Does the paucity of elastic fibres contribute to the process of keloidogenesis?

Introduction: Keloids are a prototype of excessive wound healing. Keloid fibroblasts generate traction force, which deforms and realigns the collagen network during migration. Cells move bidirectionally along aligned fibres resulting in nonuniform cell distribution. This and the anisotropic collagen properties displayed in keloids, may be governed by traction force. Excessive traction force (>elastic limit), causes permanent deformations. As recovery from deformational forces is attained mainly by elastic recoil, we hypothesised that in keloids the elastic limit is decreased by reduced numbers of dermal elastic fibres, leading to permanent plastic deformation of dermal tissue by traction force. Objective: To quantitate and compare the elastic fibre content of keloids and non-lesional skin Methods: Sections of keloids and non-lesional skin from 32 patients were stained with elastic Van Gieson. The elastic fibre content was histomorphometrically quantified and the mean (± SEM) percentage area of elastic fibres in lesional and non-lesional skin was compared. Results: Elastic fibres at the border of keloids were increased whereas internally they were minimal or absent. Statistical analysis (Wilcoxon signed ranks test) showed significant differences (p < 0.05) in elastic fibre content between non-lesional dermis and keloids. Conclusions: The lack of elastic fibres in keloids decreases the elastic limit, leading to effects of excessive deformational force. These include compression and stiffening of tissue, increased mitogenesis and cell contractility, modified DNA and protein synthesis and increased collagen biosynthesis. The manifestation of these effects in keloids, supports the hypothesis that decreased elasticity in keloids promotes permanent dermal deformation by traction forces. Keywords: Elastic fibres; wound healing fibroblasts; deformation forces; histomorphometric analysis.Running title: Comparative histomorphometric analysis of elastic fibres in lesional and non-lesional skin of patients with keloid

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

South African burn society burn stabilisation protocol

ArticleThe original publication is available at http://www.samj.org.zaENGLISH SUMMARY : No abstract available.Publisher’s versio

South African Burn Society burn stabilisation protocol

Minimal criteria for transfer to a burn centre (Modified from the Australian and New Zealand Burn Association (ANZBA) protocol) Burn injury patients who should be referred to a burn unit include the following: • All burn patients less than 1 year of age • All burn patients from 1 - 2 years of age with burns > 5% total body surface area (TBSA) • Patients in any age group with third-degree burns of any size • Patients older than 2 years with partial-thickness burns greater than 10% TBSA • Patients with burns of special areas – face, hands, feet, genitalia, perineum or major joints • Patients with electrical burns, including lightning burns • Chemical burn patients • Patients with inhalation injury resulting from fire or scald burns • Patients with circumferential burns of the limbs or chest • Burn injury patients with pre-existing medical disorders that could complicate management, prolong recovery or affect mortality • Any patient with burns and concomitant trauma • Paediatric burn cases where child abuse is suspected • Burn patients with treatment requirements exceeding the capabilities of the referring centre • Septic burn wound cases

An international consensus for medical leadership on alcohol

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