Ground Breaking Pressure Injury Research

Abstract:

Pressure ulcers present a significant healthcare challenge, particularly among the elderly population. Unraveling the underlying mechanisms that contribute to their development is vital for effective prevention and treatment. While vascular disease is a recognized risk factor for pressure ulcers, the relationship between endothelial dysfunction (ED) and pressure ulcer history remains relatively unexplored. The groundbreaking 2008 study by Paul #Takashi et al, titled "Association Between #PressureUlcers and Endothelial Dysfunction in Community-Dwelling Elderly: A Nested Case-Control Study," examined this connection in a cohort of elderly individuals aged 60 and above living in the community. The study hypothesis stemmed from the understanding that pressure ulcers are more common in those with compromised skin function, which is highly dependent on blood flow. Peripheral arterial tonometry was employed to assess endothelial function. Individuals with a history of pressure ulcers in the past five years (n=7) were matched 2:1 by age and gender with controls who had no history of pressure ulcers (n=14). The findings highlighted a significant association between endothelial dysfunction and a history of pressure ulcers, hinting at a potential vascular etiology that could mediate ulcer risk.

Introduction:

Pressure ulcers, also known as #bedsores or #decubitus ulcers, are a significant health concern, especially among elderly individuals with limited mobility or prolonged bed rest periods. These ulcers' development is multifaceted, involving factors such as compromised skin integrity, ischemia, and inflammation. Although vascular disease has been identified as a risk factor for pressure ulcers, the role of endothelial dysfunction (ED) in this context is not extensively studied.

The #endothelium, the innermost lining of blood vessels, plays a pivotal role in #vascular function and homeostasis. #Endothelial dysfunction, characterized by impaired vasodilation and decreased #nitricoxide bioavailability, has been associated with cardiovascular and cerebrovascular diseases, as well as cognitive decline. However, the role of ED in pressure ulcer development and healing remains largely uninvestigated. Previous studies on diabetic foot ulcers did not report significant healing differences between patients with presumed ED (diabetics) and controls. Therefore, there is a notable gap in the literature concerning the association between ED and #pressureulcers. The primary objective of the study by #Takeshini et al (2008) was to assess the potential link between vascular endothelial function and the development of pressure ulcers in a healthy elderly population.

Methods:

The researchers implemented a nested case-control design within a longitudinal cohort of cognitively intact elderly individuals (aged 60 and above) living in the community (n = 612). The study was conducted at the Mayo Clinic in Rochester, MN. Cases were defined as cohort members with a history of pressure ulcers within the five years preceding endothelial function testing. The Mayo Clinic's medical records linkage system was utilized to identify cases. For each case, two controls without a history of pressure ulcers within the same period were matched based on age (± 3 years) and gender.

Endothelial function was measured using peripheral arterial tonometry (PAT) with the #EndoPA-2000 device. Trained study coordinators, who were blinded to the participant status, conducted the #PAT measurements following a standardized protocol. Descriptive analysis was performed to document the demographic and medical comorbid characteristics of cases and controls. The difference in mean PAT scores between cases and matched controls was assessed using a Wilcoxon matched pairs signed rank test due to the small sample size.

Results:

Seven individuals (1.1% of the total sample) with a history of pressure ulcers within the observation period were identified. There were no significant demographic or medical comorbidity differences between cases and controls. However, the mean PAT score was significantly lower in cases compared to controls (1.31 versus 1.76, respectively; P = 0.04). Furthermore, all seven cases (100%) met the criteria for #endothelialdysfunction (PAT score < 1.9), while eight of the 14 controls (57%) also showed endothelial dysfunction (P = 0.04).

Discussion:

The study's findings provide initial evidence of a potential relationship between endothelial dysfunction and a history of pressure ulcers among elderly individuals living in the community. Endothelial dysfunction, characterized by impaired vasodilation and altered endothelial-dependent vasoreactivity, may contribute to a compromised vascular response to prolonged pressure, leading to increased vulnerability to pressure-induced ischemia and potential skin breakdown. This observation aligns with theories proposing vascular causes for elevated pressure ulcer risk.

The significant association between endothelial function and prevalent ulcer history suggests a potential role of ED as a contributing factor in pressure ulcer development. Although the study's sample sizes were limited, the findings highlight the need for further research with larger sample sizes, particularly in populations at high risk for pressure ulcer development.

One limitation of this study is its focus on a community-based cohort of ambulatory elderly individuals, which may limit the generalizability of the results to other populations, such as individuals in skilled nursing facilities or those with spinal injuries.

Conclusion:

This study adds to the burgeoning body of evidence suggesting a link between endothelial dysfunction and a history of pressure ulcers in the elderly population. Endothelial dysfunction may serve as a potential predictor of pressure ulcer risk, and additional research is necessary to further explore the underlying vascular mechanisms involved. Understanding the role of endothelial function in pressure ulcer development may lead to targeted interventions and improved strategies for pressure ulcer prevention and management in the elderly. The non-invasive assessment of endothelial function using peripheral arterial tonometry presents a promising avenue for potential clinical applications in predicting pressure ulcer risk and guiding wound healing therapies. Further studies with larger, more diverse populations are needed to reinforce the evidence and establish endothelial dysfunction as a valuable marker in pressure ulcer risk assessment.

PUB MED Reference

Takahashi P, Chandra A, Caldwell C, Cha S, Targonski P. The association between pressure ulcers and endothelial dysfunction in a cohort of community elderly . Wounds. 2008 Nov;20(11):290-1. PMID: 25941827.