I have a colostomy, about 1" opening, and for 8 years I had no problem with my pouches. Then for 3 or 4 months I can't seem to have a bag on for more than a day, and there is leakage. What is deep convexity and should I have different kind of pouches that have a deep convexity? Would that help? Thank you.
A Cross-sectional Validation Study of Using NERDS and STONEES to Assess Bacterial Burden
- 7/31/2009
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48 In a clinical trial, Armstrong et al46 reported a temperature difference of 2.81o F ± 5.75o F between diabetic foot ulcers of the infected limb and the corresponding site on the contralateral foot. In the present study, wounds with an elevated temperature using infrared thermometry were eight times more likely to be diagnosed with deep infection.
Using probing-to-bone tests in diabetic foot ulcer patients, Grayson et al47 demonstrated a sensitivity of 66% and a specificity of 86% for osteomyelitis confirmed by bone biopsies (n = 50). In a similar clinical trial, Lavery et al48 confirmed the probing-to-bone test was sensitive (0.87) and specific (0.91). In a recent review, Butalia et al49 concluded osteomyelitis was six times more likely to occur when diabetic ulcers were probed to bone. Considering all types of chronic wounds, the probing to bone test has a sensitivity and specificity of 40% and 81%, respectively, for wound infection in this analysis. Results were similar to findings reported in the literature.
Previous studies indicated that local erythema was difficult to detect: Greenwald et al,23 in a study of 115 chronic wounds, reported a kappa of 0.48, indicating poor inter-rater agreement. Lorentzen and Gottrup28 recruited six wound care specialists to assess 120 nonhealing wounds and documented that the sensitivity ranged from .34 to .91. In the original conceptualization (STONES), the three E’s — edema, erythema, and exudate — were combined together as one indicator. The current analysis suggests that exudate alone was a significant (odds ratio 4.13, CI = 1.72 to 9.91) indicator of increased bacterial count. However, edema and erythema individually were insignificant predictors of bacterial damage but in combination the odds ratio was 4.88 (CI = 1.79 to 13.27); associated sensitivity and specificity were 87% and 44%. Erythema and edema were also indicators of periwound inflammation (eg, from physical trauma, chemical irritation, and skin stripping) that may have affected their individual values as indicators for wound infection.
The findings indicate that some signs may be more valid than others for the evaluation of bacterial damage in chronic wounds. However, no one sign can be considered the most definitive or accurate. To determine how a combination of signs may help evaluate bacterial burden in wounds, sensitivity and specificity were calculated for wounds that exhibited any of the two, three, or four signs (see Table 4). Results suggest that the use of any three signs provides a valid and practical approach to determine the presence and level of bacterial damage.
Limitations
Although infection can trigger an inflammatory response in patients with chronic wounds, the proposed signs of infection also may be observed in other inflammatory conditions such as recurrent trauma, deep structure injury, vasculitis, or pyoderma gangrenosum.50 The potential confounding effect of these inflammatory conditions on the results of this study cannot be excluded. Additional patient factors such as impaired circulation, medications, and other comorbidities that may affect healing, local temperature, exudate production and bacterial contamination were not controlled in this study. In addition, both clinicians conducting the assessments were experts and familiar with the mnemonic. Content validity and reliability studies using other expert or nonexpert clinicians have not been conducted. Finally, because patients were assessed only once, neither the predictive value of the observed bacterial counts nor that of the assessment variables can be ascertained.
Conclusion
The diagnosis of infection should be made clinically.
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RE: NERDS & STONEES:
I would suggest an additional criteria in deciding whether systemic therapy is indicated: 'FARTT' (Failure to Adequately Respond to Topical Therapy)
Julie A. Anderson, M.D.
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