Influence of Nutrition and Nonnutrition Factors on Pressure Injury Outcomes Among At-Risk Asian Nursing Home Residents OBJECTIVE Given evidence that malnutrition and immobility increase the risk of pressure injuries (PIs) in nursing home (NH) residents and that body mass index guidelines related to undernutrition may differ between Asian and non-Asian populations, the purpose of this study was to describe differences in overall nutrition, dietary intake, and nonnutrition risk factors for PIs between Asian and non-Asian NH residents. DESIGN AND SETTING Secondary data analysis of a 3-week PI prevention randomized controlled trial in seven Canadian NHs. PATIENTS Asian (n = 97) and non-Asian (n = 408) residents at moderate or high mobility-related risk of PI. MAIN OUTCOME MEASURE Incident PI by racial subgroups. MAIN RESULTS Asian residents (PI = 6) consumed significantly smaller meals and marginally different patterns of daily dietary consumption of protein types, liquid supplements, and snacks; took more frequent tub baths; and had marginally lower body mass index than non-Asian residents (PI = 4). CONCLUSIONS Findings are consistent with earlier research suggesting that nutrition consumption and care patterns may predispose Asian NH residents to develop more PIs than their non-Asian counterparts. Future research should focus on the threshold for and types of nutrition support sufficient to improve nutrition status and reduce PI risk. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Effectiveness of Arginine Supplementation on Wound Healing in Older Adults in Acute and Chronic Settings: A Systematic Review OBJECTIVE To examine the effect of arginine supplementation on wound healing, as measured by wound size and healing rate, in older adults in acute and long-term care (LTC) settings. DATA SOURCES PubMed, CINAHL Plus, Google Scholar, and OpenGrey databases. STUDY SELECTION Randomized clinical trials and clinical studies were considered for this review. Selection criteria included English-language articles published after 2008 that provide data on older adults with pressure injury receiving arginine supplementation in acute care and LTC settings. DATA EXTRACTION Data were extracted from the articles using a predefined checklist including study size and design, participant characteristics (age, pressure injury stage, relevant comorbidities), nutrition intervention and dosage, duration of study, outcomes, and publication year. Studies were appraised using the National Institutes of Health’s Quality Assessment of Controlled Intervention Studies tool. DATA SYNTHESIS A preliminary search yielded 39 articles after removing duplicates. Abstracts and titles of articles were screened, and 23 full-text articles were examined further. Ultimately, six articles met the inclusion criteria. CONCLUSIONS Current evidence suggests that arginine supplementation in conjunction with oral nutrition supplementation may promote wound healing in older adult patients in acute care and LTC settings as evidenced by significant reductions in wound size and improvements in wound healing when compared with oral nutrition supplementation alone. A definitive conclusion about the use of arginine supplementation alone to promote wound healing cannot be drawn because of limitations in the available literature. Additional high-quality studies are needed to examine arginine supplementation alone as a potential therapy for PI. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Refining Heel Pressure Injury Risk Factors in the Hospitalized Patient OBJECTIVE To replicate previous research that found four independent and significant predictors of heel pressure injuries (HPIs) in hospitalized patients using a larger and more diverse patient population. METHODS Researchers conducted a retrospective, case-control study with a main and a validation analysis (N = 1,937). The main analysis had 1,697 patients: 323 patients who had HPIs and 1,374 who did not. The validation analysis had 240 patients: 80 patients who developed HPIs and 160 who did not. Researchers used a series of diagnosis codes to define variables associated with an HPI. Data were extracted from the New York Statewide Planning and Research Cooperative System for January 2014 to June 2015. Study authors conducted a series of forward stepwise logistic regression analyses for both samples to select the variables that were significantly and independently associated with the development of an HPI in a multivariable setting. Researchers generated a receiver operating characteristic curve using the final model to assess the regression model's ability to predict HPI development. RESULTS Seven variables were significant and independent predictors associated with HPIs: diabetes mellitus, vascular disease, perfusion issues, impaired nutrition, age, mechanical ventilation, and surgery. The receiver operating characteristic curve demonstrated predictive accuracy of the model. CONCLUSIONS Beyond a risk assessment scale, providers should consider other factors, such as comorbidities, which can predispose patients to HPI development. Acknowledgments: The study was funded by Sage Products, LLC. The funding source was not involved in study design, monitoring, data collection, statistical analyses, interpretation of results, or manuscript writing. The authors have disclosed no other financial relationships related to this article. Submitted January 29, 2019; accepted in revised form April 3, 2019. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Rare Presentation of Postsurgical Pyoderma Gangrenosum Presenting as Necrotizing Soft Tissue Infection Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis believed to be mediated by an autoimmune reaction. Typical treatment includes autolytic debridement, management of exudate, protection from trauma, and steroid therapy. A diagnosis of exclusion, PG is frequently mistaken for a wound infection, but antibiotics do not alleviate the condition. Incision and debridement has been observed to cause further spread of the lesions because of pathergy resulting from the additional trauma. This case report describes a patient who was misdiagnosed with necrotic soft tissue infection that was actually postsurgical PG. The authors have disclosed no financial relationships related to this article. Submitted February 11, 2019; accepted in revised form April 17, 2019. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Nurses’ Education, Confidence, and Competence in Appropriate Dressing Choice BACKGROUND Wound assessment and treatment are essential aspects of nursing care. Dressing-associated complications can delay wound healing, causing unnecessary patient distress. Despite evidence suggesting that dressings should be changed infrequently, there still remains a tendency for healthcare professionals to remove dressings regularly, increasing the risk of complications and the cost of wound care. OBJECTIVE To understand the experiences and current practices of tissue viability nurses (TVNs) involved in wound care and dressing wear time in the acute and community settings. METHODS This quality improvement project used a mixed-methods design. A retrospective audit was undertaken to establish nurse rationale for the renewal of foam dressings on patients with acute/chronic wounds. Semistructured qualitative interviews were conducted with registered TVNs (n = 12) working in acute and community care settings and focused on their experiences with all dressing types. MAIN RESULTS The analysis identified several key themes, including Training and Education (including the subthemes of TVN Experience and TVN Training), Knowledge and Information, Lack of Confidence (including the subthemes Reasons for Dressing Change and Ritualistic Practice), and Dressing Choice. CONCLUSIONS Fundamental changes in staff attitudes and beliefs about dressing wear time are essential to optimizing dressing performance and increasing patient quality of care. Flexible community services that are reflective of the needs of the service are central to changing practice and increasing dressing wear time in these settings. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Is Negative-Pressure Wound Therapy a “Bridge to Reconstruction” for Poststernotomy Mediastinitis? A Systematic Review OBJECTIVE: To assess the efficacy of negative-pressure wound therapy (NPWT) in preparing sternal wounds for flap reconstruction. METHODS: Investigators searched standard research databases with terms including “post-sternotomy mediastinitis,” “deep sternal wound infection,” “negative pressure wound therapy,” “vacuum assisted closure,” and “VAC.” Of 434 reports, 14 studies described patients diagnosed with poststernotomy mediastinitis who underwent NPWT followed by flap reconstruction. Eligible studies were assessed for length of stay, mortality, manufacturer involvement, and methodological rigor. MAIN RESULTS: Among a total 429 patients, median length of stay was 29 (±16) days. There were 41 deaths in this inpatient group (10%). Seventy-one percent of the reports were nonrandomized, and 36% of the studies accurately accounted for baseline differences in severity, whereas 14% failed to report diagnostic criteria. Only one study reported follow-up results. Nine studies (64%) failed to make a statement regarding conflicts of interest. In this analysis of quality, 48% (n = 8) of the studies were of very low to low quality. One study was of high quality. CONCLUSIONS: Investigators failed to find ample support for routine use of NPWT as a “bridge to reconstruction.” Serious complications related to the use of NPWT including right ventricular rupture, atrial fibrillation, respiratory arrest, recurrent infection, and a retained sponge were reported in this group of studies. Rigorous evaluative studies that assess the true effectiveness of NPWT as a “bridge to reconstruction” must precede its adoption. The authors have disclosed no financial relationships related to this article. Submitted September 1, 2018; accepted October 9, 2018. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.