Abstract not available

Some ill. mounted / Bibliography: leaves 179-232 / x, 232, [53] leaves : / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (M.D.)--University of Adelaide, Dept. of Medicine, 1984

The overall purpose of this thesis is two-fold; to illuminate the meaning of living with ‘impurity’ in terms of malodorous exuding ulcers, and the meaning of caring for people with ‘impure’ bodies in institutions and in people’s homes. The thesis comprises four papers based on studies using qualitative methods. To illuminate nursing care as narrated by 27 retired care providers in northern Sweden, seven audio recorded group dialogues were performed (I). The transcribed group dialogues were analysed using a hermeneutic approach. The findings formulated as cleanliness, order and clear conscience point to purity. By cleaning patients and their surroundings repeatedly, by preserving order in various ways and by keeping a clear conscience, nurses committed to preserving purity. This study opened up for questions concerning the meaning of ‘impurity’ and‘purity’ in nursing today leading to papers II-IV. Learning about ‘purity’ is possible through studying ‘impurity’. Audio recorded narrative interviews were performed to illuminate the meaning of living with malodorous exuding ulcers (II) and the meaning of caring for people with malodorous exuding ulcers (III). A phenomenological-hermeneutic method was used to analyse the nine transcribed interviews with patients (II) and 10 transcribed interviews with nurses (III). The comprehensive understanding of living with malodorous exuding ulcers (II) was formulated as being trapped in a debilitating process that slowly strikes one down. There is a longing for wholeness and purity. When finding consolation, i.e., encountering genuineness and feeling loved, regarded and respected as fully human despite ulcers, patients feel purified. The comprehensive understanding of caring for people with malodorous exuding ulcers (III) was formulated as being exposed to, and overwhelmed by suffering that is invading. One runs the risk of experiencing desolation when one cannot make the ulcers and malodour disappear and fails to protect patients from additional suffering. To illuminate nurses’ reflections on obstacles and possibilities providing care as desired by people with malodorous ulcers (IV), six nurses from a previous study (III) were interviewed. An illustration with findings from paper II was shown and participants were asked to reflect on obstacles and possibilities providing the care desired by patients. The 12 audio recorded transcribed interviews were analysed using qualitative content analyses. The interpretations were presented as one theme ‘striving to do ‘good’ and be good’. The sub-themes related to the obstacles were ‘experiencing clinical competence constraints’, ‘experiencing organisational constraints’, ‘experiencing ineffective communication’, ‘fearing failure’ and ‘experiencing powerlessness’. The sub themes related to possibilities were ‘spreading knowledge on ulcer treatments’, ‘considering wholeness’ and ‘creating clear channels of communication’. The meaning of living with ‘impurity’ in terms of malodorous exuding ulcers, and the meaning of caring for people with ‘impure’ bodies in institutions and in patients’ homes is interpreted as striving for purity. Patients experience impurity when feeling dirty, losing hope, and not being respected and regarded as fully human. Nurses experience impurity when failing to shield patients’ vulnerability and their own defencelessness, and when facing obstacles preventing them from providing good care and being good nurses. Both patients and nurses may experience purity through consolation. For nurses, mediating consolation presupposes being consoled by being recognised for their challenging work, being respected and included in multiprofessional teams supported by the health care organisation and the leaders. Then patients can become consoled, and feel restored and fully human again despite their contaminated body.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Pharmacology / Master / Master of Philosophy

published_or_final_version / Pharmacology / Doctoral / Doctor of Philosophy

Abbreviations ADP – autodermoplastics. CUL – chronic ulcers of legs. CVUL – chronic venous ulcers of legs. DGP – a doctor of general practice. KMU – Kaunas Medicine University. KMUH –Kaunas Medicine University Hospital. CSVD – Clinic of Skin and Venereal diseases. 1. Introduction The pathology of chronic ulcers of legs is quite often and it makes a huge influence on the daily life of a patient. According to the literature, ulcers open to 1,5 from 1000 people who are under the age of 65, and if we take into account healed up ulcers of legs, there are 36 people from 1000 to whom ulcers of legs have ever been opened. The reason of ulcers up to 80% of all cases is chronic insufficiency of veins. In Lithuania there are about 150 000 patients suffering from the chronic insufficiency of leg vein blood circulation, and about 30 000 of which are venous ulcers of legs. As in Lithuania in some of the medical institutions the treatment and the prophylaxis of chronic venous blood circulation and ulcers is insufficient, the above mentioned numbers of patients may be even higher. All the authors have noted that the oftenest reason of CUL is the insufficiency of venous blood circulation. In this case, CUL open due to the increased pressure in leg veins. The main reason for that is the insufficiency of surface and deep veins and the perforating vein valves. The good functioning of mentioned veins and their valves is necessary so that the blood could come back to the heart during each... [to full text]

It has previously been shown that VN can form complexes with IGF-II or IGF-I in combination with its binding proteins IGFBP-3 or -5. This study aimed to determine the efficacy of using these complexes as a treatment designed to accelerate wound healing, particularly in diabetic ulcers. The primary functions of skin cells in wound healing are attachment, proliferation and migration, thus these functions were assessed in response to these complexes in skin cells derived from patients with diabetic ulcers and from non-diabetic patients. These studies examined responses to the complexes in both skin keratinocyte and fibroblast cells. Furthermore, in order to investigate the mechanisms that underlie the responses observed, I also examined the ability of skin cells to retain these functional responses when the complexes incorporated an IGF-I analogue that does not activate the IGF receptor or when the cells had been pre-incubated with an anti-αv-integrin function blocking antibody. In addition, the ability of the cells to survive and grow when treated with the complexes under conditions mimicking the diabetic wound was assessed using growth assays in which the media contained elevated concentrations of glucose and calcium. I found that cells derived from skin from normal patients showed enhanced proliferation in response to these complexes, whereas only the presence of IGF-I and IGFBP seemed to be important in stimulating the proliferation of cells derived from diabetic patients. I also found that enhanced migration was observed in fibroblasts from diabetic ulcers in response to the complexes but these responses only required the presence of VN in normal cells. Both normal and diabetic keratinocytes showed enhanced migration in response to the complexes and the responses involved the interaction of both IGF-I and VN with their respective cell surface receptors. However the enhanced migration observed in diabetic ulcer derived keratinocytes was approximately half the level seen in normal keratinocytes. Furthermore, I showed that cells derived from skin from normal patients exhibited greater proliferation when treated with complexes in the presence of high concentrations of glucose and calcium ion compared to cells that were not treated with the complexes. Likewise, cells derived from skin surrounding diabetic ulcers were able to grow in media containing high levels of glucose and calcium when treated with VN:IGFBP:IGF-I complexes. In particular diabetic skin derived fibroblasts grown in high calcium media demonstrated enhanced proliferation when treated with the complexes, whereas diabetic keratinocyte cells seemed less affected by these conditions than their normal counterparts were. The findings in this thesis show that VN:IGFBP:IGF-I complexes can elicit enhanced growth and migration in cells derived from skin from both normal and diabetic patients. Further, these responses are maintained in conditions found in the diabetic wound microenvironment, namely in the presence of high glucose and high calcium. Together these findings demonstrate the potential of the VN:IGFBP:IGF complexes as wound healing agents to treat wounds, especially diabetic ulcers. Such delayed healing wounds represent a significant burden to health care systems and are one of the primary conditions that leads to the amputation of limbs. Current treatments do not address the co-ordination of ECM and growth factor action on cells that is here demonstrated to stimulate multiple wound healing related functional effects in skin cells. The data presented here represents important new information that may guide the design of new integrated therapeutics that may enhance the healing of recalcitrant diabetic ulcers.

Malnutrition is reported to be common in hospitals (10-60%), residential aged care facilities (up to 50% or more) and in free living individuals with severe or multiple disease (>10%) (Stratton et al., 2003). Published Australian studies indicate similar results (Beck et al., 2001, Ferguson et al., 1997, Lazarus and Hamlyn, 2005, Middleton et al., 2001, Visvanathan et al., 2003), but are generally limited in number, with none conducted across multiple centres or in residential aged care facilities. In Australia, there is a general lack of awareness and recognition of the problem of malnutrition, with currently no policy, standards or guidelines related to the identification, prevention and treatment of malnutrition. Malnutrition has been found to be associated with the development of pressure ulcers, but studies are limited. The consequences of the development of pressure ulcers include pain and discomfort for the patient, and considerable costs associated with treatment and increased length of stay. Pressure ulcers are considered largely preventable, and the demand for the establishment of appropriate policy, standards and guidelines regarding pressure ulcers has recently become important because the incidence and prevalence of pressure ulcers is increasingly being considered a parameter of quality of care. The aims of this study program were to firstly determine the prevalence of malnutrition and its association with pressure ulcers in Queensland Health hospitals and residential aged care facilities; and secondly to estimate the potential economic consequences of malnutrition by determining the costs arising from pressure ulcer attributable to malnutrition; and the economic outcomes of an intervention to address malnutrition in the prevention of pressure ulcers. The study program was conducted in two phases: an epidemiological study phase and an economic modelling study phase. In phase one, a multi centre, cross sectional audit of a convenience sample of subjects was carried out as part of a larger audit of pressure ulcers in Queensland public acute and residential aged care facilities in 2002 and again in 2003. Dietitians in 20 hospitals and six aged care facilities conducted single day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment, in either or both audits. Subjects excluded were obstetric, same day, paediatric and mental health patients. Weighted average proportions of nutritional status categories for acute and residential aged care facilities across the two audits were determined and compared. The effects of gender, age, facility location and medical specialty on malnutrition were determined via logistic regression. The effect of nutritional status on the presence of pressure ulcer was also determined via logistic regression. Logistic regression analyses were carried out using an analysis of correlated data approach with SUDAAN statistical package (Research Triangle Institute, USA) to account for the potential clustering effect of different facilities in the model. In phase two, an exploratory economic modelling framework was used to estimate the number of cases of pressure ulcer, total bed days lost to pressure ulcer and the economic cost of these lost bed days which could be attributed to malnutrition in Queensland public hospitals in 2002/2003. Data was obtained on the number of relevant separations, the incidence rate of pressure ulcer, the independent effect of pressure ulcers on length of stay, the cost of a bed day, and the attributable fraction of malnutrition in the development of pressure ulcers determined using the prevalence of malnutrition, the incidence rate of developing a pressure ulcer and the odds risk of developing a pressure ulcer when malnourished (as determined previously). A probabilistic sensitivity analysis approach was undertaken whereby probability distributions to the specified ranges for the key input parameters were assigned and 1000 Monte Carlo samples made from the input parameters. In an extension of the above model, an economic modelling framework was also used to predict the number of cases of pressure ulcer avoided, number of bed days not lost to pressure ulcer and economic costs if an intensive nutrition support intervention was provided to all nutritionally at risk patients in Queensland public hospitals in 2002/2003 compared to standard care. In addition to the above input parameters, data was obtained on the change in risk in developing a pressure ulcer associated with an intensive nutrition support intervention compared to standard care. The annual monetary cost of the provision of an intensive nutrition support intervention to at risk patients was modelled at a cost of AU$ 3.8-$5.4 million for additional food and nutritional supplements and staffing resources to assist patients with nutritional intake. A probabilistic sensitivity analysis approach was again taken. A mean of 34.7 + 4.0% and 31.4 + 9.5% of acute subjects and a median of 50.0% and 49.2% of residents of aged care facilities were found to be malnourished in Audits 1 and 2, respectively. Variables found to be significantly associated with an increased odds risk of malnutrition included: older age groups, metropolitan location of facility and medical specialty, in particular oncology and critical care. Malnutrition was found to be significantly associated with an increased odds risk of having a pressure ulcer, with the odds risk increasing with severity of malnutrition. In acute facilities moderate malnutrition had an odds risk of 2.2 (95% CI 1.6-3.0, p<0.001) and severe malnutrition had an odds risk of 4.8 (95% CI 3.2-7.2, p<0.001) of having a pressure ulcer. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in an acute facility was 2.6 (95% CI 1.8-3.5, p<0.001). In residential facilities, where the audit results were presented separately, the same pattern applied with moderate malnutrition having an odds risk of 1.7 (95% CI 1.2-2.2, p<0.001) and 2.0 (95% CI 1.5-2.8, p<0.001); and severe malnutrition having an odds risk of 2.8 (95% CI1.2-6.6, p=0.02) and 2.2 (95% CI 1.5-3.1, p<0.001), for Audits 1 and 2 respectively. There was no statistical difference between these odds risk ratios between the audits. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in a residential aged care facility was 1.9 (95% CI 1.3-2.7, p<0.001) and 2.0 (95% CI 1.5-2.7, p<0.001) for Audits 1 and 2 respectively. Being malnourished was also found to be significantly associated with an increased odds risk of having a higher stage and higher number of pressure ulcers, with the odds risk increasing with severity of malnutrition. The economic model predicted a mean of 3666 (Standard deviation 555) cases of pressure ulcer attributable to malnutrition out of a total mean of 11162 (Standard deviation 1210), or approximately 33%, in Queensland public acute hospitals in 2002/2003. The mean number of bed days lost to pressure ulcer that were attributable to malnutrition was predicted to be 16050, which represents approximately 0.67% of total patient bed days in Queensland public hospitals in 2002/2003. The corresponding mean economic costs of pressure ulcer attributable to malnutrition in Queensland public acute hospitals in 2002/2003 were estimated to be almost AU$13 million, out of a total mean estimated cost of pressure ulcer of AU$ 38 526 601. In the extension of the economic model, the mean economic cost of the implementation of an intensive nutrition support intervention was predicted to be a negative value ( -AU$ 5.4 million) with a standard deviation of $AU3.9 million, and interquartile range of –AU$ 7.7 million to –AU$ 2.5 million. Overall there were 951 of the 1000 re-samples where the economic cost is a negative value. This means there was a 95% chance that implementing an intensive nutrition support intervention was overall cost saving, due to reducing the cases of pressure ulcer and hospital bed days lost to pressure ulcer. This research program has demonstrated an independent association between malnutrition and pressure ulcers, on a background of a high prevalence of malnutrition, providing evidence to justify the elevation of malnutrition to a safety and quality issue for Australian healthcare organisations, similarly to pressure ulcers. In addition this research provides preliminary economic evidence to justify the requirement for consideration of healthcare policy, standards and guidelines regarding systems to identify, prevent and treat malnutrition, at least in the case of pressure ulcers in Australia.