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In this paper, we propose a generalized functional linear regression model with scalar and functional multiple predictors. We develop maximum likelihood estimators for the regression coefficients. For the functional predictors, we adopt the method of functional principal component analysis to reduce their dimensions. We then propose the generalized auto-covariance operator, based on which an appropriate measure quantifies the difference between the estimators and their true values is established. The asymptotic joint distribution of estimated regression functions is proved. For the scalar predictors, we establish a distance between the estimated value and the true value, and prove the asymptotic property of the estimated regression coefficients. Extensive simulation experiment results are consistent with the theoretical result. Finally, two application examples of the model are given. One is sleep quality study where we studied the effects of heart rate, percentage of sleep time on total sleep in bed, wake after sleep onset and number of wakening during the night on sleep quality in 22 healthy people. The other one is mortality rate where we studied the effects of air quality index, temperature, relative humidity , GDP per capita and the number of beds per thousand people on the mortality rate across 80 major cities in China.

Home health monitoring has the potential to improve outpatient management of chronic cardiopulmonary diseases such as heart failure. However, it is often limited by the need for adherence to self-measurement, charging and self-application of wearables, or usage of apps. Here, we describe a non-contact, adherence-independent sensor, that when placed beneath the legs of a patient’s home bed, longitudinally monitors total body weight, detailed respiratory signals, and ballistocardiograms for months, without requiring any active patient participation. Accompanying algorithms separate weight and respiratory signals when the bed is shared by a partner or a pet. Validation studies demonstrate quantitative equivalence to commercial sensors during overnight sleep studies. The feasibility of detecting obstructive and central apneas, cardiopulmonary coupling, and the hemodynamic consequences of non-sustained ventricular tachycardia is also established. Real-world durability is demonstrated by 3 months of in-home monitoring in an example patient with heart failure and ischemic cardiomyopathy as he recovers from coronary artery bypass grafting surgery. BedScales is the first sensor to measure adherence-independent total body weight as well as longitudinal cardiopulmonary physiology. As such, it has the potential to create a multidimensional picture of chronic disease, learn signatures of impending hospitalization, and enable optimization of care in the home.

Background The prevalence of pressure injuries (PIs) in critically ill patients has been extensively studied, but there is uncertainty regarding the risk factors. The main objective of this study was to describe the prevalence of PIs in critically ill patients. Secondary objectives were to describe PI, use of preventive measures for PI, and factors associated with occurrence of PI in the intensive care unit (ICU). Material and methods This was a 1-day point-prevalence study performed on a weekday in June 2017 in ICUs in France. On the same day, we noted the presence or absence of PI in all hospitalised patients of the participating ICUs, data on the ICUs, and the characteristics of patients and of PI. Results Eighty-six participating ICUs allowed the inclusion of 1228 patients. The prevalence of PI on the study day was 18.7% (95% confidence interval: 16.6–21.0). PIs acquired in the ICU were observed in 12.5% (95% confidence interval: 10.6–14.3) of critically ill patients on the study day. The most frequent locations of PI were the sacrum (57.4%), heel (35.2%), and face (8.7%). Severe forms of PI accounted for 40.8% of all PIs. Antiulcer mattresses were used in 91.5% of the patients, and active and/or passive mobilisation was performed for all the patients. Multiple logistic regression analysis identified longer length of stay in the ICU, a higher Simplified Acute Physiology Score, higher body weight, motor neurological disorder, high-dose steroids, and absence of oral nutrition on the study day as factors independently associated with occurrence of PI in the ICU. Conclusion This large point-prevalence study shows that PIs are found in about one of five critically ill patients despite extensive use of devices for preventing PI. Acquisition of PI in the ICU is strongly related to the patient's severity of illness on admission to the ICU and length of stay in the ICU.

Several studies have demonstrated improved clinical outcomes in pressure ulcer prevention using the SEM scanner, but none have compared it with other methods. In one of Scotland's health boards, ‘hot spot’ wards had been unable to reduce the number of hospital-acquired pressure ulcers (HAPUs) after several years of focused improvement work. In addition, other wards showed high use of dynamic therapy systems with associated costs. This review compares the use of a first generation SEM scanner versus a mattress and equipment selection pathway over a 6-week period. The findings show that the SEM scanner wards had zero HAPU while the equipment pathway wards developed a total of 4 HAPU. The two SEM scanner wards showed a 11% and 33% reduction in dynamic therapy use, while the pathway wards showed an average 40% increase. Consideration should be given to using SEM scanners to support staff decision-making to reduce HAPU development and dynamic therapy usage.

Objective To compare pressure injury (PI) incidence based on repositioning intervals and support surfaces in acute care settings. Methods This pragmatic, quasi-experimental trial recruited a total of 251 critically ill patients who were at low or moderate risk for PI development. Participants were assigned to three interventions: a 2-hour repositioning interval using an air mattress, a 2-hour repositioning interval using a foam mattress, or a 3-hour repositioning interval using a foam mattress. Data were collected by nurses every shift over the course of 14 days. Pressure injury incidence was analyzed using a χ2 test. Results There were no statistically significant differences in PI incidence between the groups with a 2-hour repositioning interval. However, the PI incidence in the group using a foam mattress with a 3-hour repositioning interval was significantly lower than in the group using an air mattress with a 2-hour repositioning interval (odds ratio, 0.481; 95% confidence interval, 0.410-0.565). Conclusions The findings showed that PIs decreased when the repositioning interval was extended from every 2 hours to every 3 hours while using foam mattresses. This study suggests that a 3-hour repositioning interval using a foam mattress could be applied to reduce the risk of PI development for patients at low or moderate risk.

BACKGROUND: Pressure injuries (PIs) are a significant problem for health care institutions. PURPOSE: A retrospective study of patient data was conducted at a semi-urban state hospital in France, aiming to evaluate the rate of PIs and variables that may influence PI prevalence and care at 2 different time points. METHODS: Patient demographic, clinical, PI and PI prevention, and care variables were retrieved from the charts of all patients on all wards (except pediatrics and obstetrics) on October 20, 2009, and on October 24, 2013—4 years apart. Qualitative data were compared between the 2 dates using a t-test for independent variables. The remaining variables were compared using Pearson’s chi-square method. P < .05 was considered significant. RESULTS: No significant differences were noted in PI rates (19% for 2009 and 16% for 2013) or the timing of their occurrence (51% occurred following admission in 2009, and 58.3% occurred after admission in 2013). Significant differences were found with regard to patient age (average, 73.97 and 76.22 years old in 2009 and 2013, respectively; P = .014) and rates of serious injuries (27% and 43% were stages 3 and 4 in 2009 and 2013, respectively; P = .010). Compared with 2009, in 2013, significantly more patients were placed on a specialty mattress and provided nutritional supplements and fewer were provided percutaneous endoscopic gastrostomy or nasogastric tubes. CONCLUSION: The rate of PIs was not different between these 2 time points despite improvements in the use of preventive and therapeutic measures, perhaps due to the increased age and frailty of the patient population in 2013 compared with 2009. Additional prospective research across multiple health care entities is warranted.

Objective: identify predictors of planned discharge to night care embracement in a Psychosocial Care Center Alcohol and Drugs (CAPS AD III). Methods: Quantitative, retrospective, and documentary study of 560 medical records of people with problems resulting from the use of alcohol and other drugs who were admitted to the hospital at night in a CAPS AD III in São Paulo, over five years. As a dependent variable, the type of discharge was used (planned or not). As independent variables, the profile of the subjects related to substance use and time in hospital. Results: 1,097 admissions were identified with 50.4% of unplanned discharge associated with homelessness (p = 0.007), problematic use crack (p = 0.015), length of reception proposed by the team (p = 0.029) and length of stay of the user (p < 0.001). Conclusion: Being homeless, problematic use of crack, and lack of user participation on the decisions regarding length of stay in CAPS AD III were associated with unplanned discharge. Objetivo: Identificar os preditores de alta planejada do acolhimento noturno em um Centro de Atenção Psicossocial Álcool e Drogas (CAPS AD III). Métodos: Estudo quantitativo, retrospectivo e documental de 560 prontuários de pessoas com problemas decorrentes do uso de álcool e outras drogas que foram admitidas em leitos de acolhimento noturno em um CAPS AD III de São Paulo, no período de cinco anos. Como variável dependente, no modelo logístico múltiplo, utilizou-se o tipo de alta (planejada ou não) e como variáveis independentes, o perfil dos sujeitos relacionadas ao consumo de substâncias e ao tempo em leito. Resultados: Identificou-se 1.097 admissões com 50,4% de altas sem planejamento associadas à situação de rua (p = 0,007), uso problemático de crack (p = 0,015), à duração do acolhimento - tempo proposto pela equipe (p = 0,029) e tempo final do usuário (p < 0,001). Conclusão: Estar em situação de rua, em uso problemático de crack e a não participação do usuário sobre a sua permanência em acolhimento noturno no CAPS AD III, associam-se à alta não planejada.

Aim: This project used historical hospital data to forecast demand for specialized bariatric beds. Models were evaluated that determined the relationship between the number of bariatric beds owned and service level for patients of size requiring these beds. A calculator was developed for minimizing the equipment costs of meeting demand. Background: Failing to provide enough bariatric beds may negatively affect outcomes for patients of size and healthcare workers, whereas owning more bariatric beds than required to meet demand means unnecessary cost. With rising rates of obesity increasing care costs, minimizing equipment costs is increasingly important. Method: One year of hospital admissions data were used to determine arrival rates and lengths of stay for patients of size. Two subsequent years verified the consistency of these rates. Simulations modeled the flow of patients of size through the hospital and the service level associated with the number of beds owned. A minimization function determined the optimal number of bariatric beds to be provided. A simplified, generalizable model was compared to the simulation. Results: The simplified model produced similar results to more complex simulation. The optimization was robust, or insensitive to small changes in inputs, and identified substantial opportunity for savings if demand for beds was substantially over- or underestimated. Conclusions: The simplified model and cost optimization could be used in many situations to prevent costly errors in equipment planning. However, hospitals should consider customized simulation to estimate demand for high-cost equipment or unique circumstances not fitting the assumptions of these models.

Prolonged surgery is a known risk of pressure ulcer formation. Pressure ulcers affect the quality of life, are a significant cause of morbidity and mortality, and pose a burden on the healthcare system. This study aimed to compare the effectiveness of an alternating pressure (AP) overlay with Gel pad against the Gel pad in reducing interface pressure (IP) during prolonged surgery.A total of 180 participants from a tertiary hospital were randomized to AP overlay with Gel pad group (n = 90) and Gel pad group (n = 90). Patients were placed supine on the pressure redistributing surfaces, and IP data under the sacrum and ischial tuberosities were collected at an interval of 30 min from 0 min up to a maximum of 570 min.Based on data from 133 participants, the average IPs during all the deflation cycles of the AP overlay (with Gel pad) were significantly lower than the average continuous IP recorded for Gel pad throughout the measuring period (p 0.001). Only three patients (2.26% of study participants) - Gel pad group (n = 2; 2.99%) and AP overlay with Gel pad group (n = 1; 1.52%) developed post-operative pressure ulcer (p = 0.5687).The lower IP during deflation cycles of the AP overlay (with Gel pad) suggests its potential effectiveness in preventing pressure ulcer formation in patients undergoing prolonged surgery. The prevention and reduction of pressure ulcers will have a considerable impact on the improved quality of life and cost savings for the patient. The study findings may facilitate the formulation of policies for preventing pressure ulcer development in the perioperative setting.

Aim Campaigns to prevent prone sleeping and other modifiable risk factors have greatly reduced the incidence of sudden infant death syndrome in Norway. Sleep-related infant deaths still occur sporadically and may be preventable. We studied infants' sleeping environments and whether parents followed safe sleep recommendations. Methods Parents with infants up to 12 months of age were invited to complete an online questionnaire from May to December 2018. It was publicised by health centres and on websites and social media. Results We received 4886 responses and 4150 met the age criteria and were included. Just under two-thirds (62.7%) reported routine bed-sharing, and this practice was associated with increased nocturnal breastfeeding, single parents and having more than one child. A small number of infants under six months were occasionally placed prone when they were laid down to sleep (2.1%) and 29.7% were placed on their side. Nearly three-quarters (72.6%) of the 2330 parents with infants under six months of age reported previous high-risk behaviour, such as sleeping together on a sofa or bed-sharing after smoking or drinking. Conclusion Norwegian parents rarely used prone sleeping positions for infants. However, bed-sharing was common, including high-risk scenarios such as smoking, alcohol use and sofas.

Background Patients with chronic kidney disease (CKD) and arterial calcification are considered at increased risk of adverse cardiovascular outcomes. However, the optimal site for measurement of arterial calcification has not been determined. The primary aim of this study was to examine the pattern of arterial calcification in different stages of CKD. Methods This was an observational, cross-sectional study that included 580 individuals with CKD stages 1–5 (no dialysis) from the Copenhagen CKD Cohort. Calcification of the carotid, coronary and iliac arteries, thoracic and abdominal aorta was assessed using non-contrast multidetector computed tomography scans and quantified according to the Agatston method. Based on the distribution of Agatston scores in the selected arterial region, the subjects were divided into calcium score categories of 0 (no calcification), 1–100, 101–400 and > 400. Results Participants with CKD stages 3–5 had the highest prevalence of calcification and the highest frequency of calcium scores > 400 in all arterial sites. Calcification in at least one arterial site was present in > 90% of patients with CKD stage 3. In all five CKD stages prevalence of calcification was greatest in both the thoracic and abdominal aorta, and in the iliac arteries. These arterial sites also showed the highest calcium scores. High calcium scores (> 400) in all five arterial regions were independently associated with prevalent cardiovascular disease. In multivariable analyses, after adjusting for cardiovascular risk factors, declining creatinine clearance was associated with increasing calcification of the coronary arteries (p = 0.012) and the thoracic aorta (p = 0.037) only. Conclusions Arterial calcification is highly prevalent throughout all five CKD stages and is most prominent in both the thoracic and abdominal aorta, and in the iliac arteries. Follow-up studies are needed to explore the potential of extracardiac calcification sites in prediction of cardiovascular events in the CKD population.

Aim To determine the effect of CPR delivery surface (e.g. firm mattress, floor, backboard) on patient outcomes and CPR delivery. Methods We searched Medline, Cochrane Library and Web of Science for studies published since 2009 that evaluated the effect of CPR delivery surface in adults and children on patient outcomes and quality of CPR. We included randomised controlled trials only. We identified pre-2010 studies from the 2010 ILCOR evaluation of this topic. Two reviewers independently screened titles/ abstracts and full-text papers, extracted data and assessed risk of bias. Evidence certainty for each outcome was evaluated using GRADE methodology. Where appropriate, we pooled data in a meta-analysis, using a random-effects model. Results Database searches identified 2701 citations. We included seven studies published since 2009. We analysed these studies together with the four studies included in the previous ILCOR review. All included studies were randomised controlled trials in manikins. Certainty of evidence was very low. Increasing mattress stiffness or moving the manikin from the bed to the floor did not improve compression depth. Use of a backboard marginally improved compression depth (mean difference 3 mm (95% CI 1–4). Conclusion The use of a backboard led to a small increase in chest compression depth in manikin trials. Different mattress types or delivery of CPR on the floor did not affect chest compression depth. PROSPERO CRD42019154791.

Objectives Methods for analyzing sleep as a dyadic behavior remain relatively unexplored. We aimed to (1) characterize how bedpartners influence each other's sleep, and (2) identify factors that predict sensitivity to wake transmission between bedpartners. Design Cross-sectional study. Setting Community members in Melbourne, Australia. Participants Fifty-five couples without sleep disorders, aged 18-72 years. Measurements Participants completed the Morningness-Eveningness Questionnaire, reduced version. Habitual sleep/wake patterns were monitored for seven nights via actigraphy and sleep diary. Epoch-by-epoch sleep/wake concordances (shared sleep/wake minutes), number of transmissions received (number of awakenings immediately preceded by bedpartner wakefulness), percent transmissions received (percentage of total awakenings that were transmissions), transmissibility (percentage of all bedpartner awakenings transmitted), and percent minutes resistant to transmission (percentage of bedpartner's wake minutes that an individual slept), were calculated. Mixed-effects modeling assessed predictors of dyadic sleep. Results We described rates of sleep concordance (M = 66.8% ± 6.8%), wake concordance (M = 6.8% ± 3.1%), number of transmissions received (M = 6.0 ± 2.7), percent transmissions received (M = 18.9% ± 7.5%), transmissibility (M = 20.0% ± 6.2%), and percent minutes resistant (M = 52.1% ± 13.6%). Average couple-level percent transmissions received were highest and percent minutes resistant lowest in couples who had similar bedtime (within 30 minutes), compared to couples with greater differences in bedtime. Conclusions Wake transmission is a useful metric of dyadic sleep, which varies according to relative bedtimes, and chronotypes of bedpartners. Higher wake transmissions for couples with similar bedtimes suggest dyadic preferences for shared bedtimes may be due to psychosocial benefits of shared sleep timing, rather than minimization of bedpartner-driven sleep disruption.

Background The clinical impact of head-of-bed elevation in patients with gastro-oesophageal reflux disease is unclear, because of inconsistency and methodological limitations of previous studies. Patients and methods A randomised single-blind single-centre controlled clinical trial with a 2 × 2 cross-over design, in 39 pharmacologically treated patients with gastro-oesophageal reflux disease. Active intervention was to use a head-of-bed-elevation of 20 cm for 6 weeks and then to sleep without inclination for 6 additional weeks, with a wash-out of 2 weeks between periods. The primary outcome was a change ≥10% in RDQ score and secondary outcomes were a change ≥10% in SF-36 score, patient preference and frequency of adverse events. Results 27 (69.2%) patients who used the intervention reached the primary outcome vs 13 (33.3%) patients in the control group (RR: 2.08; 95% C I: 1.19–3.61). No effect was found in SF-36 score (RR: 1.11; 95% CI: 0.47–2.60). Preference favouring the intervention was 77.1% and adverse event proportion was 54.0%. Conclusion Head-of-bed elevation improved reflux symptoms but there was no effect on quality of life. The finding of a non-optimal risk-benefit ratio warrants additional studies before this intervention can be recommended (IBELGA, ClinicalTrials.gov identifier NCT02706938 ).

Background In-hospital cardiac arrest is a medical emergency that occurs on a regular basis. As patients most at risk for an in-hospital cardiac arrest are usually positioned on a dynamic mattress, it is important to measure the effect of mattress compressibility on chest compression quality during cardiopulmonary resuscitation (CPR). High-quality CPR is essential for patient survival and good neurological outcome. Aims and objectives To examine the effect of an inflated dynamic overlay mattress on chest compression quality during CPR and to explore the predictive effect of health care providers' anthropometric factors, hand positioning and mattress type on chest compression frequency and depth. Design Manikin-based single-blinded randomised controlled trial. Methods Nursing students (N = 70) were randomised to a control (viscoelastic foam mattress) or intervention group (inflated dynamic overlay mattress on top of a viscoelastic foam mattress) and had to perform chest compressions over a 2-minute period. Compression rate, depth and hand positioning were registered. The 2015 European Resuscitation Council (ERC) guidelines were used as a reference. Results The mean difference in chest compression depth between control and intervention groups was 2.86 mm (P = .043). Both groups met the guidelines for adequate chest compression quality, as recommended by the ERC. A predictive effect of health care providers' body height and weight, mattress type and hand positioning on compression depth could be demonstrated (P = .004). Conclusions CPR in bedridden patients on a dynamic overlay mattress has a negative effect on the quality of chest compressions. Mean chest compression depth decreases significantly. However, clinical significance of the results may be debatable. Mattress type, body weight and hand positioning appear to be significant predictors for adequate chest compression depth. Relevance to clinical practice A firm surface under the patient is needed during CPR. Special attention must be paid to correct hand positioning during CPR.

Despite increasing preventive efforts, pressure injury still occurs in intensive care patients. This study was aimed to describe pressure injury prevalence, risk factors, and prevention practices in adult intensive care patients. This was a multi-centre, one-day, prospective point prevalence study in which a total of 198 intensive care units from 21 provinces in China participated. Overall and ICU-acquired prevalence in intensive care patients were 12.26% and 4.31%, respectively. Consistent with earlier reports, almost half of the ICU-acquired pressure injuries were at stage I, one-fourth were at stage 2, and the most common body sites for pressure injuries were sacral and heel region. Risk factors identified were consistent with prior studies. Repositioning was the most commonly used pressure injury prevention strategy, followed by alternating pressure mattresses/overlays, floating heels, and air-filled mattresses/overlays. These reflect a good level of adherence to recommended international pressure injury prevention clinical practice guidelines. The results provide a baseline reference for overall and ICU-acquired prevalence among adult intensive care patients in China. Future research on what contributed to the lower pressure injury incidence in China needs to be conducted to inform healthcare organisations on their future preventive strategies for pressure injury prevention.

Public complaints have raised concerns that some mattresses in the current marketplace may be potential sources of airborne fiberglass. Although mattress foam is often marketed as chemical-free, their cover compositions are not as well understood by the general public. To fill these basic information gaps, the covers of four newly purchased mattresses were sampled and analyzed using polarized light microscopy, SEM-EDS, and FTIR microspectroscopy. Two of the mattress covers contained over 50% fiberglass in their inner sock layers. Up to 1% of the fiberglass had migrated to adjacent fabric layers, representing a potential risk of consumer exposure if the zipper on the outer cover is opened. The observed fiberglass fragments had calculated aerodynamic diameters ranging between 30 and 50 µm, suggesting they are potentially inhalable into the nose, mouth, and throat, but are likely too large to penetrate deeper into the lungs. No fiberglass was observed on the brand new mattresses’ outer surfaces. Synthetic fibers also present in the sock layers were consistent with flame resistant modacrylic containing vinyl chloride and antimony. The use of fiberglass and other chemicals in mattress covers poses a potential health risk if these materials are not adequately contained. The apparent non-inclusion of mattress covers in chemical-free certifications suggests that further improvements are needed in mattress labeling and education of consumers.

BACKGROUND AND OBJECTIVES Sudden unexpected infant death often results from unsafe sleep environments and is the leading cause of postneonatal mortality in the United States. Standardization of infant sleep environment education has been revealed to impact such deaths. This standardized approach is similar to safety prevention bundles typically used to monitor and improve health outcomes, such as those related to hospital-acquired conditions (HACs). We sought to use the HAC model to measure and improve adherence to safe sleep guidelines in an entire children’s hospital. METHODS A hospital-wide safe sleep bundle was implemented on September 15, 2017. A safe sleep performance improvement team met monthly to review data and discuss ideas for improvement through the use of iterative plan-do-study-act cycles. Audits were performed monthly from March 2017 to October 2019 and monitored safe sleep parameters. Adherence was measured and reviewed through the use of statistical process control charts (p-charts). RESULTS Overall compliance improved from 9% to 72%. Head of bed flat increased from 62% to 93%, sleep space free of extra items increased from 52% to 81%, and caregiver education completed increased from 10% to 84%. The centerline for infant in supine position remained stable at 81%. CONCLUSIONS Using an HAC bundle safety prevention model to improve adherence to infant safe sleep guidelines is a feasible and effective method to improve the sleep environment for infants in all areas of a children’s hospital.

Background PRESSURE 2 is a randomised evaluation of the clinical and cost-effectiveness of two types of mattress for the prevention of pressure ulcers (PUs). The primary clinical endpoint was time to development of a category ≥2 PU. The current ‘gold standard’ for PU identification is expert clinical assessment. Due to the mattress appearance, a blinded assessment of the endpoint is not possible. This poses a risk to the internal validity of the study. A possible approach is to use photographs of skin sites, with central blinded review. However, there are practical and scientific concerns including patients’ consent to photographs, burden of data collection, photograph quality, data completeness and comparison of photographs to the current ‘gold standard’. This paper reports the findings of the PRESSURE 2 photographic validation sub-study. Method Where consent was obtained, photographs were taken of all category ≥2 PUs on the first presentation to assess over-reporting, and for the assessment of under-reporting, a random sample of 10% patients had an assessment by an independent clinical assessor who also photographed two skin sites. The staff were trained in taking and transferring photographs using standardised procedures and equipment. A card included in the photograph recorded participant details and a ‘greyscale’ for correction of white balance during processing. Three blinded reviewers assessed the photographs and rated how confident they were in their assessment. Results The trial recruited 2029 patients; 85% consented to photography, and 532 photographs were received and used in the blinded central review. The level of confidence varied by skin classification with more confidence observed when the skin was assessed as being less severe than a category ≥2 PU. Overall, there was a very good reliability compared to the gold standard expert clinical assessment (87.8%, kappa 0.82). Conclusion Study findings have usefully informed the scientific and practical issues of blinded assessment of PU status to reducing the risk of bias in medical device trials. The reliability of central blinded expert photography was found to be ‘very good’ (PABAK). Photographs have been found to be an acceptable method of data validation for participants. Methods to improve the quality of photographs would increase the confidence in the assessments. Trial registration ISRCTN Registry ISRCTN01151335. Registered on 19 April 2013

Objective: to evaluate evidence on effectiveness support surfaces for pressure injury prevention in the intraoperative period. Method: systematic review. The search for primary studies was conducted in seven databases. The sample consisted of 10 studies. The synthesis of the results was carried out descriptively and through meta-analysis. Results: when comparing low-tech support surfaces with regular care (standard surgical table mattress), the meta-analysis showed that there is no statistically significant difference between the investigated interventions (Relative Risk = 0.88; 95%CI: 0.30-2.39). The Higgins inconsistency test indicated considerable heterogeneity between studies (I2 = 83%). The assessment of the certainty of the evidence was very low. When comparing high-tech and low-tech support surfaces, the meta-analysis showed that there is a statistically significant difference between the interventions studied, with high-tech being the most effective (Relative Risk = 0.17; 95%CI: 0.05-0.53). Heterogeneity can be classified as not important (I2 = 0%). The assessment of certainty of evidence was moderate. Conclusion: the use of high-tech support surfaces is an effective measure to prevent pressure injuries in the intraoperative period. Objetivo: evaluar las evidencias sobre superficies de apoyo efectivas para la prevención de lesión por presión durante el período intraoperatorio. Método: revisión sistemática. La búsqueda de estudios primarios se realizó en siete bases de datos. La muestra estuvo formada por 10 investigaciones. La síntesis de los resultados se realizó de forma descriptiva y mediante metaanálisis. Resultados: al comparar las superficies de apoyo de baja tecnología con la atención habitual (colchón de mesa quirúrgica estándar), el metaanálisis demostró que no hay diferencia estadísticamente significativa entre las intervenciones investigadas (Riesgo Relativo = 0,88; IC95%: 0,30-2,39). La prueba de inconsistencia de Higgins indicó una heterogeneidad considerable entre los estudios (I2= 83%). La valoración de la certeza de la evidencia fue muy baja. Al comparar las superficies de apoyo de alta y baja tecnología, el metaanálisis mostró que existe una diferencia estadísticamente significativa entre las intervenciones estudiadas, siendo las de alta tecnología las más efectivas (Riesgo Relativo = 0,17; IC95%: 0,05-0,53). La heterogeneidad se puede clasificar como no importante (I2 = 0%). La evaluación de la certeza de la evidencia fue moderada. Conclusión: el uso de una superficie de apoyo de alta tecnología es una medida eficaz para prevenir lesiones por presión en el período intraoperatorio. Objetivo: avaliar as evidências sobre superfícies de suporte efetivas para prevenção de lesão por pressão no período intraoperatório. Método: revisão sistemática. A busca dos estudos primários foi conduzida em sete bases de dados. A amostra foi composta por 10 pesquisas. A síntese dos resultados foi realizada na forma descritiva e por meio de metanálise. Resultados: na comparação de superfícies de suporte de baixa tecnologia com o cuidado usual (colchão padrão de mesa cirúrgica), a metanálise demonstrou que não existe diferença estatisticamente significante entre as intervenções investigadas (Risco Relativo = 0,88; IC95%: 0,30-2,39). O teste de inconsistência de Higgins indicou heterogeneidade considerável entre os estudos (I2 = 83%). A avaliação da certeza da evidência foi muito baixa. Na comparação de superfícies de suporte de alta tecnologia com as de baixa tecnologia, a metanálise evidenciou que existe diferença estatisticamente significante entre as intervenções estudadas, sendo as de alta tecnologia as mais efetivas (Risco Relativo = 0,17; IC95%: 0,05-0,53). A heterogeneidade pode ser classificada como não importante (I2 = 0%). A avaliação da certeza da evidência foi moderada. Conclusão: o uso de superfície de suporte de alta tecnologia é a medida efetiva para prevenção de lesão por pressão no período intraoperatório.

RESUMO Objetivo: identificar a média de permanência dos pacientes antes e após a aplicação da metodologia Lean em um Pronto Socorro de um Hospital de Ensino. Método: estudo transversal, retrospectivo, documental, quantitativo. Os dados foram coletados em dezembro de 2019 via sistema TASY. Obteve-se a relação dos pacientes internados no pronto socorro no período de novembro de 2018 a novembro de 2019, no Oeste do Paraná – Brasil. Procedeu-se análise estatística descritiva e uso do programa Statistica 7.0, com os testes Levene e Scheff. Resultados: identificou-se aumento de 61% no número de internamentos, redução de 30% no tempo de permanência e 26% do tempo máximo de permanência registrado. Entretanto, não houve diferença significativa no período antes e depois do Lean no tempo de permanência. Conclusão: evidenciou-se que o Lean possui potencial para colaborar no aperfeiçoamento do fluxo de pacientes, aumentando os atendimentos e reduzindo o tempo de permanência na unidade. RESUMEN Objetivo: identificar la duración media de permanencia de los pacientes antes y después de la aplicación de la metodología Lean en un Servicio de Emergencias de un Hospital de Enseñanza. Método: estudio transversal, retrospectivo, documental y cuantitativo. Los dados fueron recolectados en diciembre de 2019 a través del sistema TASY. Se obtuvo la lista de pacientes ingresados en el servicio de emergencias en el periodo de noviembre de 2019, en el Oeste de Paraná – Brasil. Se procedió al análisis estadístico descriptivo y uso del programa Statistica 7.0, con las pruebas de Levene y Scheff. Resultados: Se identificó un aumento del 61% en el número de internamientos, una reducción del 30% en el tiempo de permanencia y un 26% en el tiempo máximo de permanencia registrado. Sin embargo, no hubo diferencias significativas en el periodo anterior y posterior a Lean en el tiempo de permanencia. Conclusión: se evidenció que el Lean tiene potencial para colaborar en el perfeccionamiento del flujo de pacientes, aumentando las atenciones y reduciendo el tiempo de permanencia en la unidad. ABSTRACT Objective: To identify the average length of patients’ stay before and after the Lean methodology application in a Teaching Hospital’s Emergency Room. Method: cross-sectional, retrospective, documentary, quantitative study. The data was collected in December 2019 via the TASY system. The list of patients admitted to the emergency room, from November 2018 to November 2019, in Western Paraná – Brazil, was obtained. A descriptive statistical analysis was carried out, and the Statistica 7.0 program was used, with Levene and Scheff tests. Results: there was an increase of 61% in the number of hospitalizations, a 30% reduction in the stay, and 26% of the maximum stay recorded. However, there was no significant difference in the period before and after Lean in the stay length. Conclusion: it was evident that Lean can potentially collaborate in improving the patients’ flow, increasing the visits, and reducing the stay period in the unit.

Sustained soft tissue exposure to localised deformations is a trigger for the formation of pressure ulcers. Immersion and envelopment are critical benchmarks that determine comfort and the pressure ulcer risk mitigation, as they have considerable influence on tissue stress concentrations near bony prominences. In the present study, we developed a computer modelling framework for quantifying the extent by which optimal envelopment disperses tissue stress concentrations near the sacrum. To compare the risk of developing a sacral pressure ulcer while lying supine on a regular foam mattress with respect to lying on a specialised, minimum tissue deformation mattress (which closely conforms to the body contours), we used a three-dimensional anatomically-realistic model of the adult female buttocks. The strains and stresses in the subdermal soft tissues reached peak values of 65% and 2.4 kPa for the regular mattress, respectively, but always remained below 45% and 1.2 kPa for the minimum tissue deformation mattress, which indicates longer safe times for supine support on the latter mattress. Our work demonstrates that alleviation of localised, sustained stress concentrations through good immersion and envelopment of the support surface protects from pressure ulcers, and has the potential to relieve chronic pain which is associated with the pressure ulcer risk.

Associations of sleep duration with human health could differ depending on whether sleep is restorative. Using data from 5804 participants of the Sleep Heart Health Study, we examined the longitudinal association of sleep restfulness combined with polysomnography-measured total sleep time (TST) or time in bed (TIB), representing different sleeping behaviors, with all-cause mortality. Among middle-aged adults, compared with restful intermediate TST quartile, the lowest TST quartile with feeling unrested was associated with higher mortality (hazard ratio [HR], 1.54; 95% confidence interval [CI] 1.01–2.33); the highest TST quartile with feeling rested was associated with lower mortality (HR, 0.55; 95% CI 0.32–0.97). Among older adults, the highest TIB quartile with feeling unrested was associated with higher mortality, compared with restful intermediate TIB quartile (HR, 1.57; 95% CI 1.23–2.01). Results suggest a role of restorative sleep in differentiating the effects of sleep duration on health outcomes in midlife and beyond.

BackgroundDespite the significant reduction decades ago in sudden unexpected death in infancy (SUDI), decline of rates has slowed and stalled in some countries, including the USA. This led to an appreciation of ethnic variations in SUDI rates and the need to increase cultural sensitivity regarding sleep practices and circumstantial factors of SUDI. The study explored SUDI-related factors, in journal articles from two geo-cultural regions (Asian and Western countries), particularly for factors related to infant sleep practices.MethodsA systematic review was conducted to identify SUDI-related factors in articles from PubMed, Scopus, and the Korean Citation Index from January 1992 to April 2019. From each article, SUDI-related factors were retrieved and categorized through the identification, aggregation, and categorization of factors into the areas of the triple risk model (TRM) of SUDI by their meanings and commonality. Significant trends in the frequency of factors were analyzed across time and between the two geo-cultural regions (Asian and Western countries) of article.ResultsFrom a review of 218 articles (38 Asian and 180 Western articles), 84 SUDI-related factors were identified: 39 factors for TRM 1, 44 factors for TRM 2, and one factor for TRM 3. Four of the top-ranked 10 factors were found in both cultural zones: sleep position, male sex, bed-sharing, and genetics. Both cultural zones identified sleep position (44.0%), bed-sharing (22.0%), and rooming-in (16.5%) as the three most important sleep-related factors for SUDI. Variations between the cultural zones were observed in the place of SUDI occurrence, overheating, swaddling or bedding standards, and smoking.ConclusionsRegardless of the urgent need to identify SUDI-related factors in low-SUDI societies, Asian cultures showed a significant lack of articles on SUDI. Several sociocultural issues were recognized such as the meaning of bed-sharing and rooming-in, along with residential styles and traditional health beliefs on sleep-related SUDI factors. Particularly little attention towards smoking was found in Asian articles in terms of frequency, suggesting the need to enhance SUDI reduction strategies by incorporating gender-sensitive smoking cessation interventions. This review of SUDI factors requests child health professionals to be alert to sociocultural variations in sleep practices and SUDI factors.

Bedrail use for fall prevention in elderly clients (>65 years) is controversial. Some healthcare providers believe bedrails prevent falls, while others think they are ineffective and dangerous. A systematic review was conducted to address: “For older adults living in nursing homes, does more or less bedrail use reduce the incidence of falls?” We searched HealthStar, MEDLINE, CINAHL, Academic Search complete ProQuest and Canadian Health Research Collection using “elder*,” “bedrail*,” “fall*,” and “assisted-living*.” After filtering for primary data, English records, older adult population, relationship between bedrails and falls, fourteen studies remained. Results suggest using alternative fall prevention measures, and bedrails are either beneficial, harmful, or do not influence falls. Bedrail reduction with fall prevention interventions led to no changes in fall frequency. Ambiguity persists regarding fall frequencies and bedrail use without using other fall prevention strategies. Educating health care providers on fall prevention is key to patient safety.

Air-fluidized therapy (AFT) has long been used in the treatment of severe burns. In patients with extensive burns involving the posterior trunk, we aim to keep affected posterior areas dry and to postpone their treatment, initially applying available split-thickness skin grafts in functionally more important regions. We retrospectively assessed the impact of AFT on the survival of patients treated in the burn intensive care unit (ICU) of the Medical University of Vienna, Austria, between 2003 and 2016.This retrospective single-center study included patients aged ≥18 years with burned total body surface area (TBSA) ≥20% and IIb-III° thermal injuries on the posterior trunk who received AFT. Survival rates were compared with those predicted by the abbreviated burn severity index (ABSI). Demographic, clinical, and surgical data were analyzed.Seventy-five of 110 patients with posterior trunk burns received AFT. Their survival rate exceeded that predicted by the ABSI score (mean ABSI, 10.0 ± 2.0; 73.3% (95% CI: 62-83%) survival rate vs. 20-40% predicted; p 0.0001); no such difference was observed in the non-AFT group (mean, 8.8 ± 1.9; 65.7% (95% CI: 48-81%) survival rate vs. 50-70% predicted). Patients receiving AFT had significantly greater TBSA (median, 50% (35-60) vs. 30% (25-45) and longer ICU stays (median, 63 (36-92) vs. 18 (9-52) days; both p 0.0001). Fifty-one (68.0%) patients in the AFT group and 26 (74.3%) patients in the non-AFT group underwent posterior trunk surgery (p = 0.66) a median of 16 (10-26) and 5 (2.5-9.5) days, respectively, after admission (p 0.0001).Patients receiving AFT had significantly better survival than predicted by ABSI score in contrast to patients not receiving AFT although burn injuries in this group were more severe (greater TBSA, higher ABSI). As intensive care was similar in these groups aside from AFT, the better survival could be attributed to this additional therapy.

This article discusses an evidence- and consensus-based support-surface algorithm designed to help clinicians choose the most appropriate support surface for preventing or treating pressure injuries based on patient, nurse, and institutional considerations.

BACKGROUND Although attention has recently been afforded to home injury prevention for young children, we often encounter young children who have experienced indoor injuries at places other than the home. We aimed to identify characteristics of unintentional indoor injuries that occurred when young children were not at home. METHODS We retrospectively reviewed the medical records of young children (aged

Bedsharing promotes breastfeeding initiation,1 duration2-7 and exclusivity.7,8 Medical and public health organizations in some countries recommend against bedsharing, citing concerns over increased risk of sleep-related infant death.9,10 However, bedsharing may only be a risk in hazardous circumstances as demonstrated by epidemiological study (See Table 1).11 We aim to clarify the currently available evidence regarding the benefits and risks of bedsharing, and offer evidence-based recommendations that promote infant and maternal health through increased breastfeeding duration.12 The recommendations in this protocol apply to mother-infant dyads who have initiated breastfeeding and are in home settings, and is not intended for use in hospitals or birth centers

Background and Objective This study evaluated the effects of a mattress with better body pressure dispersal in comparison to a control mattress on sleep quality. Methods In this randomized crossover study, 10 healthy young men slept in an experimental sleep room on either a functional mattress made from polyurethane, with a special four-layer three-dimensional structure, or a control mattress made from solid polyester wadding, which is a mattress commercially available in Japan. Polysomnography recordings were used to characterize sleep architecture, and the length of slow wave sleep (SWS) episodes and delta power density were calculated from the electroencephalography data and subjective sleep quality was evaluated by questionnaire they answered after waking. Results There were no significant differences in sleep latency, the total duration of each sleep stages, total sleep time, or sleep efficiency. Although the difference was subtle, delta power density significantly increased with the functional mattress. There was no difference in the total duration of SWS, but there were significantly fewer SWS episodes with the functional mattress (10.3 ± 1.8) than with the control mattress (16.9 ± 1.2) and longer SWS episode duration (10.9 ± 1.7 min) with the functional mattress than with the control mattress (5.6 ± 0.5 min). Conclusions It was suggested that the functional mattress lengthened SWS episode duration, and its fragmentation was effective in evaluating the sleep quality of healthy young individuals.

Objective: Active mattresses are used to prevent, treat and relieve pressure ulcers (PU) by intermittent contact pressure/relief. However, no studies have directly assessed the vascular endothelial response to long-term active mattress use. This study investigated the hypothesis that eight weeks use of an active mattress would lead to improvements in vascular endothelial function in healthy participants. Methods: Physiological parameters of baseline skin temperature (BskT), resting blood flow (RBF) and endothelial function as measured using post-occlusive reactive hyperaemia (PORH), were assessed at baseline (week 0); following eight weeks of sleeping on an active mattress, and after an eight week washout period (at week 16). Results: We recruited 10 healthy participants (four male, age 52.7±8.5 years, six female age 51.8±17.5 years). Following active mattress use RBF, PORH and BskT at the hallux pulp increased by 336%, 197% and 3.5°C, respectively. Mean values increased from 24.3±38.3 perfusion units to 106.0±100.3 perfusion units (p=0.021) and from 13,456±10,225 to 40,252±23,995 perfusion units x seconds (p=0.003) and from 22.9±2.5°C to 26.4±1.9°C (pConclusion: Active mattress use for eight weeks leads to significant improvements in RBF, PORH, and BskT. These results suggest that active mattress use can improve endothelial function. Future research is required to explore the potential of active mattress use in the treatment and management of diseases and conditions that would benefit from an improved endothelial function.

Locating open beds in hospital and residential mental health and substance use disorder treatment settings has been an ongoing challenge in the United States. The inability to find open beds has contributed to long emergency department wait times and missed opportunities to engage patients in treatment. Increasingly, states are creating online bed tracking systems to improve access to timely information about bed availability. This study aimed to document how states are implementing bed tracking systems, their successes and challenges, and lessons learned.A review was conducted of the published and gray literature available between 2008 and 2018, and 13 interviews were conducted with 18 stakeholders in five states (Connecticut, Iowa, Kansas, Massachusetts, and Virginia).The authors identified 17 states with bed tracking systems, of which five make information available to consumers. Most interviewees reported that the bed tracking systems were improving the ability of providers and consumers to more readily locate openings. Challenges identified included that some hospitals will not participate in bed registries, data on bed availability is sometimes not timely enough, bed registries do not provide enough detail on whether the facility is capable of meeting a particular patient's needs, providers have not been coached to use the bed registry system and continue existing practices, and states that provide information to the public have not publicized the registry's existence.Bed tracking systems offer promise, but more needs to be done to understand how to realize their potential and to more widely implement lessons learned.

OBJECTIVES To compare the pressure-relieving capacity of different supports used in veterinary medicine and to find the more common pressure sore locations in laterally recumbent dogs, so as to recommend protocols for decubitus ulcer prevention. MATERIALS AND METHODS We compared the support properties of: (1) blankets on the floor, (2) a standard mattress, (3) a veterinary memory foam mattress and (4) a human medicine memory foam mattress. Three cadaver dogs with different body condition scores but similar sizes were positioned on the different supports in lateral recumbency. Pressures were measured in each dog and at each support contact point over a 4-hour period using a TexiSense pressure mat. RESULTS Regardless of the body condition score and the support used, the skin overlying the scapula-humeral articulation, the greater trochanter and the thirteenth rib were the recurrent risk zones. In these risk zones, pressure-relieving mats led to lower pressures than did the standard mats or the blanket placed on the floor. The contact pressures appeared to depend on body condition score, with maximal pressures observed in thin dogs. CLINICAL SIGNIFICANCE It is important to use a pressure-relieving mat to reduce the risk of pressure sores, but static pressure-relieving mats are generally insufficient to maintain safe pressures in risk zones (

Sleeping microenvironment (SME), is characterized by higher temperature, humidity, and CO2 concentration. Emission of Volatile Organic Compounds (VOC) in SME is important considering the long duration people spend there with high proximity between their respiration inlets and potential emission sources, such as bedding material. This study concentrates on the influence of SME conditions on VOC emissions from polyurethane mattresses, and provides first approximation for inhalation exposure during sleep, based on measured emissions. Eight types of polyurethane mattresses were tested in a parallel continues-flow chamber system, to compare between VOC emission under different temperature, relative humidity, and CO2 concentrations. Contribution of mattress covers to emission fluxes was also examined. Eighteen VOCs were quantified with fluxes ranging from 10-4 to 10-1 mg/(h·m-2). Under sleeping conditions VOC emissions increased significantly. Elevated heat seems to be the major contributor to the enhanced emissions, compared to elevated relative humidity and CO2 concentration. Exposure levels estimated for sleeping child/infant indicate that SME can be a significant contributor to VOC exposure, yielding concerning exposure levels for few compounds. Furthermore, the present study demonstrates the strong dependency of sleeping person exposure on air exchange rate between his breathing zone and bedroom air (λBZ).

Objective Compare mothers’ reports of injuries for infants and toddlers sleeping with crib-bumpers/mesh-liners/no-barriers and reasons for these sleep environment choices. Methods A cross-sectional survey of mothers subscribing to a parenting magazine and using crib bumpers (n = 224), mesh liners (n = 262), and no barriers (n = 842). Analyses of four possible injuries (face-covered, climb-out/fall, slat-entrapment, hit-head) including multivariate logistic regression adjusted for missing data/demographics and Chi squared analyses of reasons for mothers’ choices. Results Maternal reports of finding infants/toddlers with face covered had 3.5 times higher adjusted odds (aOR) for crib bumper versus mesh liner use. Breathing difficulties and wedgings were reported for infants/toddlers using crib bumpers but not mesh liners. Climb-outs/falls showed no significant difference in aORs for crib bumpers versus no-barriers and mesh liners versus no barriers. Reports of slat-entrapment were less likely for mothers using crib bumpers and mesh liners than using no barrier (aOR = .28 and .32). Reports of hit-heads were less likely for crib bumpers vs no barrier (aOR = .38) with no significant difference between mesh liners versus no barrier use. Mothers using crib bumpers and mesh liners felt their choice prevented slat-entrapment (89%, 91%); 93.5% of crib bumper users felt their choice prevented hit-heads. Significantly more mesh liner than crib bumper users chose them because “There is no suffocation risk” (64.1% vs. 40.6%), while 83.6% of no-barrier users chose them because “I was concerned about suffocation risk.” Conclusions for Practice Mothers appeared to be more concerned about preventing minor risks than suffocation. Understanding reasons for mothers’ use of barriers/no-barriers is important in tailoring counseling for mothers with infants/toddlers. Electronic supplementary material The online version of this article (10.1007/s10995-019-02803-7) contains supplementary material, which is available to authorized users.

This study examined medicolegal death investigation records and autopsy reports of a medical examiner's office to identify the circumstances surrounding sudden unexpected infant deaths (SUID) and geospatial analyses to pinpoint areas of infant death concentration. Analysis of 732 records of SUID deaths occurring in a 10-year span resulted in the conclusion that environmental factors associated with the sudden death were to some extent modifiable. Co-sleeping (sharing a sleeping surface, or bed-sharing) on various surfaces (mattress, pallet, couch) occurred in 53.4% of the infant deaths. Geographic areas where the largest number of deaths occurred were characterized as areas of high poverty level. The inclusion of additional information at the time of investigation (eg, alcohol and tobacco use of co-sleepers, illness of others in household, exceptions to normal sleep routine of infant) may aid in identifying modifiable circumstances to reduce infant mortality attributable to sudden infant death.

Objective: To quantify differences in physical workload afforded by turn-assist surfaces relative to manual patient turns, and between nursing caregivers (turn-away vs. turn-toward) while performing partnered patient turning. Background: Nurse caregivers experience an increased risk of musculoskeletal injuries at the back or shoulders when performing patient-handling activities. Use of turn-assist surfaces can reduce the physical burden and risk on caregivers. Method: Whole-body motion capture and hand force measures were collected from 25 caregivers (17 female) while performing partnered manual and technology-facilitated turns. Shoulder and low back angles and L4/L5 joint contact forces were calculated at the instant of peak hand force application for both caregivers. Results: Hand force requirements for the turn-away caregiver were 93% of the estimated maximum acceptable force when performing a manual turn. Use of a turn-assist surface eliminated hand forces required to initiate the patient turn for the turn-away caregiver, where their role was reduced to inserting appropriate wedging behind the patient once the facilitated turn was complete. This reduced shoulder moments by 21.3 Nm for the turn-away caregiver, a reduction in exposure from 70% of maximum shoulder strength capacity to 15%. Spine compression exposures were reduced by 302.1 N for the turn-toward caregiver when using a turn-assist surface. Conclusion: Use of a turn-assist surface reduced peak hand force and shoulder-related exposures for turning away and reduced spine-related exposures for turning toward. Application: Turn-assist devices should be recommended to decrease the risk of musculoskeletal disorder hazards for both caregivers when performing a partnered patient turn.

Patients with advanced- or terminal-stage cancer and persons receiving palliative care are at high risk for pressure ulcers (PUs). Purpose The purpose of this study was to examine the rate of PU development and levels of comfort of a dual-fit, air-cell mattress compared with an alternating, 2-layer overlay air-cell mattress in patients with advanced- or terminal-stage cancer receiving palliative care. Methods From January 2011 to December 2013, hospitalized patients with advanced- or terminal-stage cancer who were referred to a palliative care team, at least 20 years of age, able to communicate, experiencing pain, and did not have a PU were recruited to participate. Patients who consented were alternately placed on the intervention (dual-fit, air-cell) or control (2-layer air) mattress until hospital discharge or death. Demographic and clinical data, pain scores, performance status, Palliative Performance Scale scores, Braden Scale scores, tissue interface pressure, and comfort were assessed via interview using closed-end questions. If a PU developed, clinical characteristics were assessed using DESIGN-R. Descriptive statistics and the Mann-Whitney U, chi-squared, and Fisher's exact tests were used to analyze the data. Results Of the 123 eligible patients, 73 were randomized and 52 completed the study (23 intervention patients, median age 63 [range 27-80] years; and 29 control group patients, median age 61.0 [range 27-82] years). Mattresses were used a median of 17 (range 4-113) days in the intervention group and a median of 32 (range 3-270) days in the control group. The incidence of PUs did not significantly differ between the 2 groups (13% in the intervention and 17.2% in the control group). Interface pressures were significantly higher in the intervention group (27.0 mm Hg vs. 24.3 mm Hg). Comfort scores at rest were significantly better in the intervention than in the control group (sinking into bed [3 vs. 14, respectively]; slipping on bed [o vs. 16, respectively]; and feel pressure of air cell [2 vs. 14, respectively]), as were scores with movement (instability during movement [4 vs. 18, respectively] and feeling of floating of the buttocks [6 vs. 21, respectively]) (P Conclusion Dual-fit, air-cell mattresses may help prevent PUs and improve comfort at rest and during activity among patients with end-stage cancer receiving palliative care. Further research regarding mattress selection protocols for this patient population is warranted.

Background Korea is in a condition where the impact of patient and supplier factors on cesarean section rates can be clearly described. The cesarean section rates in Korea are among the highest in the world while the number of obstetricians is decreasing sharply. This study aimed to investigate the geographic variation in cesarean section rates in Korea and its factors. Methods The data were obtained from the National Health Insurance database in Korea in 2013. We calculated the age-standardized and crude cesarean section rates of 251 districts in Korea and variation statistics. A linear regression analysis was performed to determine factors for cesarean section rates. Results The overall cesarean section rate in Korea was 364.6 cases per 1000 live births. The deprivation index score was strongly associated with the increase in the cesarean section rate while the density of hospital obstetricians and hospital beds showed a negative association. Average maternal age and total fertility rate showed a negative relationship with the cesarean section rate. Conclusions Korea is suffering from a continuing decrease in obstetricians. Our study shows that this decline has more of an effect on mothers in the disadvantaged areas. Securing equal access to obstetric care among areas is necessary, and measures to encourage obstetricians and mothers not to opt for cesarean section are required. Electronic supplementary material The online version of this article (10.1186/s12884-019-2300-0) contains supplementary material, which is available to authorized users.

Pressure injuries resulting from long surgeries may be caused by prolonged ischemia. Operating table surfaces with alternating pressure (AP) features may reduce the risk of ischemia-induced pressure injuries by providing periodic relief of blood flow occlusions. Prior research investigated alternating loading applied with a single isolated rigid indenter and demonstrated increased perfusion. This study quantified effects of an overlay with AP on sacral skin perfusion for individuals lying supine for 60-min while blood flow was monitored. The mean normalized sacral skin blood flow was found to be greater with the AP overlay over an operating table pad compared to the operating pad alone (pad with AP mean SBF = 1.45 ± 1.16, pad without AP mean SBF = 1.03 ± 0.46, p = 0.10). Peak and average interface pressure at the sacrum was significantly lower during the deflation cycle of the AP surface compared to the operating pad alone (P 0.001), suggesting this periodic reduction resulted in higher mean blood flow. Post-hoc regression analysis showed participant body mass index was a significant predictor of the effectiveness of the AP overlay (p = 0.012). The results suggest risk for pressure injuries due to prolonged ischemia might be mitigated by the addition of an alternating pressure feature on operating table pads for lower BMI patients.

Objective: The purpose of this study was to find out the frequency of low back pain in young adults and its relationship with the mattresses they use.Methodology: This cross sectional study was carried out in 6 months in twin cities (Rawalpindi and Islamabad). The sample size for this study was 366. For data collection, self-structured questionnaire was used along with Modified Oswestry Scale and Numeric Pain Rating Scale (NPRS). The inclusion criteria for this study was young adults with age limit 18-35 years and the participants who used the same kind of mattress for more than 3 months. Post-surgical patients and the patients diagnosed with lumbar pathology were excluded from this study. Data was then analyzed through SPSS statistics 24.Results: Mean age of the participants was 22.06±3.74 years. Majority 208(56.38%) participants were feeling low back pain and out of these 208 participants, Pain was most prevalent 30(68.18%) in firm mattress users followed by 128(59.25%) in foam mattress users. Low back pain was more associated with those participants who were not changing their mattresses for more than three years.Conclusion: Low back pain is frequently present in young adults and more prevalent in those participants who were using same firm or foam mattresses for more than three years.Keywords: Back pain, Mattresses, Posture, and Young Adults. Continuous...

This article shares the results of a quantitative analysis of the space use and physical attributes of 140 acute care units (ACU) completed since 2007. Objective: To fill a gap in the literature with respect to the state of practice for ACU design over the study period by investigating relationships among the physical characteristics and density of completed ACUs. Background: Robust industry interest about the topic—further agitated by the dearth of large-scale quantitative research regarding ACU space use—motivated completion of the study. Method: Through extraordinary collaboration by participating firms, floor plans of 140 new ACUs from the study period were gathered, systematically measured, and then analyzed. Results: Structural bay size, nurse station location, and the number of beds per unit were found to have significant relationships to ACU floor-gross area per bed. Additionally, nine significant associations among the explanatory variables were found, including moderate relationships among bay size, nurse station location, room handedness, and toilet room placement. Conclusion: The results suggest that project design teams tend to bundle key physical attributes together when planning ACUs. Moreover, density increases resulting from bay size reduction diminish as the bay size drops below 31′. Any impacts resulting from the major external events demarking the last decade were not sufficient to appreciably affect ACU density. Lastly, those concerned with increasing density and controlling ACU floor gross area are alerted to explore design options featuring bay sizes of approximately 30′ in conjunction with a centralized nursing model containing more than 32 beds per unit.

Background Pressure ulcers (also known as pressure injuries, pressure sores and bed sores) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Specific kinds of beds, overlays and mattresses are widely used with the aim of preventing and treating pressure ulcers. Objectives To summarise evidence from Cochrane Reviews that assess the effects of beds, overlays and mattresses on reducing the incidence of pressure ulcers and on increasing pressure ulcer healing in any setting and population. To assess the relative effects of different types of beds, overlays and mattresses for reducing the incidence of pressure ulcers and increasing pressure ulcer healing in any setting and population. To cumulatively rank the different treatment options of beds, overlays and mattresses in order of their effectiveness in pressure ulcer prevention and treatment. Methods In July 2020, we searched the Cochrane Library. Cochrane Reviews reporting the effectiveness of beds, mattresses or overlays for preventing or treating pressure ulcers were eligible for inclusion in this overview. Two review authors independently screened search results and undertook data extraction and risk of bias assessment using the ROBIS tool. We summarised the reported evidence in an overview of reviews. Where possible, we included the randomised controlled trials from each included review in network meta‐analyses. We assessed the relative effectiveness of beds, overlays and mattresses for preventing or treating pressure ulcers and their probabilities of being, comparably, the most effective treatment. We assessed the certainty of the evidence using the GRADE approach. Main results We include six Cochrane Reviews in this overview of reviews, all at low or unclear risk of bias. Pressure ulcer prevention: four reviews (of 68 studies with 18,174 participants) report direct evidence for 27 pairwise comparisons between 12 types of support surface on the following outcomes: pressure ulcer incidence, time to pressure ulcer incidence, patient comfort response, adverse event rates, health‐related quality of life, and cost‐effectiveness. Here we focus on outcomes with some evidence at a minimum of low certainty. (1) Pressure ulcer incidence: our overview includes direct evidence for 27 comparisons that mostly (19/27) have very low‐certainty evidence concerning reduction of pressure ulcer risk. We included 40 studies (12,517 participants; 1298 participants with new ulcers) in a network meta‐analysis involving 13 types of intervention. Data informing the network are sparse and this, together with the high risk of bias in most studies informing the network, means most network contrasts (64/78) yield evidence of very low certainty. There is low‐certainty evidence that, compared with foam surfaces (reference treatment), reactive air surfaces (e.g. static air overlays) (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.29 to 0.75), alternating pressure (active) air surfaces (e.g. alternating pressure air mattresses, large‐celled ripple mattresses) (RR 0.63, 95% CI 0.42 to 0.93), and reactive gel surfaces (e.g. gel pads used on operating tables) (RR 0.47, 95% CI 0.22 to 1.01) may reduce pressure ulcer incidence. The ranking of treatments in terms of effectiveness is also of very low certainty for all interventions. It is unclear which treatment is best for preventing ulceration. (2) Time to pressure ulcer incidence: four reviews had direct evidence on this outcome for seven comparisons. We included 10 studies (7211 participants; 699 participants with new ulcers) evaluating six interventions in a network meta‐analysis. Again, data from most network contrasts (13/15) are of very low certainty. There is low‐certainty evidence that, compared with foam surfaces (reference treatment), reactive air surfaces may reduce the hazard of developing new pressure ulcers (hazard ratio (HR) 0.20, 95% CI 0.04 to 1.05). The ranking of all support surfaces for preventing pressure ulcers in terms of time to healing is uncertain. (3) Cost‐effectiveness: this overview includes direct evidence for three comparisons. For preventing pressure ulcers, alternating pressure air surfaces are probably more cost‐effective than foam surfaces (moderate‐certainty evidence). Pressure ulcer treatment: two reviews (of 12 studies with 972 participants) report direct evidence for five comparisons on: complete pressure ulcer healing, time to complete pressure ulcer healing, patient comfort response, adverse event rates, and cost‐effectiveness. Here we focus on outcomes with some evidence at a minimum of low certainty. (1) Complete pressure ulcer healing: our overview includes direct evidence for five comparisons. There is uncertainty about the relative effects of beds, overlays and mattresses on ulcer healing. The corresponding network meta‐analysis (with four studies, 397 participants) had only three direct contrasts and a total of six network contrasts. Again, most network contrasts (5/6) have very low‐certainty evidence. There was low‐certainty evidence that more people with pressure ulcers may heal completely using reactive air surfaces than using foam surfaces (RR 1.32, 95% CI 0.96 to 1.80). We are uncertain which surfaces have the highest probability of being the most effective (all very low‐certainty evidence). (2) Time to complete pressure ulcer healing: this overview includes direct evidence for one comparison: people using reactive air surfaces may be more likely to have healed pressure ulcers compared with those using foam surfaces in long‐term care settings (HR 2.66, 95% CI 1.34 to 5.17; low‐certainty evidence). (3) Cost‐effectiveness: this overview includes direct evidence for one comparison: compared with foam surfaces, reactive air surfaces may cost an extra 26 US dollars for every ulcer‐free day in the first year of use in long‐term care settings (low‐certainty evidence). Authors' conclusions Compared with foam surfaces, reactive air surfaces may reduce pressure ulcer risk and may increase complete ulcer healing. Compared with foam surfaces, alternating pressure air surfaces may reduce pressure ulcer risk and are probably more cost‐effective in preventing pressure ulcers. Compared with foam surfaces, reactive gel surfaces may reduce pressure ulcer risk, particularly for people in operating rooms and long‐term care settings. There are uncertainties for the relative effectiveness of other support surfaces for preventing and treating pressure ulcers, and their efficacy ranking. More high‐quality research is required; for example, for the comparison of reactive air surfaces with alternating pressure air surfaces. Future studies should consider time‐to‐event outcomes and be designed to minimise any risk of bias., Plain language summary What are the benefits and risks of beds, mattresses and overlays for preventing and treating pressure ulcers? The overview presents a lot of data from randomised controlled trials and contains an advanced analysis called 'network meta‐analysis'. The analysis allows comparisons of all types of support surfaces for preventing or treating pressure ulcers. This interactive tool may help with navigation of the datahttps://stopthepressure.shinyapps.io/Cochrane_support_surface_reviews/. Key messages Static air mattresses or overlays, alternating pressure air mattresses or overlays, and gel pads used on operating tables may be better than foam mattresses for preventing pressure ulcers. Compared with foam mattresses, alternating pressure air mattresses or overlays probably result in health benefits that outweigh their costs in preventing pressure ulcers. Static air mattresses or overlays may be better than foam mattresses for ulcer healing, but may cost more. It is unclear what the best treatment is for either preventing or treating pressure ulcers; what the effects of these treatment options are on people’s comfort and quality of life; and whether or not there are any unwanted effects. What are pressure ulcers? Pressure ulcers (also known as pressure sores or bed sores) are wounds to the skin and underlying tissue caused by prolonged pressure or rubbing. People who have mobility problems or who lie in bed for long periods are at risk of developing pressure ulcers. What did we want to find out? There are many types of beds, mattresses and overlays specifically designed for people with pressure ulcers. These can be made from a range of materials (such as foam, air cells and gel pads) and are divided into two groups: ‐ reactive (static) surfaces that apply a constant pressure to the skin; and ‐ active (alternating pressure) surfaces that regularly redistribute the pressure under the body. We wanted to find out if different types of reactive and active surfaces: ‐ prevent pressure ulcers; ‐ help ulcers to heal; ‐ are comfortable and improve people’s quality of life; ‐ have health benefits that outweigh their costs; and ‐ have any unwanted effects. We also wanted to find out what the best treatment options are for either preventing or healing pressure ulcers. What did we do? We searched for Cochrane Reviews that summarised the results of all available carefully designed studies (controlled trials) evaluating different beds, mattresses and overlays in preventing and treating pressure ulcers. A Cochrane Review provides a high level of evidence on the effectiveness of healthcare interventions. We summarised the results of these reviews in a single document (called an overview of reviews). We also collected studies included in these reviews and compared all available treatments at the same time in a single analysis (called network meta‐analysis). We then summarised these results, and rated our confidence in the evidence, based on factors such as study methods and sizes. What did we find? Effects in preventing pressure ulcers We found four reviews on the use of beds, mattresses and overlays for preventing pressure ulcers. From these, we included 40 studies (12,517 people) in a network meta‐analysis evaluating reduction of pressure ulcer risk. The network meta‐analysis evidence suggests that static (reactive) air overlays, alternating pressure air mattresses, and (reactive) gel pads used on operating tables may reduce pressure ulcer risk compared with foam mattresses. We also included 10 studies (7211 people) in a network meta‐analysis evaluating the time taken for new ulcers to develop. The network meta‐analysis evidence suggests that reactive air surfaces may reduce the chances of developing new ulcers compared with foam surfaces. Effects in treating pressure ulcers We found two reviews on pressure ulcer healing. From these, we included four studies (397 people) in a network meta‐analysis. The network meta‐analysis evidence suggests that more people with ulcers may heal completely using reactive air surfaces than foam surfaces. The overview evidence suggests that, if the time needed to completely heal an ulcer is looked at, reactive air surfaces may improve the chances of pressure ulcers healing when compared with foam mattresses. However, it is unclear which treatment is best for either preventing or treating pressure ulcers. Other effects in preventing and treating pressure ulcers The overview evidence suggests that: ‐ compared with foam mattresses, alternating pressure air surfaces probably result in health benefits that outweigh their costs in preventing pressure ulcers; ‐ reactive air‐filled surfaces may cost more than foam mattresses in healing ulcers; and ‐ the other benefits and risks of these beds, mattresses and mattress overlays are unclear. What are the limitations of the evidence? Although the reviews we found used reliable methods, most of the studies in them were small and used methods likely to introduce errors in their results. How up‐to‐date is this evidence? The evidence in this overview is current to July 2020.