Draft definition of stage I pressure ulcers: inclusion of persons with darkly pigmented skin. NPUAP Task Force on Stage I Definition and Darkly Pigmented Skin.

The National Pressure Ulcer Advisory Panel appointed a task force to review the definition of Stage I pressure ulcers, specifically to assess its adequacy in people with darkly pigmented skin. The process used by the task force to draft a new definition is described in this preliminary report of their work. The proposed definition and initial critique of it are given.

Role of angiotensin and adrenoceptors in hemodynamic response to aortic cross-clamping.

An earlier study has shown that angiotensin and catecholamines were responsible for the vasoconstriction observed in the isolated hindlimb preparation during aortic cross-clamping. That study also demonstrated that when vasoconstriction was blocked with an alpha-adrenergic antagonist, phenoxybenzamine, vasodilation was elicited by aortic cross-clamping. The present study tested the hypothesis that this vasodilation was mediated via beta-adrenergic receptors. Eighteen dogs had their hindlimb denervated, vascularly isolated, and pump perfused with blood drained from the inferior vena cava, after passing through a gas-exchanging membrane where oxygen and carbon dioxide tensions were normalized. Left and right thoracotomies were performed, and the aorta and inferior vena cava were cross-clamped. The cross-clamping was associated with 29-37% increase in limb vascular resistance in control dogs (n = 6), in animals pretreated with propranolol (2 mg/kg, n = 6), and in dogs pretreated with a combination of phenoxybenzamine (3 mg/kg) and propranolol (2 mg/kg, n = 6). In animals pretreated with a combination of phenoxybenzamine, propranolol, and enalaprilat (2 mg/kg, n = 6), an angiotensin-converting enzyme inhibitor, limb vascular resistance did not change. This study has confirmed that aortic cross-clamping is associated with vasoconstriction induced by angiotensin and activation of alpha-adrenoceptors and has further demonstrated that vasodilation is attributable to beta-adrenoceptor activation.

Prolonged tube feeding in long-term care: nutritional status and clinical outcomes.

This study examines nutritional status and clinical outcomes, including pressure ulcers and death in 40 chronically tube-fed long-term care patients. Anthropometric, biochemical, clinical and dietary data were collected over a 3-month period, with follow-up of mortality at 1 year. Subjects' functional and cognitive status was generally poor. Adequate calories and protein were provided, with sample means exceeding standard means for energy, protein and micronutrients. Still, subjects showed weight loss and severe depletion of lean and fat body mass. Mean serum protein and micronutrient status measures were in the low normal range. Hemoglobin, hematocrit, and serum zinc and carotenoid levels were below normal in a sizable proportion of patients. Pressure ulcers were present in 65% of patients. Weight loss was associated with longer time on tube feeding and more pressure ulcers. Negative correlations with ulcer number were observed for cholesterol, albumin, zinc, retinol, alpha-tocopherol and iron. This study shows that despite administration of apparently adequate formula, micronutrient deficiencies and marasmic malnutrition exist in chronically ill patients. Causes may include the combined effects of chronic disease, sepsis, immobility, and severe neurologic deficits. Clinical outcomes may be expressions of an organism-wide diminution of protein synthesis, the cause of which is unknown. For clinical management, serial measures of weight, albumin, cholesterol, hemoglobin and hematocrit are recommended. Future research must address the many subsets of the population of chronically tube-fed patients.

Simultaneous cardiac output measurements by transtracheal Doppler, electromagnetic flow meter, and thermodilution during various hemodynamic states in pigs.

The transtracheal Doppler (TTD) method of cardiac output (CO) measurement was compared with thermodilution (TDL) and aortic electromagnetic flow meter (EFM). Simultaneous CO measurements with the three methods were obtained during various hemodynamic states in eight pigs. Cardiac output ranged from 1 to 3 L/min during the study. For 128 measurements, the mean difference +/- SD between TTD-TDL and TTD-EFM measurements was -0.037 +/- 0.24 L/min and -0.055 +/- 0.23 L/min, respectively. TDL-EFM mean difference +/- SD was -0.017 +/- 0.15 L/min. The limits of the agreement between TTD and the reference methods were 0.4 to -0.5 L/min. The limits of agreement between the reference methods were 0.3 to -0.3 L/min. Regression analysis yielded TTD = 0.383 + 0.779 TDL (r = 0.86); TTD = 0.351 + 0.788 EFM (r = 0.87); TDL = 0.077 + 0.95 EFM (r = 0.95). Only a change greater than 0.6 L/min in TTD CO could predict with 95% confidence a change in TDL or EFM CO. These results suggest that, in the CO range of this study, the TTD method does not accurately reproduce the CO measurements obtained by TDL or EFM.

Safe and effective tube feeding of bedridden elderly.

An increasing number of patients with swallowing disorders due to stroke, head trauma, degenerative neurologic diseases, and other causes are surviving for prolonged periods with tube feeding of commercial formulas as their sole source of nutritional support. Reviewed in this article are the indications, methods, strategies for formula selection, complications, and outcomes of tube feeding in the long-term care patient.

Normal serum response to oral beta-carotene in humans.

This study was performed to determine (1) the normal serum response to a single oral dose of beta-carotene (BC), (2) the effect of meal timing and serum response to meal lipids on serum BC, (3) the effect of administered BC on other serum carotenoids and retinoids, and (4) the relationship of body composition to serum BC response. Subjects consumed one BC dose with a liquid 500 kcal BC-free diet; fasting and hourly venous blood was collected for 8 hours and again at 24 hours. A second liquid BC-free meal was consumed 4 hours post-dosing; this midday meal was omitted in some subjects. Serum BC levels rose and peaked initially at 5 hours, but continued to be absorbed in most subjects, remaining significantly elevated at 24 hours as compared to baseline values (p less than 0.001), independent of BC dose. The area under the BC absorption curve (8-hr AUC) increased linearly with BC dose and correlated positively with peak serum triglycerides (TG) after a meal (n = 26 tests, r = 0.56, p less than 0.003). Omission of the midday meal significantly delayed the initial BC peak to 7 hours (p less than 0.0004). Serum levels of retinol, alpha-carotene, cryptoxanthin, lycopene, and lutein remained unchanged. Serum retinyl esters did not rise in all subjects following BC intake; when it did, retinyl esters rose and peaked concomitantly with BC, but declined within 8 hours. There was no correlation between the initial serum BC, peak BC, 24-hr BC, 8-hr AUC, or peak serum TG and the percentage of body fat. We conclude that: (1) the timing of the serum response to oral BC is independent of dose, (2) the serum BC response is greater in those with a greater serum triglyceride response to meal lipids, (3) BC at the doses given does not alter the levels of other serum carotenoids, and (4) there is no correlation between the serum BC parameters measured and adiposity.

Constipation and fecal impaction in the long-term care patient.

Constipation is a significant problem in the long-term care patient. There is a high prevalence of both primary and secondary causes of constipation in this population. Common primary causes include deficient dietary fiber, deficient fluid intake, and immobility. Common secondary causes include carcinoma, constipating medications, and neurologic and endocrine diseases. Moreover, complications of constipation such as fecal impaction, fecal incontinence, stercoral ulceration, and obstruction can be catastrophic in the debilitated elderly patient. Many cases of constipation can be treated by supplementing dietary fiber and fluid intake, with attention to nonmedical forms of intervention. In some patients, therapies such as bulk-forming agents, emollients, and periodic enemas may be necessary. In addition, there are some newer therapies available. Chronic stimulant laxative therapy should be reserved for patients with certain conditions that warrant their use.

Nutrition and malnutrition in the elderly nursing home patient.

The impact of chronic illness on nutrient needs in elderly long-term care patients is poorly understood. Nutritional care begins with assessment of malnutrition risk, functional nutrient intake capacity, and physical and laboratory findings. Patient weight, food intake, and laboratory parameters should be monitored. Nutrient intake is often below RDA in these patients, with losses increased by chronic and acute illness.

Foreign body ingestion: review and suggested guidelines for management.

Eighty percent of ingested foreign bodies which reach to stomach will pass uneventfully through the gastrointestinal tract. The remainder may cause obstruction, perforation or hemorrhage. The risk of complications is increased with long sharp metal objects and animal bones, and may be higher in patients with adhesions due to prior abdominal surgery. Pre-existing intestinal disease such as Crohn's or intestinal stenosis may predispose to complications. The use of overtubes has made endoscopic removal of sharp objects safer. In patients at increased risk for complications, we recommended early endoscopic retrieval of ingested foreign objects.

Metabolic disposition of 2-phenylethylamine and the role of depression in methadone-dependent and detoxified patients.

We have now postulated that differences in the innate capacity of individuals to synthesize, store and utilize biogenic amines may provide the biological basis for human abuse of narcotic and other drugs, and that these drugs are used in an apparent unconscious effort to self-medicate against an inherent affective disorder. In this communication, we attempted a preliminary characterization of the narcotics withdrawal syndrome on biochemical and clinical parameters. Abstinence was found to be characterized by low urinary excretion of 2-phenylethylamine and depression. An indication for use of tricyclic drugs has been discussed.