*University of Southern California, Los Angeles, California Address correspondence and reprint requests to: Richard Bennett, MD, 1301 20th Street, Suite 570, Santa Monica, CA 90404, or e-mail: [email protected]. Muba Taher, MD, and Richard Bennett, MD, have indicated no significant interest with commercial supporters.

OBJECTIVETo identify pressure ulcer research funding sources. DESIGNA systematic review of the acknowledgment sections of pressure ulcer literature published between 2000 and 2002. RESULTSSixty-four papers were identified that acknowledged funding sources. Governmental funding sources were acknowledged in 53% (n = 34) of these papers, followed by manufacturers (30%, n = 19), consumer/professional organizations (17%, n = 11), provider organizations (11%, n = 7), philanthropic organizations (11%, n = 7), and academic institutions (9%, n = 6). CONCLUSIONAlthough various governmental organizations fund most pressure ulcer-related projects, this systematic review found that many other sources of funding are available. Researchers are encouraged to explore multiple sources for funding clinical research.

More than 20% of residents who have been in long‐term care (LTC) facilities for 2 or more years will develop at least one pressure ulcer (PU). Residents suffer pain, disfigurement, and decreased quality of life, and their risk of illness and death increases. LTC facilities face censure from residents, their families, and surveyors and the threat of expensive lawsuits. Lawsuits are typically based on contentions of residents with a PU—or their advocates—that the LTC facility was negligent and failed to provide the care that, by industry standards, it must provide to prevent or manage such wounds (managing pressure, incontinence, and nutrition). In this article, data from 1999 and 2002 are presented, showing that lawsuits related to PUs are increasingly common and costly for LTC owners and care providers. Residents realized some type of recovery against the facility in 87% of the cases (verdicts for the resident plus settlements) and were awarded amounts as high as $312 million in damages. Even LTC administrators who believe that care in their facility equals or exceeds industry standards often settle lawsuits out of court to avoid jury verdicts. The data also show that jury awards were highest for PUs caused by multiple factors and that the highest awards for PUs caused by a single factor were seen when that factor was inadequate nutrition. LTC providers can help improve the health and quality of life of their residents, improve survey results, and minimize their risk of expensive lawsuits by developing, implementing, and documenting a plan of basic measures to prevent PUs.

OBJECTIVE:To identify how current pressure ulcer staging systems and experts describe pressure-related deep tissue injury under intact skin in the published research literature. DESIGN:A systematic review of published English-language literature as of November 2002 with the words decubitus or pressure ulcer(s) in the title. Additional relevant articles were identified by National Pressure Ulcer Advisory Panel members and were included in the analysis. An expert commentary was developed by iterative review by the National Pressure Ulcer Advisory Panel members. MAIN OUTCOME MEASURES:Manuscripts were reviewed for staging systems cited or described, definitions of Stage I pressure ulcers, and descriptions or definitions of pressure-related deep tissue injury under intact skin. MAIN RESULTS:Ninety-four relevant articles were identified. Seventy-three articles (78%) described a staging system, and 55 of 73 (75%) cited the staging definitions from Shea, the National Pressure Ulcer Advisory Panel, or the Agency for Health Care Policy and Research. The National Pressure Ulcer Advisory Panel's staging definitions were the most frequently cited overall. Twenty-three articles (25%) included some discussion that could be interpreted as relevant to the topic of pressure-related deep tissue injury under intact skin; however, no consistency in definitions of Stage I pressure ulcers or terminology for pressure-related deep tissue injury under intact skin was found. CONCLUSIONS:Several pressure ulcer staging systems are frequently cited, but none define pressure-related deep tissue injury under intact skin. The National Pressure Ulcer Advisory Panel recommends using the terms "pressure-related deep tissue injury under intact skin" or "deep tissue injury under intact skin" for describing these lesions and encourages investigators to establish the epidemiology and natural history of these lesions.

OBJECTIVE:The objective of this study was to describe the nursing documentation of telephone communication with physicians in community nursing homes.DESIGN:We conducted a prospective observational study evaluating nursing documentation of all telephone calls to one physician group.SETTING:We studied two proprietary community nursing homes in Baltimore, Maryland.MEASUREMENTS:Data were collected by physicians at the time of each call regarding the time, day, nursing facility, reason for the call, and any orders given. Calls were also categorized as to whether documentation was necessary by defined criteria. The nursing home charts were then reviewed for the presence of documentation of 1) the issue that prompted the call, 2) physician's participation in the matter, and 3) any orders given by the physician. The relationships between the characteristics of the telephone calls and the rates of documentation were then analyzed.RESULTS:There were 248 calls from the two nursing homes during the 2-month study period. Nursing documentation of the issue that prompted the call was present for 80% of total calls. This documentation was more likely to be present with calls for change of patient status and notification of laboratory/radiograph results compared with calls for other issues (117 of 125 [94%] vs. 57 of 63 [90%] vs. 24 of 60 [40%], respectively; chi(2) = 78.3, P <0.0001). Calls that were categorized as "documentation necessary" by the Medical Director were more likely to be documented than calls that were not (132 of 150 [88%] vs. 9 of 35 [26%], respectively; chi(2) = 60.8, P <0.001). Of the 198 calls with any form of documentation, specific mention of physician participation in the communication was present in 89% of these calls. This documentation of physician participation was more likely to be present with calls for laboratory/radiograph notification than with calls for change of patient status or calls for other reasons (57 of 57 [100%] vs. 99 of 117 [85%] vs. 20 of 24 [83%], respectively; chi(2) = 10.0, P = 0.007). Physicians indicated that orders were given during 69% of calls, but orders were only documented for 79% of these interactions. No characteristics of the call were associated with likelihood of order documentation.CONCLUSIONS:In this study, documentation of issues that lead to telephone calls to physicians was not always present. Similarly, orders given by the physician were absent over 20% of the time. Nurses, physicians, and facilities should develop efficient and routine strategies to optimize rates of documentation of telephone communication with physicians.

Dr. Bennett's letter warned of the risk of deep venous thrombosis (DVT) as a complication of treatment with megestrol acetate among nursing home patients. We agree that DVT is an established risk of this treatment, but we believe there are good reasons why our experience1Weisberg J Wanger J Olson J et al.Megestrol acetate stimulates weight gain and ventilation in underweight COPD patients.Chest. 2002; 121: 1070-1078Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar is different than the one he previously reported. We would like to point out that Bennett's observation2Bolen J Andersen R Bennett R Deep vein thrombosis as a complication of megestrol acetate therapy among nursing home residents.J Am Med Dir Assoc. 2000; 48: 248-252Google Scholar was retrospective and without a randomized control group, and that only 18 patients were at risk (patients who received megestrol acetate over a specific 9-month period at a nursing home). Although DVT developed in six patients, two patients were at especially high risk since one patient had endometrial cancer and another patient had a recent fracture. Because the study was initiated when a cluster of DVT episodes were observed, we believe that projecting incidence in the nursing home population is questionable. Also, reporting DVT incidence per 100,000 patient-years is misleading when the summed observation period for all patients receiving megestrol acetate was approximately 7 years. Furthermore, of the at-risk patients, one was not ambulatory, three had presence of arrhythmia, two had suffered stroke, and three had coronary artery disease. The average age of the patients with DVT was 80 years. Moreover, Dr. Bennett's study is in apparent conflict with that of Yeh et al,3Yeh S-S Wu S-Y Lee T-P et al.Improvement in quality-of-life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: results of double-blind placebo-controlled study.J Am Geriatr Soc. 2000; 48: 485-492Crossref PubMed Scopus (133) Google Scholar who specifically studied nursing home patients for weight and quality-of-life measures. None of the 36 patients treated with megestrol acetate in their study acquired DVT. The average age of our patients was 67 years, and all were ambulatory. Our intervention was limited to 56 days; most of Dr. Bennett's nursing home residents experienced DVT after > 50 days of treatment. Although Dr. Bennett's article is thought provoking, it hardly refutes the safety findings of our study, where no patient was reported to have DVT in our randomized, prospective, and much larger patient population (72 receiving megestrol acetate and 73 receiving placebo). Based on our study, we believe the benefits of short-term administration of megestrol acetate in underweight patients with COPD might outweigh the risks. We believe that future trials will prove that megestrol acetate can be an important component in the management of the underweight COPD patient. Megestrol ComplicationsChestVol. 123Issue 1PreviewI am writing following the publication of a recent article in CHEST,1 which reported that megestrol acetate safely increases appetite and body weight among underweight COPD patients. Full-Text PDF

OBJECTIVE:To systematically collect information on active research grants to characterize pressure ulcer research funding in the United States and to identify potential targets for future research and funding initiatives. DESIGN A descriptive study.MAIN RESULTS:The investigators identified 32 grants, representing 16,444,117 US dollars in research funding. The majority of this funding came from federal sources, including the National Institutes of Health (90%), the Department of Veterans Affairs (7%), the National Institute on Disability and Rehabilitation Research (2%), and the Agency for Healthcare Research and Quality (1%). One quarter of pressure ulcer research grants related to quality improvement. Additional topic areas included risk factors or risk assessment tools (19%), adjunctive therapy (16%), mobilization (13%), and pressure management in foot care for patients with diabetes mellitus (9%). Further grants were in the areas of incidence, assessing tissue damage or healing, support surfaces, dressings and topical agents, nutrition, economic evaluation, and pain.CONCLUSION:The investment in pressure ulcer research is minute compared with pressure ulcer treatment expenditures. Policy makers are urged to encourage increased federal and foundation funding for research concerning pressure ulcers. Researchers are also encouraged to develop well-designed proposals to obtain available research funding. Additional research is needed in the areas of pressure ulcer incidence and prevalence, support surface design and use, pain, operative treatment, economic impact, and education strategies for caregivers and patients.

Objective To describe physician telephone management of newly admitted nursing home residents before direct evaluation by the physician, and the effect on resident outcomes. Design Retrospective chart review of 111 consecutive discharge records from two proprietary community nursing homes in Baltimore, Maryland in 1999. Measurements Data regarding the admission process were collected, with an emphasis on physician telephone orders at admission and all subsequent telephone orders before the first physician visit. Physicians were categorized as attending physicians or on-call physicians. Unexpected outcomes defined as an unplanned admission to an acute hospital or an unanticipated death within 14 days of admission to the nursing home were identified. The relationships among resident, physician, and admission characteristics and unexpected outcomes were analyzed. Results Most residents (97 of 111 (87%)) were admitted from an acute hospital, and the remaining 13% were admitted from home or another nursing home. An attending physician confirmed admission orders for 87 of 111 (78%) residents, and an on-call physician confirmed admission orders for the remainder. Physicians changed medications at the time of admission, as compared with preadmission medications, in 58 of 111 (52%) residents and ordered laboratory studies or radiographs in 59 of 111 (53%). On-call physicians were just as likely to make both types of changes as attending physicians. In the time interval after the initial telephone contact but before the first physician visit, medication changes were made in 35 of 111 (32%) residents and testing was ordered in 16 of 111 (14%). Nineteen of 111 (17%) residents were either readmitted to the hospital or died within 14 days of admission to the nursing home. These unexpected outcomes were statistically less likely to occur in the group of residents for whom physicians made medication changes at the time of admission as compared to the group for whom no medication changes were made [6 of 58 (10%) versus 13 of 53 (25%), P = 0.04, respectively], and in the group for whom tests were ordered at the time of admission as compared to not ordered [4 of 59 (7%) versus 15 of 51 (29%), P = 0.002, respectively]. There were no differences in the likelihood of unexpected outcomes when physicians made medication changes or ordered tests after the time of admission but before the first physician visit. Conclusions In this study, physicians made adjustments in medications and ordered tests for newly admitted nursing home patients before seeing the resident in the majority of cases. Unexpected outcomes including readmission to the hospital or death within 14 days of admission were less common among those residents when such changes were made at the time of admission. Further studies are needed to identify those changes as well as those resident and physician characteristics that might lead to improved outcomes. To describe physician telephone management of newly admitted nursing home residents before direct evaluation by the physician, and the effect on resident outcomes. Retrospective chart review of 111 consecutive discharge records from two proprietary community nursing homes in Baltimore, Maryland in 1999. Data regarding the admission process were collected, with an emphasis on physician telephone orders at admission and all subsequent telephone orders before the first physician visit. Physicians were categorized as attending physicians or on-call physicians. Unexpected outcomes defined as an unplanned admission to an acute hospital or an unanticipated death within 14 days of admission to the nursing home were identified. The relationships among resident, physician, and admission characteristics and unexpected outcomes were analyzed. Most residents (97 of 111 (87%)) were admitted from an acute hospital, and the remaining 13% were admitted from home or another nursing home. An attending physician confirmed admission orders for 87 of 111 (78%) residents, and an on-call physician confirmed admission orders for the remainder. Physicians changed medications at the time of admission, as compared with preadmission medications, in 58 of 111 (52%) residents and ordered laboratory studies or radiographs in 59 of 111 (53%). On-call physicians were just as likely to make both types of changes as attending physicians. In the time interval after the initial telephone contact but before the first physician visit, medication changes were made in 35 of 111 (32%) residents and testing was ordered in 16 of 111 (14%). Nineteen of 111 (17%) residents were either readmitted to the hospital or died within 14 days of admission to the nursing home. These unexpected outcomes were statistically less likely to occur in the group of residents for whom physicians made medication changes at the time of admission as compared to the group for whom no medication changes were made [6 of 58 (10%) versus 13 of 53 (25%), P = 0.04, respectively], and in the group for whom tests were ordered at the time of admission as compared to not ordered [4 of 59 (7%) versus 15 of 51 (29%), P = 0.002, respectively]. There were no differences in the likelihood of unexpected outcomes when physicians made medication changes or ordered tests after the time of admission but before the first physician visit. In this study, physicians made adjustments in medications and ordered tests for newly admitted nursing home patients before seeing the resident in the majority of cases. Unexpected outcomes including readmission to the hospital or death within 14 days of admission were less common among those residents when such changes were made at the time of admission. Further studies are needed to identify those changes as well as those resident and physician characteristics that might lead to improved outcomes.

The safety and immunogenicity of the live attenuated cold-passaged, temperature-sensitive (cpts) 248/404 respiratory syncytial virus (RSV) A2 and the RSV A2 purified F glycoprotein (PFP-2) vaccine candidates were evaluated in a placebo-controlled trial in 60 healthy young adults and 60 healthy elderly subjects using simultaneous and sequential (cpts 248/404 followed by PFP-2) vaccination schedules. Both vaccines were well tolerated. The cpts 248/404 vaccine was moderately infectious in both young and old volunteers, but was highly restricted in replication in those who were infected. After both vaccines, RSV neutralizing antibody (neut Ab) titers increased fourfold in 22% of young subjects and in 16% of elderly subjects. Of those with low levels of RSV neut Ab (titer <9), 10/12 (83% of) young subjects and six/eight (75% of) elderly subjects had a ≥four fold rise in neut Ab titer. Young and elderly subjects immunized simultaneously had similar serum IgG and IgA postimmunization titers to RSV F (IgG, 16.4 vs 16.2, IgA 11.6 vs 12.5, respectively) as did those who were immunized sequentially (IgG 17.4 vs 17.0, IgA 13.0 vs 13.5). In both age groups, sequential immunization elicited higher postimmunization RSV F IgG and IgA titers than simultaneous immunization. Further studies that combine the PFP-2 subunit vaccine with a less attenuated RSV vaccine should be performed.

Background: Specific factors affect the outcome of full-thickness skin grafts after Mohs micrographic surgery. No recent clinical studies have systematically investigated the clinical factors that may affect the success of full-thickness skin grafts.Objective: Our objective was to analyze patient data to define factors that may influence the success of full-thickness skin grafts.Methods: We reviewed the clinical course of 117 patients who had full-thickness skin grafts after Mobs micrographic surgery. We analyzed these cases using patient variables, tumor variables, and skin graft variables and then correlated these variables to skin graft success.Results: Delay of skin graft placement (>1 day) was significantly correlated with subsequent skin graft success (p = 0.015). Skin graft necrosis was more likely to develop in men than in women (p = 0.021).Conclusion: A delay of 2 to 8 days between Mohs micrographic surgery and full-thickness skin graft placement resulted in a lower incidence of skin graft necrosis than no delay or a delay of 1 day.