Surgery May Not Be The Answer To An Aching Back
By:Mehraj Sheikh
April 18, 2010

Back Pain Explained

Ruptured disc, spinal stenosis or degenerating spinal joints? See three common and chronic spine problems.
Too many complex back surgeries are being done and people are suffering as a result, according to a study in the current issue of the Journal of the American Medical Association. The general tendency noted in the study — that many patients and doctors think more medical care is always better — has implications for the new health overhaul law.
Back pain associated with aging can be treated in one of numerous ways: rest and physical therapy, surgery to remove the bony growths that can push on nerves, fusing two vertebrae together, or fusing many vertebrae together.
In the past few years, several studies have failed to show a big advantage for surgery — especially for complex surgery. Researchers from Oregon Health and Science University and several other places looked at Medicare billing records to see whether the rates or type of back surgeries went down as a result.
They found the number of surgeries has gone down very slightly. But when they looked specifically at complex surgeries, they found a big difference.
"The most complex type of back surgery has increased dramatically between 2002 and 2007, with a 15-fold increase," says co-author Richard Deyo. In 2002, the rate of complex surgery was 1.4 per 100,000 people in Medicare. It jumped to 19.9 per 100,000 just five years later.
Deyo and his colleagues also checked the rate of complications. "This more complex form of surgery is associated with a higher risk of life threatening complications," he says. Among people who just had the bony growths removed (a surgery called decompression), 2.3 percent had problems associated with their treatment, such as a heart attack, stroke or pneumonia. The complication rate was 5.6 percent among people who had multiple vertebrae fused together.
Deyo says there's no reason to think people suddenly started developing the spinal deformities that justify the complex surgeries. He offers several possibilities for the upswing. "Many surgeons genuinely believe that the more invasive procedures offer some benefits," he says. "But certainly there are important financial incentives at play as well." Surgical fees for simple decompressions are about $600 to $1,000. The complex surgeries earn surgeons as much as 10 times more. He says another possible factor is the tendency for both doctors and patients to go for a new, more expensive approach just because it sounds better.
Orthopedist Eugene Carragee, a professor at Stanford University School of Medicine, wrote an editorial accompanying the research, saying that financial incentives are part of the problem. There's also a problem with how new technologies are introduced, he says. In surgery, someone can just introduce a new procedure.
"The burden of proof in the system as it is now is that researchers have to go out to try and prove that what this guy wants to do doesn't work, and that's a backwards kind of thinking," he says.
It's far better to have to prove that something works before it becomes common practice, he says.
JAMA study researcher Deyo would like his study to alter the practice of medicine. "The effect I would hope it would have is to have surgeons and patients choose the least invasive procedure that would accomplish the surgical aim," he says. But he's pessimistic about it, unless there's a change in the financial incentives.
James Weinstein is also calling for a rejiggering of financial incentives. Weinstein is an orthopedic surgeon and the director of the Dartmouth Institute for Health Policy and Clinical Practice. He did some of the original studies showing that most back surgeries make a minimal difference, if any. He says Deyo's study shows one thing clearly. "The practice of medicine doesn't always follow the best evidence," he says.
The new health overhaul law sets up a new institute that would do studies like Deyo's, comparing the risks and benefits of various treatments for various conditions. The law explicitly says the information can't be used by insurers or government to set reimbursement policies, but Weinstein says the institute could make a big difference.
"I think if patients were well informed, they would choose the right thing," Weinstein says. "We've done lots of studies with shared decision-making. Where patients are given good information they generally choose the least invasive, less risky procedure."
He says health overhaul plans need to go beyond what's in the new law. "Right now we have health insurance reform," he says. "We need health care delivery reform, we need to change how we're delivering practice and how we're reimbursing for it." What he'd like to see is a system that pays doctors and hospitals based on overall patient care, not separately for individual procedures.
Thank you.

Let’s first admit that knee arthritis like eye cataract is a disease of old age bound to affect all of us. Blaming our genes or considering familial reasons for this will not be correct. Early arthritis responds nicely to physical therapy, intra articular injections, weight reduction and analgesics. This is the stage when alternative therapies like ayurved or Homeopathic medicines might also work . As the disease progress these modalities become ineffective and require additional treatment modalities. Understanding this simple fact is important as the patients are reluctant to accept these additional treatments indicated in late arthritis.
Late Arthritis if untreated remarkably reduces the physical movement of patient. Due to fear of pain patient gradually restricts his / her activities like daily walk, social interaction and is eventually confined to the house. This results in serious effects on body and lead to worsening of high blood pressure, Diabetes, kidney problems etc. Such patients also suffer from depression and other psychological problems.

Till date , for late arthritis when the joint is almost destroyed, Total knee replacement (TKR)remains the only answer. Knee replacement done in indicated patients have almost 100% success rate.
From patients prospective I think there are some major questions which create a mind block against knee replacement. ..” I am over sixty , can I undergo this surgery safely” .. . Yes of course TKR is a surgery meant for old age. Before this surgery is undertaken a complete medical check up including ECG, ECHO, Renal status etc is done. Besides Orthopedic Surgeon, a Physician (cardiologist if needed) and Anaesthetist are part of team who ensure total well being of patient. Needless to say a good hospital with ICU back up is must. At our centre we have even undertaken surgery in patients who were above 90 years old.
“ How much it will cost ?” Considering the Indian scenario where insurance sector is still in its infancy , majority of patients pay from their savings. In this situation a affordable package and which does not compromise on quality is needed. We have introduced the concept of “NANO Knee Replacement” where in one lakh and twenty five thousand the patient will undergo this surgery at the selected city hospitals.
“ How much bed rest is required ?” . Complete bed rest is required not more than 2-3 days. On 3rd post operative day patient is mobilized with walker and full weight bearing is allowed. Thereafter a physiotherapy regimen is followed and by 3-4 weeks patient shifts to walking stick.
“How long will a joint replacement last? “Longevity of the prosthetic knee varies from patient to patient. It depends on many factors, such as a patient's physical condition, activity level, and weight, as well as the accuracy of implant placement during surgery. Today, total knee replacement has become a common and predictable procedure. Many patients enjoy relief from pain and improved function, compared to their status before surgery. As a result, some patients may have unrealistic expectations about what the prosthetic knee can do and how much activity it can withstand. Activities that place a lot of stress on the joint implants, as may be the case with heavier and more active patients, may reduce the service life of the prosthesis. Some activities need to be avoided like heavy loads , steep stairs, impact sports like jogging or running and kneeling. We now know that about 85 percent of the joint implants will last 20 years. Improvements in surgical technique and artificial joint materials should make these artificial joints last even longer.

Let us not forget the importance of mobility in old age. There is no reason that one should lead a life of pain and agony. Knee replacement offers best treatment option for late arthritis and its safe , affordable and gives the best results .


Dr. Harinder Batth, M.S (PGI)
Consultant Orthopedic Surgeon
INSCOL Hospital, Chandigarh
COSMO Hospital, Mohali


Mob- 9888003333

Wall Street Journal carried a deeply researched article on Acupuncture. Just sharing this good essay.

Decoding an Ancient Therapy
High-Tech Tools Show How Acupuncture Works in Treating Arthritis, Back Pain, Other Ills

By MELINDA BECK

Acupuncture has long baffled medical experts and no wonder: It holds that an invisible life force called qi (pronounced chee) travels up and down the body in 14 meridians. Illness and pain are due to blockages and imbalances in qi. Inserting thin needles into the body at precise points can unblock the meridians, practitioners believe, and treat everything from arthritis and asthma to anxiety, acne and infertility.
Does It Work?

While scientists say further research is essential, some studies have provided evidence of acupuncture's effects.

* Arthritis of the Knee: Acupuncture significantly reduced pain and restored function, according to a 2004 government study.
* Headaches: Two 2009 reviews found that acupuncture cut both tension and migraine headaches.
* Lower Back Pain: Acupuncture eased it in a big study last year, but so did a sham treatment where needles didn't penetrate the skin.
* Cancer: Has proven effective in reducing nausea and fatigue caused by chemotherapy.
* Infertility: Improves the odds of pregnancy for women undergoing in-vitro fertilization, according to a 2008 review of seven clinical trials.
* Addiction: Often used to help quit smoking, drinking, drug use and overeating, but there is no conclusive evidence that it works.

As fanciful as that seems, acupuncture does have real effects on the human body, which scientists are documenting using high-tech tools. Neuroimaging studies show that it seems to calm areas of the brain that register pain and activate those involved in rest and recuperation. Doppler ultrasound shows that acupuncture increases blood flow in treated areas. Thermal imaging shows that it can make inflammation subside.

Scientists are also finding parallels between the ancient concepts and modern anatomy. Many of the 365 acupuncture points correspond to nerve bundles or muscle trigger points. Several meridians track major arteries and nerves. "If people have a heart attack, the pain will radiate up across the chest and down the left arm. That's where the heart meridian goes," says Peter Dorsher, a specialist in pain management and rehabilitation at the Mayo Clinic in Jacksonville, Fla. "Gallbladder pain will radiate to the right upper shoulder, just where the gallbladder meridian goes."

Many medical experts remain deeply skeptical about acupuncture, of course, and studies of its effectiveness have been mixed. "Something measurable is happening when you stick a needle into a patient—that doesn't impress me at all," says Edzard Ernst, a professor of complementary medicine at the University of Exeter in England and co-author of the book, "Trick or Treatment." Acupuncture "clearly has a very strong placebo effect. Whether it does anything else, the jury is still out."

Even so, the use of acupuncture continues to spread—often alongside conventional medicine. U.S. Navy, Air Force and Army doctors are using acupuncture to treat musculoskeletal problems, pain and stress in stateside hospitals and combat zones in Iraq and Afghanistan. Delegations from Acupuncturists Without Borders are holding communal ear-needling sessions to reduce stress among earthquake victims in Haiti. Major medical centers—from M.D. Anderson in Houston to Memorial Sloan-Kettering in New York—use acupuncture to counteract the side effects of chemotherapy.

In a 2007 survey, 3.2 million Americans had undergone acupuncture in the past year—up from 2.1 million in 2001, according to the government's National Center for Complementary and Alternative Medicine.

The most common uses are for chronic pain conditions like arthritis, lower back pain and headaches, as well as fatigue, anxiety and digestive problems, often when conventional medicine fails. At about $50 per session, it's relatively inexpensive and covered by some insurers.
Journal Community

It is also generally safe. About 10% of patients experience some bleeding at the needle sites, although in very rare cases, fatalities have occurred due to infections or injury to vital organs, mostly due to inexperienced practitioners.

Most states require that acupuncturists be licensed, and the Food and Drug Administration requires that needles be new and sterile.

Diagnoses are complicated. An acupuncturist will examine a patient's tongue and take three different pulses on each wrist, as well as asking questions about digestion, sleep and other habits, before determining which meridians may be blocked and where to place the needles. The 14 meridians are thought to be based on the rivers of China, and the 365 points may represent the days of the year. "Invaders" such as wind, cold, heat, dampness, dryness factor into illness, so can five phases known as fire, earth, metal, water and wood.
Using Acupuncture to Treat Stress

View Interactive

"It's not like there's a Merck Manual for acupuncture," says Joseph M. Helms, who has trained some 4,000 physicians in acupuncture at his institute in Berkeley, Calif. "Every case is evaluated on an individual basis, based on the presentation of the patient and the knowledge of the acupuncturist."

Dr. Helms notes that Western doctors also examine a patient's tongue for signs of illness. As for qi, he says, while the word doesn't exist in Western medicine, there are similar concepts. "We'll say, 'A 27-year-old female appears moribund; she doesn't respond to stimuli. Or an 85-year old woman is exhibiting a vacant stare.' We're talking about the same energy and vitality, we're just not making it a unique category that we quantify."

Studies in the early 1980s found that acupuncture works in part by stimulating the release of endorphins, the body's natural feel-good chemicals, much like vigorous exercise does. Now, a growing body of research suggests that it may have several mechanisms of action. Those include stimulating blood flow and tissue repair at the needle sites and sending nerve signals to the brain that regulate the perception of pain and reboot the autonomic nervous system, which governs unconscious functions such as heart beat, respiration and digestion, according to Alejandro Elorriaga, director of the medical acupuncture program at McMaster University in Ontario, which teaches a contemporary version to physicians.
[healthcolJ] Vitaly Napadow

A specialized MRI scan shows the effects of acupuncture. The top two images show the brain of a healthy subject. In the middle two images, a patient with carpal tunnel syndrome registers pain (indicated by red and yellow). The bottom images show the calming effect (indicated by blue) in the brain after acupuncture.

"You can think Western, you can think Eastern. As long as your needle goes to the nerve, you will get some effect," Dr. Elorriaga says.

What's more, an odd phenomenon occurs when acupuncture needles are inserted into the body and rotated: Connective tissue wraps around them like spaghetti around a fork, according to ultrasound studies at the University of Vermont. Helene Langevin, research associate professor of neurology, says this action stretches cells in the connective tissue much like massage and yoga do, and may act like acupuncture meridians to send signals throughout the body. "That's what we're hoping to study next," she says.
Related

* Health Mailbox: Confronting People With Anger Issues
* Acupuncture Benefit Seen in Pregnancy
* Aches & Claims: Using Acupuncture to Ease Chronic Pain

Journal Community

* discuss

“ My former spouse had shingles. Doctors told her that the terrible pain would probably last 2 or 3 years. She got acupuncture treatments, plus some Chinese herbs, and the pain was totally gone with 6 weeks. ”

—Alan Agardi

Meanwhile, neuroimaging studies at the Martinos Center for Biomedical Imaging at Massachusetts General Hospital in Boston have shown that acupuncture affects a network of systems in the brain, including decreasing activity in the limbic system, the emotional part of the brain, and activating it in the parts of the brain that typically light up when the brain is at rest.

Other studies at the Martinos Center have shown that patients with carpal tunnel syndrome, a painful compression of nerves in the wrist, have heightened activity in parts of the brain that regulate sensation and fear, but after acupuncture, their brain patterns more closely resemble those of healthy subjects. Brain scans of patients with fibromyalgia show that both acupuncture and sham acupuncture (using real needles on random points in the body) cause the release of endorphins. But real acupuncture also increased the number of receptors for pain-reducing neurotransmitters, bringing patients even more relief.

The fact that many patients get some relief and register some brain changes from fake acupuncture has caused controversy in designing clinical trials. Some critics say that proves that what patients think of as benefit from acupuncture is mainly the placebo effect. Acupuncture proponents counter that placebos that too closely mimic the treatment experience may have a real benefit.

"I don't see any disconnect between how acupuncture works and how a placebo works," says radiologist Vitaly Napadow at the Martinos center. "The body knows how to heal itself. That's what a placebo does, too."

Write to Melinda Beck at HealthJournal@wsj.com
weblink: http://online.wsj.com/article/SB10001424052748704841304575137872667749264.html?KEYWORDS=acupuncture

Bedsores - A comprehensive review.

Gurvinder Singh Sandhu*, Gourishankar Patnaik**

Introduction: One of the most nagging and frustrating problems in long term patient care is decubitus ulcer or commonly referred as Bed Sores. The problem becomes more compounded in cases of Diabetes Mellitus where there are problems ranging from delayed tissue healing to various biochemical changes that virtually frustrates every attempt to treat these patients. Proper Nursing Care is what is stressed up on.

According to www.medterms.com , Bed sore is defined as a painful often reddened area of degenerating, ulcerated skin caused by pressure and lack of movement, and worsened by exposure to urine or other irritating substances on the skin. Untreated bed sores can become seriously infected or gangrenous. Bed sores are a major problem for patients who are confined to bed or a wheelchair. They can be prevented by moving the patient frequently, changing bedding, and keeping the skin clean and dry. Synonyms include pressure sore, decubitus sore, or decubitus ulcer.



In a study conduced by the Healthcare Cost and Utilization Project (HCUP-USA) titled Hospitalizations Related to Pressure Ulcers among Adults 18 Years and Older in the year 2006 it was found that there were a total of 503,300 hospitalization with pressure ulcers noted as a diagnosis which is an increase in 78.9% since 1993 when there were about 281,300 hospitalization due to the same. Adult hospital stays bearing a diagnosis of pressure sores totaled up in 11.0 billion US Dollars in hospital bills in the year 2006 alone. (2)

Amongst others “highlighted” in the published report were: (2)

• Of the total admission, more than 90% of patient (among adults) with pressure ulcer related hospitalization were actually intended for other medical conditions like septicemia, pneumonia, and urinary tract infection to name a few.
• In comparison to hospital stays due to other medical conditions, pressure ulcers patients were more often discharged to a long-term care facility and are more likely to result in death in coming years.
• Almost every three out of four adult patients hospitalized with a secondary pressure ulcer diagnosis 72% were 65 years and older. On the contrary, adult patients with a principal diagnosis of pressures ulcers 56.5% of them are 65 or older.
• Moreover, the younger adults that are hospitalized primarily due to pressure ulcers often go hand in hand with paralysis and spinal cord injury.





Risk-factors

There are numerous risk factors listed below in development of pressure sores. (3)

• Prolong immobility :
Paraplegia
Arthritis
Operation and postoperative states
Plaster casts
Intensive care
• Decrease sensation :
Coma
Neurological disease or deficits
Diabetes Mellitus
Drug Induced Sleep
• Vascular Disease :
Atherosclerosis
Diabetes Mellitus
Scleroderma
Vasculitis
• Poor Nutrition :
Anaemia
Hypoalbuminemia
Vitamin C or Zinc deficiency




As the saying goes prevention is better than cure, after years of study on the topic per-say, several risk assessment tools have been devised for the immobile patient based on the known risk factor such as the “Norton scale”, and “Waterlow Pressure Sore Risk Assessment” are 2 validated systems which produce a numerical sore I while enabling staff to identify those at most risk. The table below depicts “Norton Scale”.


In recent days “Brandon Scale” for predicting risk for pressure ulcers is being used by many health care set-ups. Brandon’s scale is divided into six risk categories: sensory perception, moisture, activity, mobility, nutrition, friction and shear. The best possible interpretation is a score of 23 whilst the worst is a 6. If the total score is below 11, the patient is at risk for developing bedsores.
The patho-physiology & staging
Bedsores are predisposed by 5 main factors: pressure, injury, anaemia, malnutrition and moisture. (6) There are 3 main etiology for pressure ulcers to develop are namely:
1. Compression between bony prominences and contact surfaces, as when a patient remains in a single decubitus position for a prolonged period of time which will lead to decreased tissue perfusion, ischemia occurs and resulting in tissue necrosis
2. Friction  rubbing against bed linen or patient’s gown.
3. Shearing forces. It’s the force that is created when skin of a patient stays in one place as the deep fascia and skeletal muscle slide down with gravity leading to pinching off of blood vessels which eventually ends up with tissue necrosis.
Infuriating the situation may be other conditions such as excess moisture from incontinence, perspiration or exudates where in elapse of time this excess moisture may deteriorate the bonds between epithelial cells resulting in the maceration of the epidermis.
At present there are two major theories about the development of pressure ulcers. The first and most accepted is the deep tissue injury theory which claims that the ulcers begin at the deepest level, around the bone, and move outward until they reach the epidermis. The second, less popular theory is the top-to-bottom model that says that skin first begins to deteriorate at the surface and then proceeds inward.
The results of all this will eventually lead to erosion, tissue ischemia, and finally infarction over the site. The most common sites where bed sores most frequently build up is over the sacrum, ischial tuberosities, trochanters, malleoli, and last but non the least the heels. It is not necessarily for the ulcers to only develop at these areas but they can develop elsewhere, including behind the ears when nasal cannulae are used for prolonged periods. Poorly fitting prosthetic devices are also grounds for pressure ulcers to develop over bony prominences. Increased force and duration of pressure directly influence risk and severity.
Pressure sores can as little as 3 to 4 hours to develope in some settings (for example trauma patients who are immobilized on rigid spine-immobilization boards) and these ulcers worsen when skin is overly moist and macerated (e.g., from perspiration or incontinence).
In February 2007 the National Pressure Ulcer Advisory Panel (NPUAP) added unstageable pressure ulcers on to the list of the already existing original 4 stages which are further described below.
Stage I: Intact skin, non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, and soft, with local temperature change as compared to adjacent tissue. It may be difficult to detect this stage in individuals with darker skin tones.
Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Patient in this stage may also present as an intact or open/ruptured serum-filled blister. Presentation is of a shiny / dry shallow ulcer without slough or with bruising which may very well be deep tissue injury. Conditions like skin tears, tape burns, perineal dermatitis, maceration or excoriation should not be mistaken and described in this stage.
Stage III: In this stage pressure ulcer varies by anatomical location. There is full thickness tissue loss with visible subcutaneous fat but bone, tendon or muscles are not exposed or palpable. Slough may be present but does not obscure the depth of tissue loss with possibility of undermining and tunneling. Areas that do not have subcutaneous tissue namely the nose-bridge, ear, occiput and malleolus shows shallow ulcer. On the contrary areas with significant adipose tissue can develop extremely deep stage III pressure ulcers.
Stage IV: In this stage there is full thickness tissue loss with exposed bone (visible and palpable), tendon or muscle with presence of slough over the wound bed with significant undermining and tunneling. Osteomyelitis may transpire in tandem of this stage as ulcers can extend into muscle and/or supporting structures namely fascia, tendon or joint capsule.
Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed if and until the debris are removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.



Prevention
One must bear in mind that bedsores are easier to thwart than to treat. A task is never easily achievable even if it’s the smallest of task need work, the same goes here although wounds can develop in spite of the most scrupulous care, it's possible to prevent them in many cases. First and foremost, the treating physician needs to devise a plan that is comprehendible and easy to follow by caregivers. The cornerstones of such a plan include position changes along with supportive devices, daily skin inspections and a maximally nutritious diet further explained below.
Position changes:  As mentioned before it takes a mere 2-3 hours for a sore to develop over immobilized area hence changing of posture has to be frequent (experts claims to shift position every 15 minutes) and consistent as it’s crucial to prevent bedsores. If one is wheelchair bounded he/she should reposition 2 hourly. When night falls a caregiver should be there to assist a bed ridden patient to change position. Some guidelines that are readily available by some physician on position change are as listed:
• Lie at a 30-degree angle so to avoid lying directly on hipbones..
• When in supine position a head size sleeping pillow should be kept from below knee onwards supporting calf and up to the heel.
• Try to avoid contact between knees and ankle using a foam pad or pillow..
• A higher incline head of the bed makes it more prone that one will slide down, where in there will be friction and shearing injuries.
• A pressure-reducing mattress / bed should be used as there are many options readily available in market stores including foam, air, gel or water mattresses.
• Pressure-release wheelchairs have recently been introduced in the market where in it functions to redistribute pressure hence making sitting for long periods easier and more comfortable. All wheelchairs need cushions in order to reduce pressure and provide maximum support and comfort.
Skin inspection  Skin should be inspected thoroughly at least once a day for pressure sores as its fundamental part of prevention. Inspect your skin thoroughly at least once a day, using a mirror if necessary. Special attention are to be paid to these areas hips, spine and lower back, shoulder blades, elbows and heels if a patient is bed ridden. When in a wheelchair, look especially for sores over the buttocks and tailbone, lower back, legs, heels and feet If an area of your skin is red or discolored but not broken, keep pressure off the sore, wash it gently with mild soap and water, dry thoroughly, and apply a protective wound dressing. If there is visible skin damage or any sign of infection such as drainage from a sore, a foul odor, and increased tenderness, redness and warmth in the surrounding skin, get medical help immediately.
Nutrition  Malnourished populaces are the ones highly predisposed to bed sores. It's crucial to get enough calories, protein, vitamins and minerals in preventing skin breakdown and in aiding wound healing. Markers of under nutrition include albumin < 3.5 mg/dL or weight < 80% of ideal. Protein intake of 1.25 to 1.5 g/kg/day is desirable for optimal healing. Zinc supplementation supports wound healing, and replacement at a dose of 50 mg thrice daily may be useful. Supplemental vitamin C 1 g/day may be provided. Providing a drink of water to patients at each repositioning may be useful to aid hydration.
Lifestyle changes including cessation of smoking as tobacco use damages skin and slows wound healing as on the other hand exercise improves circulation, helps builds up vital muscle tissue strengthen the body overall.

Treatment
The 1994 consensus guidelines provide a brilliant approach to the rational treatment of pressure ulcers. Listed below are the general summaries indicating steps necessary in management of this important issue.
Debridement of necrotic tissue can be done through a variety of potential techniques, which aids in healing of the wound. Several different debridement techniques are available.
• Sharp debridement is used in critical situations like cellulitis where in devitalized tissue are removed..
• Mechanical debridement where Hydrotherapy (whirlpool baths), ultrasound, medical maggots, wound irrigation, or dextranomers are to be used to remove thick exudates and loose necrotic tissue. Urgent debridement is indicated in advancing cellulitis or sepsis. Wounds with very loose exudates- debridement with wet-to-dry dressings can be done but only with utmost care as it is often painful and it may remove healthy tissue.
• Enzymatic debridement involves applying topical debriding agents to remove devitalized tissue using collagenase, papain, fibrinolysin, or streptokinase.
• Autolytic debridement requires the use of synthetic dressings that allow devitalized tissue to self-digest from enzymes present in wound fluids. DuoDERM or Contreet (which is impregnated with silver and thus offers antimicrobial effects) are commonly applied.
Wound cleansing using a 30 ml syringe and a 18 gauge angiocatheter will provide sufficient force to remove eschar, bacteria, and other debris from the wound site. Initially wound should be cleansed with normal saline and not using solutions that are cytotoxic in nature, such as povidone iodine, sodium hypochlorite solution and hydrogen peroxide, should be avoided to avoid further damage to tissue.
Treatment of Infected sites following the procurement of swabs from the area which are immediately sent for culture n sensitivity test. Conventionally first line therapy should cover gram-positive skin organisms, such as the use of a first-generation cephalosporin (e.g. Cephalexin 250-500 mg po qid). If the clinical picture is suggestive and/or swab results are confirmatory, consideration for antipseudomonal coverage should be made. Broader coverage should be emperically instituted in diabetic patients.
Dressing selection should be based on its ability to keep ulcer tissue moist and the surrounding intact skin, dry. Multiple types of dressings are available, and the choice should be based on clinical judgement. Objectives are to keep the ulcer bed moist to retain tissue growth factors while allowing some evaporation and inflow of oxygen, to keep surrounding skin dry, to facilitate autolytic debridement, and to establish a barrier to infection. Adjuvant therapy and /or operative repair are made on a case-by-case basis. Modes of operation include electrical stimulation, hyperbaric oxygen and laser irrigation. Electrical stimulation is only recommended for stage III and IV pressure ulcers. The table below tabulates the different options of dressing available for pressure ulcers.





Conclusion
Pressure ulcers are a preventable and treatable medical problem. Proper management of this problem can result in significantly improved quality of life and shorter hospital stays for elderly patients. When ulcers do develop, a multidisciplinary approach to treatment is recommended.

*Final year Medical student
**Professor of Orthopedics ,Melaka Manipal Medical College, Melaka

N.B.This article is a product of a project given to one of the final year medical student as an exercise to make medical students and future doctors aware of their responsibility to treat preventable conditions like bed sores.
It comprehensively deals with the types, pathophysiology and necessary treatment regimens of this condition which is an indicator of nursing standards in a given setting.

References
1. Bedsores definition. http://www.medterms.com/script/main/art.asp?articlekey=11035
2. Russo C.A., Steiner C., Spector W. Statistical Brief # 64 Healthcare Cost and Utilization Project “Hospitalizations Related to Pressure Ulcers among Adults 18 Years and Older, 2006.” http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.jsp
3. Kumar P., Clark M. Kumar & Clark Clinical Medicine Textbook 6th edition. Elsevier Saunders 2005
4. Russel R.C.G., William N.S., Bulstrode C.J.K. Bailey & Love Short Practice of Surgery 24th Edition. Hodder Arnold 2004.
5. Wolff K., Goldsmith L. A., Katz S.I., Gilchrest B.A., Paller A.S., Leffell D.J., Fitzpatrick's Dermatology in General Medicine, 7th edition McGraw-Hill Professional 2008.
6. Niezgoda JA, Mendez-Eastman S (2006). "The effective management of pressure ulcers". Adv Skin Wound Care 19 Suppl 1: 3–15. doi:10.1097/00129334-200601001-00001. PMID 16565615. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?an=00129334-200601001-00001
7. Support surfaces for pressure ulcer prevention by McInnes E, Cullum NA, Bell-Syer SEM, Dumville JC. http://www.cochrane.org/reviews/en/ab001735.html
8. Cervo FA, Cruz AC, Poscillico JA. Pressure ulcers: Analysis of guideline for treatment and management. Geriatrics. Mar 2000;55:55-60.
9. Pieper B. Mechanical Forces: Pressure, shear, and friction. In: Bryant RA. Acute and Chronic Wounds: Nursing Management, Second Edition. Mosby, Inc., 2000
10. Bergstrom N, Bennet MA, Carlson CE et al. Treatment of Pressure Ulcers. Clinical Practice Guideline, No 15. Rockville, MD. US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 95-0652. December, 1994.
11. Malone J.R., McInnes E. Pressure Ulcer Risk Assessment and Prevention. Royal College Of Nursing U.K. April 2001
12. Bedsores. Mayo Clinic. http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=symptoms
13. Encyclopedia for surgery. Bedsores. http://www.surgeryencyclopedia.com/A-Ce/Bedsores.html