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Guidelines for Scientific Writing

The art of scientific writing has guidelines that distinguish it from literary writing, documentation, or conversation, especially when preparing a journal article for publication.  Dr. Michael Schneir of the Ostrow School of Dentistry, University of Southern California, is a master of scientific writing and I was fortunate to spend over a year studying with him while preparing my first educational module. I still keep his 600+ page handbook on my desk whenever I write.  At the request of the Communications Committee, here are some of the guidelines that can help avoid the most frequent mistakes I find when editing papers.

Organization

A journal article is organized into the following headings: Abstract, Introduction, Materials and Methods, Results, Discussion, Conclusions or Summary, and References.  Each heading is recommended to have conceptual components with sub-headings that focus on a grouping of information, including a topic sentence and flow of information from general to specific (termed the deductive flow of information).  In producing the article, Dr. Schneir suggests doing the most objective components (e.g. tables, graphs, charts) first, followed by the narrative exposition (results), interpretation of the results (discussion), introduction to the results (introduction), and lastly, the abstract.  Because it is the second most frequently read part of the article (after the title), the abstract needs to be interesting and conceptual with the following components: background information, rationale, purpose, hypothesis, conclusion, and significance.  I remember one graduate school professor stating, “One can learn a lot from reading just the abstract.”  Make every word count!!!

Word Selection

When we had one-on-one sessions over something I had written, Dr. Schneir could spend an hour discussing the option of “a” or “the” before a noun.  For example, is it “a sample” or “the sample”?  “A” is indefinite and singular, whereas “the” is definite and can be either singular or plural and refers to a previously mentioned noun or concept.  Some other words that require careful consideration are which/that (I was often called the “which witch”!), about/concerning, among/between, thereby/thus/because, kind/type – and the list is endless!!

Another concern with word selection is to avoid using literary phrases or words, instead use medical or scientific terminology, e.g. Q-tip in medical terms is cotton-tipped applicator, bed sores are pressure injuries, nowadays is currently.  “Further” implies a distance, whereas “in addition” alerts the reader to another idea relevant to the topic.

The medical community has agreed that providers do not treat diagnoses, they treat patients who have disorders, e.g. patients with diabetes rather than diabetics. 

The use of personal pronouns in scientific writing is discouraged and can usually be avoided by changing the sentence from the active voice (using I, we, they) to the passive voice of the verb.  For example, “we saw the patient in our clinic one week later.”  The passive voice would be “the patient was seen in the clinic one week later.”  Thus, the article reads more scientifically and less like a personal journal.  In addition, words within a sentence are advised to agree in terms of numbers.  For example, after 10 treatment sessions, the patient was discharged to their homes with caretakers to provide daily dressing changes.  The patient has one home, and daily is once per day.  The sentence could be reworded this way: The patient was discharged home with a caretaker instructed to change the dressing daily.  These are very subtle innuendoes, but they become distractors to an experienced reader.

Sentence structure

Whenever possible, it is suggested to combine short, choppy sentences that have some common thread of thought into one sentence that expresses the entire conceptual idea.  For example, the following two sentences can be combined into one: The patient did not have any signs of wound infection.  The team decided not to prescribe any antibiotics for the patient. OR Because there were no signs of wound infection, antibiotics were not indicated.  This also save words and space in the article, and the reader has fewer words to process; therefore the intent is more easily grasped.

Prepositional phrases add unnecessary words to a sentence and can be avoided by transferring the objective of the preposition (a noun) before another noun, thus making it an adjective.  For example, “complications after a stroke” becomes “post-stroke complications.”

Any adjective, adverb, or descriptive phrase should be as close as possible to the noun or verb that is being modified.   And speaking of “should,” the writer does not want to sound authoritative; therefore, words such as advised, recommended, or suggested are similar alternatives that do not leave the reader feeling “preached to” by the author.

Punctuation

The most common mistake observed in punctuation is the use of a colon after “following.”  Colons are not to be used between the verb and its direct objects, but rather after “the following:” and a subsequent list of items.  For example:  Possible causes of lower extremity edema include the following: trauma, chronic venous insufficiency, medications, and congestive heart failure. 

Semicolons are used 1) to separate two independent clauses of a compound sentence, 2) to separate compound elements of a sentence when one or more of the elements contains a comma, and 3) when the elements of a sentence are long. 

Summary

In closing, I will break all of the above rules and share with you a non-scientific pearl of wisdom about writing.  Before ever putting pencil to paper or fingers to keyboard, I close my eyes and dig deep into my soul and ask, what do I really want to tell the reader?  This helps me to organize my thoughts, focus my concepts, and eliminate extraneous information. 

Any of you reading this blog have a story to tell (either a patient case, a clinical dilemma and solution, a pilot study, or organized research) that will help all of us become better clinicians for patients with wounds.  I hope this is helpful, but know that it only scratches the surface of what Dr. Schneir would tell you!!!

The Pressure Is On: Pressure Injury Basics

Pressure Injuries are skin and/or tissue damage which occurs a result of pressure and shear forces which usually occurs over a bony prominence, for example the occiput, cheek bones, chin, shoulders, scapula, spinous process, greater trochanter, sacrum, coccyx, ischium, knee, ankle, and heel. Persons who develop pressure injuries may be chair/bedbound and/or may have some sensory deficit which may not alert the patient about the need to shift positions. Some persons are more at risk to develop a pressure injury due a medical diagnosis, such as a stroke, low or high body mass index, contractures, or a decrease in nutritional intake. By reviewing some of the basics of a pressure injury, formerly known as a pressure ulcer, one may be able to better assess those patients at risk for these skin concerns.

Contrary to popular belief, every incidence of skin breakdown is not a pressure injury. Skin tears present a challenge due to the severity that may be mistaken for a pressure injury. The International Skin Tear Advisory Panel (ISTAP) has established a separate classification for skin tears which notes skin tears as Type 1, Type 2, and Type 3. A Type I skin tears is a tear which has a skin flap which could be replaced to cover the wound.  A Type 2 skin tear has a small skin flap, but the flap does not cover the entire wound.  Type 3 skin tears do not have a skin flap, which causes the entire wound to be visible. Another cause of skin breakdown may be moisture associated skin damage (MASD), which is caused by an overexposure of moisture to the skin and there allows for forces such as friction and shear to increase the risk of pressure injury.  The moisture may be due to urinary or fecal incontinence, wound drainage, fistula output, or perspiration. Over exposure to urinary or fecal incontinence is known as Incontinence Associated Dermatitis or IAD.   Inflammation and skin breakdown related to IAD may be misidentified as a pressure injury wound.

There are unique circumstances when a clinician may question if the wound is related to pressure or another factor. Some examples are:

  1. An immobile person may develop an area of skin breakdown due to moisture associated dermatitis coupled with the evidence of pressure injury to the bony prominence. In such an instance, the bony prominence in question may be palpated to further determine if pressure may be included as a causative factor.
  2. An ambulatory patient has a diagnosis of Diabetes Mellitus and has a full thickness wound to the plantar surface of the foot.  This wound would be considered a diabetic foot wound or a neuropathic wound. Diabetic neuropathy or a decrease in sensation to the foot is the real culprit in this case, in addition to repeated mechanical forces on bony abnormalities.
  3. A paraplegic patient with a diagnosis of Diabetes Mellitus now has full thickness loss to the right heel. Would the wound be considered a neuropathic wound or a pressure injury? In this case, the cause of the wound to the heel would be likely due to pressure.

Another issue which can challenge a clinician is accurately staging a pressure injury.  Only pressure injuries are staged. One would not stage an arterial wound or a surgical wound. Terms such as a partial thickness or full thickness tissue loss are used in the description of these wounds, but they would not be given a stage. Once a pressure injury is identified as a certain stage, the injury is not “back staged”. For example:

From the onset, the wound is noted to be a stage 3 pressure injury.  As the wound begins to heal, it will be noted as a stage 3 pressure injury in the proliferative or remodeling phase of healing. The wound will not progress from a stage 3, then to a stage 2 or to a stage 1 pressure injury.

Pressure Injuries Stages at a Glance:

Stage 1: Intact skin over a bony prominence with erythema that does not blanch to the touch.  Key word is INTACT. In some individuals, this site resembles a sunburn.  In darker skin persons, the site in question may not have evidence of erythema. The patient may not have an increase in pain to the site. However, the clinician may notice a difference in temperature, texture, or hardness to the area of concern and the surrounding skin when palpated.

Stage 2: Partial thickness loss usually over a bony prominence. The tissue loss extends to the dermis, but no subcutaneous tissue is observed. Blisters that contain serous or clear fluid are also defined as Stage 2. 

Stage 3: Full thickness tissue loss usually over a bony prominence. The tissue loss extends to the subcutaneous tissue. Slough, tunneling, or undermining may be noted, but no tendon, bone, or muscle is noted.

Stage 4: Full thickness tissue loss over a bony prominence with visible tendon, bone, or muscle. If cartilage is visible to areas such as the nose or ear, the wound is considered a Stage 4 pressure injury.

Unstageable pressure injuries are mostly covered by slough or eschar. The amount of tissue loss is unknown because the depth of the wound is unseen.

Device related pressure injuries are injuries caused by a medical device, such as a nasal cannula or ill-fitting thromboembolic hose.

If a wound is noted in the mouth or mucous membranes, list this wound as a mucosal injury, but do not stage this injury as a pressure wound.

In a wound with Deep Tissue Pressure Injury (DTPI), the skin is intact or there may be an intact blister that appears maroon or purple due to the deep tissue bleeding that has occurred due to the capillary disruption in the deep tissue. These wounds may evolve into a full thickness wound and become a Stage 3 or Stage 4 pressure injury.

Now that pressure injuries have been identified, as well as a few other skin concerns, the goal is to identify those patients at risk, as well as endeavor to prevent and manage these life changing skin issues for the patient! 

 

References:

Beeckman D, Campbell J, Campbell K et al. (2015).  Incontinence associated dermatitis: moving prevention forward. Proceedings of the Global IAD Expert Panel. Wounds International. https://tinyurl.com/ycmyfv2d.

FISHER, P., & HIMAN, C. (2020). Moisture-associated skin damage: a skin issue more prevalent than pressure ulcers. Wounds UK16(1), 58–63.

Gray, M. , Black, J. M. , Baharestani, M. M. , Bliss, D. Z. , Colwell, J. C. , Goldberg, M. , Kennedy-Evans, K. L. , Logan, S. & Ratliff, C. R. (2011). Moisture-Associated Skin Damage. Journal of Wound, Ostomy and Continence Nursing, 38(3), 233–241.  doi:10.1097/WON.0b013e318215f798.

International Skin Tear Advisory Panel (ISTAP) (n.d.). ISTAP skin tear classification. Retrieved March 15, 2021 from http://www.skintears.org/education/tools/istap-skin-tear-classification/

LeBlanc, K., Alam, T., Langemo, D., Baranoski, S., Campbell, K., & Woo, K. (2016). Clinical challenges of differentiating skin tears from pressure ulcers. EWMA Journal16(1), 17–23. 

National Pressure Injury Advisory Panel (NPIAP) (n.d.). Pressure injury stages. Retrieved March 15, 2021 from https://npiap.com/page/PressureInjuryStages

National Pressure Injury Advisory Panel (NPIAP) (2017). National Pressure Ulcer Position Statement on Staging-2017 Clarifications. Retrieved March 16, 2021 from https://cdn.ymaws.com/npiap.com/resource/resmgr/npuap-position-statement-on-.pdf

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How Does a Whole-Food Plant-Based (WFPB) Diet Work in Wound Care? Seven WFPB nutrition tips to remember in wound care.

Today, we will discuss seven WFPB nutrition tips that apply to wound care and the role of the wound care physician/practitioner in caring for a patient with a disease that can be complicated by poor diet and lifestyle habits. While reading today, take the time to reflect on what obligations we have toward those who are at risk but have not sought our help. Any wound care practice must be evidence-based. Just as prescribing services must be founded on solid evidence, the same is true for dietary advice.  Was there a sincere evaluation of the patient's nutrition status? What should be done next with this information? Should time be spent reviewing articles to place in your personal armamentarium?  Primary care physicians do not perform general surgeries or run  urinalysis; neither do they need to do their own diet counseling. That is the job of a qualified dietitian/nutritionist. The wound care practitioner simply needs to know that nutrition is important, wound healing nutritional deficiencies need correction, and clear communication with the patient is imperative, while providing a solid referral to other interdisciplinary professionals.

TIP #1: The building evidence of a healthy diet
What type of diet is recommended for a patient with a wound?
With accumulative scientific evidence supporting a healthy diet, whole-food plant-based (WFPB) diets are steadily on the rise. A WFPB diet consists of vegetables, fruits, legumes, whole grains, nuts, seeds, herbs, and spices. The United States Department of Agriculture, American Heart Association, American Institute for Cancer Research, National Kidney Foundation, and American Diabetes Association all promote WFPB diets, and it doesn't have to be an all or nothing.  Evidence-based studies show a positive correlation between WFPB diet compliance and overall well-being.

TIP #2: WFPB benefits
Why are WFPB diets becoming more popular? 
Aside from improved healing with proper nutrition, what benefits are there to my patient? WFPB diets are associated with:

  1. Lowering overall mortality
  2. Lowering ischemic heart disease mortality
  3. Supporting a healthy weight
  4. Reducing medications
  5. Reducing obesity
  6. Reducing obesity-related inflammatory markers
  7. Reducing hyperglycemia
  8. Reducing hyperlipidemia
  9. Reducing hypertension
  10. Reversing advanced cardiovascular disease
  11. Reversing Type 2 Diabetes.

TIP #3: Protein
Can the protein needs of wound and geriatric patients be met with WFPB diets? 
Absolutely! The primary food sources for proteins are legumes (beans, lentils, peas, peanuts), nuts, seeds, and soy foods. Poor appetite and poor dentition are complications with geriatric wound care patients, making meat alternatives, such as smoothies, cooked cereals, lentil or bean-rich soups, and spreadable hummus nutritionally dense additions to their diets. Nevertheless, one must remember to temper the increased desire for a high protein wound care diet and the need to satisfy a low protein diet in chronic kidney disease patients, especially CKD Stage II and Stage III. This is similar to the scenario of a patient with severe lymphedema, aggressive congestive heart failure, or pulmonary edema.

**Brenner BM. Remission of renal disease: recounting the challenge, acquiring the goal. J Clin Invest. 2002;110(12):1753-1758. doi:10.1172/JCI17351

TIP #4: Vitamin B12
Will you have to supplement vitamin B12? 
Yes! Numerous research studies demonstrate vitamin B12 supplementation in metformin-treated type 2 diabetes patients is beneficial in order to prevent the occurrence of vitamin B12 deficiency complications.  Deficiency in the elderly population is high due to inadequate intake and malabsorption. Treatments are safe and effective for adults over 60 years, regardless of their diet. Vitamin D should also be supplemented if sun exposure is not a viable option for patients.

**Goraya N, Munoz-Maldonado Y, Simoni J, Wesson DE. Fruit and Vegetable Treatment of Chronic Kidney Disease-Related Metabolic Acidosis Reduces Cardiovascular Risk Better than Sodium Bicarbonate. Am J Nephrol. 2019;49(6):438-448. doi:10.1159/000500042


TIP #5: Nutritional Drinks
Are commercial products the only option for complete nutrition, muscle loss prevention, and wound care healing? No. Therapeutic nutrition drinks and powders have been shown to support wound healing clinically. However, eating a balanced diet high in fiber and low in animal proteins has shown to support wound healing.  For example, pumpkin seeds have one of the highest concentrations of arginine. Other foods are sesame & sunflower seeds, and tree nuts, which all have high omega-3 fatty acids. Another supplement frequently added to nutritional drinks is beta-hydroxy-beta-methyl butyrate (HMB). But is it necessary?  HMB on exercise performance and body composition did not make a difference when comparing whey, soy, or leucine-enriched soy protein. HMB helps with slowing age-related muscle loss (sarcopenia). How do you balance supplements versus instructing patients to eat healthier with a soy product?

**Wilson GJ, Wilson JM, Manninen AH. Effects of beta-hydroxy-beta-methylbutyrate (HMB) on exercise performance and body composition across varying levels of age, sex, and training experience: A review. Nutr Metab (Lond). 2008;5:1. Published 2008 Jan 3. doi:10.1186/1743-7075-5-1


TIP #6: What about fats? 
A high-fatty diet and alcohol consumption delay the healing process by decreasing stimulation of collagen synthesis and reduction of granulation tissue and reepithelialization. Diabesity is the worldwide twin epidemics of obesity and diabetes. The American Heart Association recommends limiting saturated fats to less than 14 grams in a 2000 calorie daily diet. By the way, trans fats have been banned in the United States since 2018, with an extended compliance date for these foods until January 1, 2020. 

Monounsaturated fat (MUFAs) and polyunsaturated fats (PUFAs) are associated with lowering blood pressure, improving blood cholesterol levels, and decreasing the risk of heart attack and stroke.  Omega-6 PUFAs have a particular role in the structural integrity and barrier function of the skin. Omega-3 PUFAs give aid in signaling molecules that influence the inflammatory response in the skin, while MUFAs aid in angiogenesis and aid in the regulation of insulin levels and blood sugar control. 

Eating a colorful variety of WFPB foods promotes a large variety of micronutrient exposure, antioxidants, and other cellular regulatory properties such as vitamin C, calcium, iron, vitamin K, selenium, zinc, and healthy MUFAs & PUFAs. Nothing new here.  


TIP #7: Got a fiber gap?
Currently, only 5% of the United States population meets the daily target of 25 grams of fiber for women and 38 grams of fiber for men. The benefits of prescribing a high fiber diet are correlated with a reduction in comorbidities for patients with wounds. However, how does a high fiber diet help wound care patients? Well, gut bacteria of vegans produce neuroactive molecules like gamma-aminobutyric acid (GABA) which in turnreduces the stress response in humans, along with decreasing cortisol levels. GABA also counters high glucocorticoid levels, which impair wound healing. Overall, WFPB high fiber diets modulate GABA, which regulates blood pressure and heart rate, influences GI motility, and plays a role in anxiety, depression, pain sensation, and immune response.  Emotionally happy wound patients with reduced stress heal faster. 

**Briguglio M, Dell'Osso B, Panzica G, et al. Dietary Neurotransmitters: A Narrative Review on Current Knowledge. Nutrients. 2018;10(5):591. Published 2018 May 10. doi:10.3390/nu10050591

**Ebrecht M, Hextall J, Kirtley LG, Taylor A, Dyson M, Weinman J. Perceived stress and cortisol levels predict speed of wound healing in healthy male adults. Psychoneuroendocrinology. 2004;29(6):798-809. doi:10.1016/S0306-4530(03)00144-6


Finally, the wrap-up,  I hope this stimulates your view into the world of nutrition, WFPB, and patient care. Jump into your research and become a student in the adventure toward better patient care. None of the information is new, but the POV might be. History has taught us that Occam's razor or law of parsimony states, "plurality should not be posited without necessity" --  translation -- The state of fact should not be assumed as a fact.

It's all about the simplicity of two competing theories; the simpler explanation of an entity is to be preferred. 

Unhealthful eating habits affect the whole family. Medications are no substitute for dietary interventions.

 
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