations of behavior were used as a gold standard, and we determined the accuracy of the students' self-report of their smoking counseling practices with families and of their preceptors' educational interventions. RESULTS: We observed 38 pediatric preceptors and 85 Boston University School of Medicine (BUSM) III students in 85 clinical encounters. Sensitivities of the students' report of assessing smoking practices and counseling parents and children ranged from 0.60-1.00, and specificities ranged from 0.41-0.88. Specifically, with regards to the students' report of performing a smoking assessment with the family, the sensitivity was 0.97 (95 per cent confidence interval, 0.89-0.99) and the specificity was 0.88 (95 per cent confidence interval, 0.72-0.97). For measures where the observer could not determine practice, agreement between the student and preceptor was between 57 per cent and 83 per cent . Specifically, with regard to whether the preceptor made expectations clear with the student, students and preceptors agreed 83% of the time. CONCLUSION: Although direct observations of behavior may still be the most accurate report of true practice, when this is not feasible, student self-report appears to be a valid measure of smoking assessment and counseling practices during pediatric clerkships.

Tobacco control competencies for US medical students.

The 2004 National Action Plan for Tobacco Cessation recommended that the US Department of Health and Human Services convene a diverse group of experts to ensure that competency in tobacco dependence interventions be a core graduation requirement for all new physicians and other key health care professionals. Core competencies would guide the design of new modules and explicitly outline the learning objectives for all graduating medical students. In 2002, the National Cancer Institute funded a consortium to develop, test, and integrate tobacco curricula at 12 US medical schools. Because there was neither an explicit set of tobacco competencies for medical schools nor a process to develop them, one of the consortium's tasks was to articulate competencies and learning objectives.