Wound healing and hyper-hydration - a counter intuitive model

Winters seminal work in the 1960s relating to providing an optimal level of moisture to aid wound healing (granulation and re-epithelialisation) has been the single most effective advance in wound care over many decades. As such the development of advanced wound dressings that manage the fluidic wound environment have provided significant benefits in terms of healing to both patient and clinician. Although moist wound healing provides the guiding management principle confusion may arise between what is deemed to be an adequate level of tissue hydration and the risk of developing maceration. In addition, the counter-intuitive model ‘hyper-hydration’ of tissue appears to frustrate the moist wound healing approach and advocate a course of intervention whereby tissue is hydrated beyond what is a normally acceptable therapeutic level. This paper discusses tissue hydration, the cause and effect of maceration and distinguishes these from hyper-hydration of tissue. The rationale is to provide the clinician with a knowledge base that allows optimisation of treatment and outcomes and explains the reasoning behind wound healing using hyper-hydration

Retrospective study on the comparison of out-of-hospital and in-hospital sudden cardiovascular death: An italian experience

A retrospective study of forensic autopsies was carried out in the time interval January 2007 to December 2012 at the Forensic Pathology Service, Catania, south Italy, with a reference population of 3 000 000 inhabitants. During the study period, 1346 forensic autopsies were performed, including 223 (16.57%) sudden/unexpected deaths. Among the latter, 116 fulfilled the criteria of out-of-hospital (Group A) and 107 were in-hospital (Group B) sudden/unexpected deaths with suspected medical malpractice and/or a professional liability claim. In Group A, coronary artery disease was the most common cause of death (N=67; 57.65 %), followed by cardiomyopathies (N=19, 16.38%) and myocarditis (N= 6; 17%). In Group B, coronary artery disease (N=32, 29.91%), post-procedural or post-surgical complications (N=30, 28.04%), pulmonary thromboembolism (N= 17; 15.89%) and aortic dissection (N=7, 6.54%) were the main causes of death

Adverse mucocutaneous reactions to chemotherapeutic agents: part I

O tratamento local e sistêmico das neoplasias pode causar alterações na pele, membranas mucosas, cabelos e unhas. O diagnóstico preciso e o tratamento adequado destes efeitos colaterais requerem conhecimento dos padrões das reações adversas mais comuns para as medicações que o paciente está utilizando. O dermatologista deve estar familiarizado com as manifestações tegumentares das neoplasias, bem como com os efeitos adversos mucocutâneos dos tratamentos antineoplásicos.The local and systemic treatment of tumors can cause changes in the skin, mucous membranes, hair and nails. Accurate diagnosis and appropriate treatment of side effects require knowledge about the patterns of the most common adverse reactions to drugs the patient may be using. The dermatologist must be familiar with the manifestations of certain soft tissue neoplasms, as well as with the adverse mucocutaneous forms of cancer treatment

Megalencephaly due to impaired cerebral venous return in a Sturge-Weber variant syndrome.

An infant with a Sturge-Weber variant syndrome developed progressive megalencephaly and eventual hydrocephalus, which required shunting. Cerebral angiography revealed absence of the deep cerebral venous system and the development of abnormal drainage channels via the periorbital veins. It is postulated that the abnormal enlargement of the brain was due to the impaired venous return. Resistance of the brain to continued expansion may have caused an increase in hydrostatic pressure and the development of hydrocephalus

Lesions associated with calcium gluconate extravasation: presentation of 5 clinical cases and analysis of cases published

Review[Abstract] Introduction: Calcium gluconate extravasation is a process, which, while not common, occurs more frequently in neonatal intensive care units. The aim of this study is to present a number of cases of calcium gluconate extravasation, which have occurred in our hospital, and to carry out a review of those clinical cases published in the literature to obtain relevant epidemiological data. Methods: Data were gathered on the medical histories of 5 patients who presented lesions secondary to calcium gluconate extravasation in our center. A review of the literature was also performed to include clinical cases of calcium gluconate extravasation already published. Results: Data were collected on 60 cases published in 37 articles. Most patients (55%) were neonates. The average age of these neonates was 8 days. The commonest location of injuries was the back of the hand and wrist (42%). The 2 most frequent symptoms were the appearance of erythema (65%) and swelling/edema (48%) followed by the appearance of skin necrosis (47%), indurated skin (33%), and yellow-white plaques or papules (33%). Most cases are cured within a period of 3 to 6 months. Fifty percent of patients required surgery, and in 13% of cases, skin grafts were performed. The most frequent histological finding was the presence of calcium deposits. Other histological findings described were the presence of necrosis, lymphohistiocytic infíltrate, and granulomas. Most histological findings were located in the dermis. Most x-rays showing calcium deposits had been performed at 3 to 4 weeks. Conclusions: Calcium gluconate extravasation is a process, which, although infrequent, is associated with serious skin and soft-tissue lesions, mainly affecting infants. Further studies are needed to determine possible specific procedures to be carried out in these cases

Fish Skin Graft: Narrative Review and First Application for Abdominal Wall Dehiscence in Children

Summary: Acellular fish skin grafts (FSGs) are tissue-based products created by minimally processing the skin of the Atlantic cod (Gadus morhua). The FSG is rich in omega-3 and facilitates tissue regeneration by supporting revascularization and ingrowth in the proliferation and remodeling phases of wound healing. FSG is structurally more similar to human skin than antiviral-processed skin substitutes such as amniotic membrane, and there are no known prion, bacterial, or viral diseases that can be transmitted from North-Atlantic cod to humans. The FSG is processed using a proprietary method that preserves the structure and lipid composition of the skin. FSG is CE marked, and US Food and Drug Administration cleared for multiple clinical applications in partial and full-thickness wounds. FSG is currently the only acellular dermal matrix product that does not originate from mammalian tissues. For this narrative review, Medline and UpToDate were used to include a total of 21 articles published from 2015 to 2022 about fish skin graft use. We also reported a case of a 7-year-old boy who underwent treatment with FSG for abdominal wall dehiscence at our department of pediatric surgery, IRCCS Sant’Orsola- Malpighi, Alma Mater Studiorum, University of Bologna, University Hospital of Bologna. FSG provides a valuable and sustainable treatment that improves wound healing in both adult and pediatric populations. We described the first application of an FSG for wound dehiscence of the abdominal wall in a pediatric patient, reporting how FSG was completely reabsorbed and improved the skin’s repai

Development of a Murine Model for the Exploration of the Biological Effects of External Volume Expansion. Sviluppo di un modello murino per l'esplorazione degli effetti biologici dell'espansione volumetrica esterna

Background: External Volume Expansion (EVE) refers to a class of devices that non-invasively stretch and expand tissue compartments by external application of suction. EVE has been suggested to increase compartments volume and stimulate the formation of a more developed vascular network, leading to less stiff and better vascularized tissues. It is proposed to patients as a method to prepare recipient sites, in particular breasts, in view of a fat grafting procedure, basing on the theory that fat grafts will better survive and retain volume if the recipient site is more vascularized and provides less compression. However, the method requires high patient compliance and no experimental validation for it has been attempted. Aims: basing on our group's previous experience in downsizing and testing in animal models clinical devices for wound healing, in particular in settings requiring the application of mechanical forces to soft tissues, we proposed to design an animal model for EVE in which to test the validity of the hypothesis of its being beneficial to fat grafting and explore its mechanisms and potentials. Methods: we designed and built a miniaturized EVE device to be applied to the dorsum of mice. We then designed a series of stepwise incremental studies. We tested the capacity of EVE of inducing angiogenesis and cell proliferation with 28 days long continuous stimulation. We analyzed its effects on tissues in terms of mechanical stretch, hypoxia and ischemia, edema, inflammation, cell proliferation and angiogenesis after a single 2 hours stimulation. We produced a mathematical modeling for the effects of EVE on tissues in relation to fat grafting. We tested if EVE is beneficial to fat grafting and if beneficial effects are maintained also in the setting of chronic radiation damage. We tested if EVE can stimulate adipogenesis and what role inflammation can play in it. Results: in our series of studies, we successfully designed a miniaturized animal model in which to test External Volume Expansion. We demonstrated that the hypotheses of stimulation of cell proliferation, angiogenesis, and expansion of tissue compartments on which it is proposed as a preparatory method to fat grafting is confirmed in experimental settings. We showed how mechanical stretch of tissues, hypoxia and ischemia, edema, and inflammation are all intervening factors that can contribute to these effects. Our results suggest that pre-stimulation with EVE is successful in achieving increased fat graft weight and volume retention, and that its beneficial effects are maintained also in the setting of recipient sites having sustained radiation injury. We also demonstrated that EVE has a potential for direct stimulation of adipogenesis, and gathered supportive results to a role for macrophages in this. Discussion: our results validate the technique for its use in the preparatory phase to fat grafting, and can help moving towards making fat grafting a more effective and reliable procedure with improved outcomes for patients. We gathered evidence that help increasing our understanding of how EVE works and what it implies for tissues. This is the basis for optimizing the technique, make it safer, and increase patients' compliance. For example, stimulation patterns can be improved, duration of treatment can be reduced, and practices such as continuation of EVE after fat grafting should be abandoned as detrimental. Our unexpected observations on adipogenesis also open interesting opportunities, such as that of re-starting EVE after fat grafting when this is at the peak of its remodeling phase. And linking this effect with the understanding of the similarity to other conditions in which adipogenesis is seen and desired, such as tissue engineering, or pathological, such as lymphedema, can expand the potential of our animal model to alternative broader fields