Eventual Healing Research Articles

Time-sequence histologic imaging of laser-treated cherry angiomas with in vivo confocal microscopy

Objective: To chronicle the pathophysiologic changes that occur subsequent to laser treatment of vascular lesions, we used a confocal scanning laser microscope that yields high-resolution microscopic images of skin in vivo. Methods: Cherry angiomas were treated with the 585-nm flashlamp-pumped pulsed-dye laser (PDL) and the 568-nm continuous-wave krypton laser. Repeated confocal reflectance imaging was performed before and immediately after treatment, as well as after several hours, 1 day, 2 days, 1 week, 2 weeks, 3 weeks, and 4 weeks. Results: Before treatment, confocal images revealed dilated blood vessels ranging from 10 to 50 μm in caliber, closely spaced at 5 to 50 μm apart. After PDL treatment, amorphous cords of refractile material conformed to the shape of the original vessels, followed by dark nonrefractile spaces where the vessels once were. Inflammation and necrosis ensued, with eventual replacement after 3 weeks by normal-appearing skin. After krypton laser treatment, dark nonrefractile spaces appeared immediately, with subsequent inflammation, necrosis, and eventual healing by 4 weeks. Conclusion: Confocal laser microscopic imaging elucidates the dynamic pathophysiologic events that occur after laser treatment of vascular lesions and has added insight into the different mechanisms of vessel damage induced by the PDL and krypton laser. (J Am Acad Dermatol 2000;43:37-41.)

The concept of organizing pneumonia.

At the beginning of the 19th century, Laennec described the sequential gross pathological stages of acute lobar pneumonia, which was later related to pneumococcal infection [27]. The first stage is congestion, in which the involved lobe is heavy and congested. During the next stage, called red hepatization, the lobe becomes red and dense, much like the liver. After a stage of gray and airless lung (grey hepatization), resolution of pneumonia usually occurs with eventual complete healing.

Widespread cutaneous necrosis associated with antiphospholipid syndrome

Widespread cutaneous necrosis as the catastrophic manifestation in antiphospholipid syndrome (APLS) is rather uncommon. Even in the few documented cases, the extensive skin necrosis lesions have been stabilized and regressed with eventual healing utilizing pulse steroid therapy alone or in conjunction with further treatment with plasmapheresis. We describe one case of APLS associated with lupus-like disease. The young female suffered from widespread cutaneous necrosis of the lower legs and gangrene change in the digital end of hands and feet. This condition necessitated amputation of major lower extremities and digital amputation of both hands.

The fate of the osteotomized free radial forearm osteocutaneous flap in mandible reconstruction.

The radial forearm osteocutaneous free flap has become a standard method of mandible reconstruction. In order to improve the contour of the reconstructed jaw in large resections, especially the anterior defect, the radial forearm bone graft needs to be osteotomized. The bone graft is nourished by small branches of the radial artery via the fascial connections between the skin flap and bone. The effect of the osteotomy, fixation devices, and the angulation of the bone segment on bone viability and eventual bone healing is not known. Forty-two radial forearm osteocutaneous flaps were used for composite mandible reconstruction. In 25 patients, the bone graft required osteotomy to achieve contour, of which 16 required single osteotomy and nine required double osteotomy. In a remaining 17 cases, no osteotomy was performed. Only those patients who had at least a 1-year follow-up were included in this study. The proportion of patients who achieved bone union was similar for both groups (i.e. osteotomy vs. nonosteotomy). Performing osteotomies on the segment of the radius in free osteocutaneous transfers is safe, and it allows for more flexibility in reconstruction, to achieve a natural-appearing jaw.

Treatment of the mucosa with local anaesthetics in ulcerative colitis

A new paradigm for the treatment of ulcerative colitis has recently been presented: Treatment of the mucosa with lidocaine (2%) enemas for prolonged periods. This therapy was introduced based on the hypothesis that hyperreactive autonomic nerves may play a pathogenetic role in the disease. One hundred consecutive patients have now been treated and the results presented. The proctitis patients all responded to the treatment, despite previous therapeutic failures in more than two-thirds of the cases. They were treated for 3-12 weeks, but 68% had a relapse (observation period 20 months). Of the 49 patients with proctosigmoiditis, two-thirds had chronic symptoms resistant to previous therapy. One of these patients did not respond to lidocaine, but developed fulminant total colitis. The other patient had therapeutic failure with lidocaine but responded well to subsequent cortisone enemas. The patients were treated until the subsets of T-lymphocytes (OKT4+ and OKT8+) disappeared from the mucosa. This occurred in parallel with symptomatic relief and eventual healing in 83% of the patients after treatment for 6-34 weeks. Of all the patients with proctosigmoiditis, 42% presented with recurrent symptoms (observation period 16 months). Of the 17 patients with left-sided colitis, all went primarily into remission within 2-4 months, but 23% had a relapse (observation period 13 months). The 6 patients with total colitis had symptomatic relief and improvement of histology when treated over 3-8 months. One patient had recurrence after 12 months. Treatment with a local anaesthetic in ulcerative colitis is a new approach to mucosal inflammation. The beneficial effects may be due to blockade of certain neural effects, such as epithelial proliferation and shedding and congestion of the mucosal vasculature, with actions on cells of the immune system.

MEASUREMENT OF THE HEALING OF VENOUS ULCERS

The surface area of 99 leg ulcers was measured from a scaled photograph using a computerized ultrasonic digitizer. This was compared with the area obtained by multiplying the two maximal perpendicular diameters of each ulcer. There was an extremely good correlation between these two methods (r = 0.951). Seventy-four patients were followed up as part of a placebo-controlled double-blind study. In this study, treatment was assessed by the time taken for the ulcerated limb to heal completely. The initial ulcer size was found to be a weak predictor of subsequent ulcer healing (r = 0.49). The healing rates of individual ulcers calculated over 1 month intervals from presentation proved to be a poor predictor of the time required for complete ulcer healing (Spearman rank correlation coefficients ranged from 0.15 to 0.61). The healing curves of individual ulcers showed considerable fluctuations during the process of healing. The product of the maximal dimensions of an ulcer provides an easy and accurate method of monitoring treatment. The reduction in ulcer size within a set time interval, used in many ulcer studies, is a poor predictor of eventual ulcer healing. The percentage of ulcers completely healed within a pre-determined time interval is a better method of assessing new treatments.

Local Fasciocutaneous Flap Skin Coverage for the Dorsal Foot and Ankle

Recalcitrant wounds of the distal leg and foot are notorious for requiring complex solutions even when deceptively small or benign in appearance. The simplicity of local flap options is always preferable, but is limited about the dorsal foot and ankle region. Inclusion of the well-defined deep fascia with the overlying integument in this area permits creation of local fasciocutaneous flaps that may be an important viable alternative. Over the past 6 years, 13 patients have had 15 such fasciocutaneous flaps for ankle or dorsal foot soft tissue reconstruction, with vascular ischemia being the most common etiology. Although four major complications occurred (27%), no limb amputation was a sequela as local wound care was satisfactory for eventual healing. Seven of these patients (54%) either declined or technically were not candidates for a complicated microvascular tissue transfer, which usually would have been preferable, but nevertheless all results proved satisfactory.

The infected knee arthroplasty: A 6-year follow-up of 357 cases

The incidence of deep infection after 12,118 primary knee arthroplasties performed in Sweden from October 1, 1975 through 1985 with a median follow-up of 6 years was 1.7 percent for arthrosis and 4.4 percent for rheumatoid arthritis. Risk factors for infection were large prostheses, postoperative wound-healing complications, rheumatoid arthritis, a prior deep infection, and skin infections. We have analyzed the treatment of 357 knee arthroplasties with a deep infection. Systemic antibiotics alone were primarily used in 225 knees, with healing of the infection in 44 knees, 20 of which had a functioning prosthesis at the final follow-up; the treatment did not compromise later revision surgery. Soft-tissue surgery was used in 154 knees--37 healed, 15 of which had a functioning prosthesis. Resection arthroplasty resulted in healing of the infection in 11 of 22 knees. Revision arthroplasty was performed in 107 knees, with eventual healing of the infection in 81 knees, 36 of which had a functioning prosthesis; there were no differences in the outcome of one-stage and two-stage procedures. Arthrodesis was attempted in 135 knees, with eventual healing of the infection in 120 knees and fusion in 105. Twenty-two patients were amputated. Thus, the infection healed in 315 knees (88 percent), but only 71 (20 percent) recovered with a functioning prosthesis, and 8 patients died of the infection. Attention should therefore focus on prophylactic measures directed towards the soft-tissue problems--by avoiding conflicting skin incisions, by gentle handling of the periarticular soft tissues, by avoiding the use of constrained prostheses and oversized compartmental prostheses, by letting wound healing take priority over motion in knees with compromised soft tissues, and by using prophylactic antibiotic treatment for skin ulcers until these have healed.

The Influence of Renal Function on Diabetic Foot Ulceration

We examined the effect of renal function on the formation, severity, and outcome of diabetic foot lesions. Information was collected from a retrospective hospital chart survey and analyzed by univariate and multivariate linear regression analysis. Creatinine clearance, peripheral neuropathy, and peripheral vascular disease were all found to be independently associated with formation of foot lesions, indicating that each of these acts by distinct biologic mechanisms. Renal function had no bearing on the severity of lesions or on their eventual healing. We conclude that foot ulcers are more likely to develop in diabetic patients who also suffer from renal impairment, but they are no less likely to heal than are those in patients with normal renal function. We further conclude that attempts to preserve functional limbs in these patients are justified.

Effect of a failed distal reconstruction on the level of amputation

Controversy exists as to whether the level of amputation is adversely affected by an unsuccessful limb salvage attempt. Two hundred ten amputations following failed reconstruction attempts in 191 patients were studied and compared with 551 amputations in limbs with no prior revascularization. Initially, 147 of those with failed reconstruction attempts underwent below-knee (BK) amputation and 63 underwent above-knee (AK) amputation. One hundred ten of 143 (77%) surviving BK amputations eventually healed. This is in contrast to the eventual healing in 266 of 298 (89%) of the BK amputations performed with no prior attempts at reconstruction. A statistically significant (p less than 0.05) difference in eventual healing favoring those with no prior reconstruction was demonstrated. Successful reconstruction of the ischemic extremity is the goal of vascular surgery and should be attempted when indicated. However, it should be realized that unsuccessful revascularization attempts may adversely affect healing in those limbs initially considered for a BK amputation.

Blunt liver trauma in children: Nonoperative management

Since 1978, we have treated 19 of 23 (83%) children with blunt liver trauma nonoperatively. Management consisted of observation in an intensive care unit, repeated physical examination, frequent reevaluation of laboratory values, special investigations, and bed rest. The 19 patients all remained stable, required no surgical intervention, and showed resolution of the hepatic injuries with no early or delayed complications. Ultrasonography, although not as reliable a method as computed tomography or liver isotope scans for identification of hepatic trauma at first presentation, provided a very useful method for documenting subsequent progress and eventual healing of the lesions. The presence of an isolated hepatic injury is insufficient indication for surgery. If there is significant extrahepatic injury requiring surgery, or if the patient with hepatic trauma is deteriorating, operative intervention is mandatory.

A radiographic five-year follow-up of femoral neck fractures.

Forty femoral neck fractures were followed for 5 years in a prospective clinical, roentgenographic and scintimetric investigation. Thirteen cases had uncomplicated healing, 22 necrosis and five non-union. The diagnostic value of radiographic changes was analysed with reference to development of necrosis of the femoral head or non-union. Sclerosis of the femoral head, and compression and displacement of the fracture were compatible with eventual healing and clinical recovery. Subchondral fracture and collapse of the load-bearing surface, diagnostic for necrosis, were observed in only 7 of 22 cases at 1 year and as late as 3-5 years in three cases. By contrast, four out of five non-union cases were established radiographically within 1 year. Patients needing an arthroplasty after fracture of the femoral neck should be identified on clinical grounds after early radionuclide scintimetry. Waiting for radiographic documentation of necrosis in cases with pain will increase the risk for physical and social impairment associated with poor function of the hip.

Leishmania tropica and Leishmania mexicana: Cross-immunity in mice

The effect of a previous or concurrent Leishmania tropica major infection on a L. mexicana infection was studied. Mice which were recovering from or had recovered from a L. tropica infection were found to be totally resistant to L. mexicana. Infection of mice already carrying a L. mexicana infection with L. tropica resulted in subsequent ulceration and eventual healing of the lesions caused by both Leishmania species. Mice infected with L. mexicana were found normally to be no more susceptible to L. tropica than untreated mice: Only when L. tropica infections were located in the region of a draining lymph node already serving a L. mexicana infection did lesions of the former parasite persist.

Management of lacerations and scars

The purpose of this paper is to review and update the subject of management of scars and lacerations. The surgion who accepts responsibility for management of soft tissue injuries must be aware of fundamental surgical principles as well as detailed technique. Knowledge of basic anatomy and wound physiology is utilized and applied. Emphasis is placed on management of the total pateint. The specialist must accept the role of team captain and establish an order of priority in management and in wound analysis. By having a basic knowledge of wound healing and the lines of favorable contracture, one is better able to prognosticate the eventual healing of the wound after proper management. By being able to predict wound contracture and scar maturation, the patient can be better informed as to what to expect during the period of healing. With lacerations immediate repair is carried out. With scars there is more time for planning and photographic analysis. The contracting forces will by this time have identified themselves and the degree of release of the contracture or camouflage can be determined. Specific wound management emphasized meticulous closure in layers and the use of skin hooks with the interrupted subcuticular suture. Skin sutures with both the continuous subcuticular suture and interrupted sutures of monofilament nylon using the spring-loop are described. Emphasis is placed on the preparation of the skin margins with slight beveling of the skin edges and undermining with precise even thickness of the skin especially at the wound margin. For scar revisions a minimum time of six months should elapse, and 12-18 months is better. Complications include infection, hematoma, wound separation, and rejection of suture materials. Keloids are discussed briefly, particularly regarding the use of intralesional injection steroids. Broken line camouflage techniques are discussed with the regard to breaking up contracture without lengthening. Lengthening either existing or anticipated contractures is accomplished with Z-plasty. The multiple Z-plasty, W-plasty, and Zig-Zag plasty are aimed towards creating a less conspicuous scar and creating some diffusion of the forces of contracture. A technique for a "practical Z-plasty" is described. Both free grafts and skin flaps sometimes must be utilized to fill tissue defects and break up line of contracture. The materials presented and conclusions drawn are based on 25 years of active emergency room coverage and long term follow-up of treated patients. It is the responsibility of the physician to act within the first few hours and to take the time necessary for accurate approximation and realignment of both soft tissue and bone injuries. Minimal scarring depends on accurate approximation of skin margins without tension. The need for early meticulous repair, so that unsightly scars and disfigurements may be prevented, cannot be overemphasized.

Massive osteolysis (phantom bone, disappearing bone): Report of a case with mandibular involvement

A rare case of spontaneous osteolysis is reported. The mandible was the only bone seriously affected, although numerous bones were involved. This case is of particular interest because of the extensive information obtained during investigation of the disease over a 7-year period. The natural course of the disease during this interval showed little change, except for the progressive resorption of the mandible. Attempts to detect metabolic abnormalities and to influence the course of the disease by systemic therapy were unsuccessful. Similarly, numerous biopsies of the involved bones failed to show appreciable change from normal. Conventional, conservative treatment of several pathologic fractures resulted in eventual healing of all but two fractures.

Controlling gastric secretion.

Although the etiology of peptic ulcers is not known the removal of hydrochloric acid from the stomach leads to pain reduction and eventual healing of the ulcer. Antiacid therapy usually provides pain relief and contributes toward healing. Preventing ulcer recurrence is much more difficult. A number of new therapeutic methods aimed at controlling gastric secretion are being tested. These new treatments include the use of sodium amylosulfate and X-ray therapy. In the future it is possible that prostaglandins may be used to reduce gastric secretions.

Deep-seated mycotic infections, allergy to fungi and mycotoxins (concluded).

HistoplasmosisDuring the last five years, there has been increasing awareness of previously overlooked aspects of histoplasma infection in man. Schwarz, Baum and Floyd have emphasized that multiple primary lesions may occur in the lungs simultaneously, producing roentgenologic infiltrates which wax and wane for a period of months or years before eventual healing.104 Mediastinal adenopathy due to Histoplasma capsulatum has produced obstruction of both the trachea and the superior vena cava.105 , 106 I have observed a case of Loeffler's syndrome due to histoplasma infection and have also seen a patient who had wandering pneumonia involving, over a two-year period, all 5 . . .

ELECTRIC TRAUMA AND THE FUNCTION OF ELASTIC FIBRES: A New Mode of Action Demonstrated in Four Victims of Electric Trauma

In four cases of lesions produced by electricity, the notably good eventual healing is thought to have been due to elastic-fibre reaction, which took three forms.

Necrotizing herpes simplex viral infection of the cervix during pregnancy: A mimic of squamous cell carcinoma

A case of severe necrotizing herpes simplex viral infection of the cervix occurring during a twin pregnancy is presented. Its eventual healing with severe cervical scarring and atrophy made vaginal delivery impossible. The babies were unaffected. Speculation is made regarding other unrecognized instances of such infection in pregnant patients. The value of cytological testing to arrive at the diagnosis was clearly demonstrated.

HIDRADENITIS AND OTHER VARIANTS OF ACNE

HIDRADENITIS suppurativa and the more severe types of acne, such as acne conglobata and dissecting cellulitis of the neck and scalp, not infrequently occur in the same persons. These disorders have been described as distinct entities; however, in clinical characteristics and in the course of the disease, they have many similarities which indicate a close relationship among them. They may be considered as regional counterparts in which the acne process is manifested in its extreme variants and in its more fulminating forms. Acne conglobata, dissecting cellulitis, hidradenitis, and other variants of acne have these features in common: functional glandular hyperplasia of the apocrine gland and pilosebaceous apparatus; double comedo formation and impaction of the follicular orifice; bacterial invasion with suppuration and undermining of the loose areolar tissue, and eventual healing with cicatrization and not infrequent keloid formation. This presentation is concerned with a correlation of various aspects of the