Scars Holistic Treatment

The Scar Solution Book

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Scarring or sensitization

This notion, sometimes referred to as scarring or sensitization, has attracted a good deal of attention from investigators of the neurobiological (Post, 1992) and psychological (Rohde et al., 1990) processes that may be involved in the relapsing and remitting course of depression in adults. Post and colleagues (Post, 1992), for instance, have suggested that the first depressive episode may sensitize people to further episodes. They hypothesized that such sensitization may help to explain three characteristics of depression in adults the tendency to recur, the decreasing length of interval between episodes, and the greater role of psychosocial stress at the first episode. The idea is that the first episode of depression, which can often be linked to a psychosocial stressor, is associated with long-lasting changes in biology and responsivity to stressors. There may be biochemical and microstructural changes in the central nervous system that put the individual at risk of further...

Granulomatogenic Metals

However, only when the normal elimination mechanism fails, as in cases where the foreign body has low biological activity and resists the action of the body's degradative enzymes, and when the skin lesion persists for months or years does significant tissue destruction result and the term granuloma become appropriate. Granuloma is characterized by a collection of cells of the mononu-clear phagocyte series, with or without the presence of other inflammatory cell types, and the inflammation typically heals with scarring.

Stem Cell Therapy for Cardiovascular Disease

The adult mammalian heart lacks the potential for effective regeneration. The infarcted myocardium is usually transformed into a noncontractile fibrous scar. This remodeling process leads to expansion of the initial infarcted area and dilatation of the left ventricular lumen (8). A novel and attractive approach to the cure of ischemic heart disease is the use of stem cells (9-13). Pluripotent stem cells are cells that have not taken on the identity of any specific cell type and are not yet committed to any dedicated function they can divide indefinitely and may be induced to give rise to one or more specialized cell types. Murry et al. (14) and Balsam et al. (15) recently reported that hematopoietic stem cells failed to transdifferentiate into cardiac myocytes in myocardial infarcts. The stem cells, however, developed into different blood cell types, despite being in the heart. Thus, for physicians, the use of stem cell therapy in treating cardiac-muscle diseases remains a worthy, but...

Contamination By Human Pathogens

It is particularly important that water used for hydrocooling produce be free of pathogenic microorganisms, as when warm produce is placed in cold water, intercellular air spaces within fruits and vegetables contract, creating a partial vacuum (pressure differential). This has been demonstrated to facilitate infiltration of water, which may contain human pathogens, into fresh produce items. While this phenomenon is known to be an important source of plant pathogen infections during postharvest handling of fruit and vegetables 46-49 , only recently has direct evidence been brought forward to show that human pathogens may enter produce by this same mechanism. In a follow-up investigation of potential sources of imported mango contamination, Penteado et al. 50 provided evidence that Salmonella spp. may be internalized in fresh mangoes during simulated postharvest hot water insect disinfestation procedures which included a water bath cooling step 51 . However, Richards and Beuchat 52...

The Migratory Process

First identified as the primary organelles of cell motility by Abercrombie in 1971, lamellipodia are sites of active actin polymerization, and their formation requires the local recruitment of a whole array of molecular components to mediate cytoskeletal reorganization. These include actin filament nucleating factors such as Arp 2 3 and SCAR filament depolymerizing proteins such as cofilin barbed-end capping proteins and actin monomer binding factors such as profilin. Filopodia also form as a result of actin polymerization however, these filaments are cross-linked into long, stiff bundles that can extend to up to tens of micrometers in length.

Advances in Computed Tomography

Figure 1 Biphasic liver imaging (A) Axial image through the upper abdomen during the late hepatic arterial phase reveals a hyper-enhancing mass in the caudate lobe (segment I) (arrow). The mass is relatively homogenous and there is no evidence of either a central scar or a capsule. (B) During the portal venous phase, the mass demonstrates subtle hypo-attenuation and is much less conspicuous. This is a metastasis from an endocrine primary tumor. Figure 1 Biphasic liver imaging (A) Axial image through the upper abdomen during the late hepatic arterial phase reveals a hyper-enhancing mass in the caudate lobe (segment I) (arrow). The mass is relatively homogenous and there is no evidence of either a central scar or a capsule. (B) During the portal venous phase, the mass demonstrates subtle hypo-attenuation and is much less conspicuous. This is a metastasis from an endocrine primary tumor.

Percutaneous tracheotomy

A more rapid procedure with less tissue trauma and scarring than the standard open surgical technique. It can be performed in the ICU, avoiding the need to transfer patients to theatre. Coagulopathy should be excluded or treated first. Subcutaneous tissues are infiltrated with 1 lidocaine and epinephrine (adrenaline). After a 1-1.5cm midline skin crease incision, the subcutaneous tissue is blunt dissected to the anterior tracheal wall. The endotracheal tube tip is withdrawn to the level of the vocal cords. The trachea is then punctured in the midline with a 14G needle between the 1st and 2nd tracheal cartilages (or lower), allowing guide wire insertion. The stoma is created by dilatation to 32-36Fr (Ciaglia technique) or by a guided forceps dilating tool (Schachner-Ovill technique). In the former case, the tracheostomy tube is introduced over an appropriate sized dilator and in the latter through the open

Colorectal Physical Evaluation

A detailed physical examination is conducted on all patients. Careful abdominal examination, looking for any evidence of tenderness, masses, incisions, or hernias is an important initial component. Anorectal examination is first conducted in the prone jackknife position. A proper light source is essential. Initial inspection of the perianal skin can reveal any dermatologic conditions such as excoriation or dermatitis. Previous scars from either episiotomy or anorectal surgery are identified. The anus is assessed, and it is noted if the anus is closed or patulous in the resting state. Assessment of sensation is the next step in the examination. Any loss of either sharp or dull sensation is noted in the perianal area. The presence or absence of the anal wink reflex is also ascertained. Absence of the anal wink may signify pudendal neuropathy.

Location Of Internalized Organisms In Plants

The xylem, composed of specialized vessels, tracheids, and associated parenchyma, connects the water-absorbing tissues in the root system with the rest of the plant 18 . Vessels and tracheids are filled with water containing dissolved minerals and occasionally organic solutes. The general structure of these water-conducting elements tends to exclude microorganisms such that only a few specialized types are able to enter and move through the system. Individual vessel cells connect through perforation plates that would appear to allow passage of suspended particulates such as bacteria 18 . However, Pao et al. 19 observed multiple, helical perforations in the walls and ends of the vessels in the stem scar of orange fruits that blocked movement of bacteria. Whether these were xylem vessels or tracheid cells, which do not possess perforation plates 18 , is unclear. Both types of water-conducting cells attach to adjacent cells through pits in their secondary walls. The pits are paired with...

Process Of Internalization

Most surface apertures of plants are large enough to allow passage of bacteria and smaller particulates, whereas fungal spores would likely be excluded. The stem scar of tomato fruit may allow the passage of spores of the sour rot fungus, Geotrichum candidum 33 , although the evidence was not conclusive. Lesions of Rhizopus stolonifer and Geotrichum candidum developed around and beneath the stem scar of tomato fruit that had been previously treated to cause an internalization of the spores of these fungi 28 . Vigneault et al. 34 reported that tomatoes cooled with water containing spores of R. stolonifer usually decayed during subsequent storage. However, whether the spores in these examples internalized through the stem scar is unclear. In contrast, wounds involving tissues with large intercellular spaces appear likely to internalize fungal spores.

Surgery for Primary Cancers

As the field of multimodality therapy has developed, the role of surgery as primary therapy for certain solid malignancies has changed. The concept of neoadjuvant therapy where chemotherapy and or radiation therapy is administered before surgical resection has become standard care for some tumors. A prime example of this is the treatment of anal squamous cell cancers. Before the 1970s, the primary therapy for this cancer was an abdominoperineal resection, which involves removal of the rectum and creation of a permanent colostomy. The discovery of effective chemoradiation therapy for this tumor has resulted in a high percentage of complete responses in many patients who then require having only excisional biopsies of residual scar.14,15 This change has spared patients from having an abdominoperineal resection, which is now reserved for those who fail to completely respond to chemoradiation or who subsequently relapse. Another example is the treatment of childhood rhabdomyosarcomas. In...

Biological Activities

The increased microvascular permeability induced by VEGF-A leads to tissue edema, a characteristic of tumors, healing wounds, and other pathologies in which VEGF-A is overexpressed. Extravascular fluid accumulation is particularly prominent in tumors growing in body cavities such as the peritoneum (ascites tumors). Plasma protein leakage has several consequences. One of these is activation of the clotting system via the tissue factor pathway, leading to deposition of a fibrin gel that retards clearance of edema fluid and results in locally increased interstitial tissue pressure, a characteristic feature of many solid tumors. Deposited fibrin also provides a provisional stroma for endothelial cell and fibroblast migration that supports the angiogenesis and fibrogenesis necessary for generating mature stroma (desmoplasia in the case of tumors or scar formation in wound healing).

Implications And Control

Certain handling steps after harvest can reduce the internalization hazard. For example, the porosity of tomato stem scars to water is greatest immediately after harvest and then decreases over time 32 . Leaving a stem attached until just before water treatment only slightly reduces this characteristic. Studer and Kader 51 observed that tomato fruits split readily (from water uptake) if they were submerged in water immediately after harvest but did not if stored overnight before treatment. Additionally, warm fruit is more likely to absorb water than cool fruit during exposure to hydrostatic pressure as well as during exposure to water cooler than the fruit 30,31,51 . Thus, allowing tomatoes to cool overnight before packing them should decrease the likelihood of water infiltration during the unloading and washing processes at packinghouses. Although this prepacking storage would allow pathogen growth on damaged fruit (which otherwise would have been culled), small wounds would begin to...

Fine Needle Aspiration

Fine-needle aspirations obtain cell suspensions suitable for cytology or flow cytometry. This technique can be helpful in aspirating a thyroid nodule, sometimes a breast lump, or a lymph node whenever lymphoma is not primary in the differential diagnosis. The advantages to fine-needle aspiration include the lack of a scar, lack of need for anesthetic, good patient tolerance of the procedure, and the relatively fast turnover of cytology in obtaining a diagnosis. Cell-surface receptors cannot be evaluated, and cytology cannot distinguish between invasive and noninvasive cancers. A fine-needle aspiration should be done only when the determination of atypical or malignant cells will help in diagnosis or treatment, such as proceeding with a thyroid lobectomy or documenting whether a lesion is recurrent cancer in a patient with a known history of the disease. Although a determination of cell abnormality and malignancy can be done, it is usually not sufficient for determining the definitive...

Noninvasive investigations

In the presence of significant coronary stenosis, exercise or other chronotropic and inotropic stimuli (e.g. infusion of adrenergic agonists such as dobutamine) will result in localized ischemia. This manifests itself as typical pain and also results in changes in the contractility of the ischemic myocardium, which can be detected by echocardiography (stress echo) or isotope ventriculography (multiple-gated acquisition (MUGA) scanning). ECG changes are repolarization abnormalities with ST segment depression. Thallium-201 is distributed in the myocardium in proportion to blood flow. Areas of infarction and scar tissue do not take up the isotope, and ischemic areas take up less than normal. The isotope is detected by a gamma camera.

Morphological changes in infarction

After the onset of arterial occlusion. In non-reperfused infarcts, the myocytes swell and lose all intracytoplasmic organization, and myofibrillary material forms amorphous masses. In reperfused infarcts the myocyte shows brightly eosinophilic cross-banding in the cytoplasm. This appearance (contraction band necrosis) is due to intense hypercontraction of the myofibrils owing to the influx of calcium ions and occurs only when blood supply is restored by fibrinolysis to myocardium which is undergoing infarction. Infarcted myocardial tissue invokes an inflammatory repair response. By 12 h small intramyocardial vessels contain polymorphs which also infiltrate the interstitial tissue. By 24 h myocytes have begun to disintegrate, and there is a florid macrophage response followed in turn by invasion of the infarct zone by fibroblasts and new capillaries. Collagen deposition begins by day 4 and continues for many weeks. The rate of repair depends on the original structure of the infarct....

Microbial Stress Adaptation On Produce

Information in published literature regarding microbial stress adaptation on produce is scarce. However, greater processing resistance of natural microbial contaminants on produce surfaces compared with those inoculated onto these products may support the hypothesis that most produce microbiota are adapted to stresses encountered in the field and throughout the production chain. Readers are cautioned that apparent processing resistance of produce microbiota also could be attributed to their inaccessibility to treatments, or the inability of the analyst to recover these microorganisms using common sample preparation and processing techniques. Association of microbial contaminants with pores, stem scars, wounds, and other surface irregularities could protect microorganisms and make them appear resistant to processing.

The concept of core depression

This chapter has already given some examples of how the biological models of depression can be tied in with other characteristics of depression from other disciplines such as epidemiology. The predisposition to suffer depression entailed by childhood experiences can be paralleled by the presence of 'endocrine scars'. Acute and chronic stress from the environment can be shown to have profound neurobiological correlates. High cortisol levels are associated with cognitive dysfunction (Van London et al., 1998). Recent neuroimaging studies reveal a brain that is overresponsive to unhappy stimuli and underresponsive to happy ones (Elliott et al., 2002). It is easy to see how such a brain dysfunction can be linked to the perceptual biases in depression, and also to cognitive theories of depression in which such cognitive distortions are felt to be a primary disturbance in depression.

Morphology And Development The flowering plant

The 'dormant' narcissus bulb in autumn consists of a more-or-less disc-shaped stem plate (base or basal plate) bearing adventitious roots below and storage organs (bulb scales) surrounding a bud above. The bulb 'scales' consist of true scales, which are almost entirely within the bulb and serve a purely storage function, and the bases of foliage leaves after anthesis the base of the flower stalk becomes flattened and is also scale-like in function. Leaf bases can be distinguished from bulb scales because the former have a thicker tip and a scar where the leaf lamina became detached. In the 'model' case of a narcissus bulb with a single, terminal growing point (a 'single nosed round' bulb), a transverse section of the bulb in autumn shows a series of concentric 'scales' surrounding the old flower stalk base and a terminal bud (Figure 1.3). The exception to the concentric nature of the 'scales' is that the inner leaf, which subtends the flower, has a semi-circular base with keeled...

Macular Hole and Vitreomacular Traction

Case 3-17, Macular Hole and Atrophic Laser Scar A 75-year-old man with age-related macular degeneration had undergone indocynanine green enhanced diode laser photocoagulation in his right eye eight months earlier for choroidal neovascularization. Slit-lamp biomi-croscopv (A) showed an atrophic laser scar in the center of the macula with no subretinal fluid, hemorrhage, or exudate. The visual acuitv in this eve was 20 100. Flu ores- cein angiography (B) showed an area of hypofluorescence in the macula with surrounding hyper fluorescence, and late staining consistent with a fibrovascular scar

Electrode and Pulse Generator Considerations

When electrode replacement was necessary, it became obvious that removal of the four-strand non-encased electrode had became infiltrated with glial tissue between the four wires, and removal was accompanied by a core of scar that if attached to a cerebral vessel could produce vascular injury with resulting intracerebral hemorrhage and hemiplegia or death (personal communications). This required the old electrode to be clipped at the cortex and left in place (Figure 6.7). This problem has been corrected by the most recent revision of the DBS electrode, which is smooth and does not allow glia to infiltrate or adhere to its surface.

Thyroid Follicular Hyperplasia And Neoplasia

Sporadic nodular goitre is characterised by numerous follicular nodules with heterogeneous architecture and cytology, features that have suggested a hyperplastic rather than neoplastic pathogenesis (7-10). The gland may be distorted by multiple bilateral nodules and can achieve weights of several hundred to a thousand grams, but this disorder is often identified as a dominant nodule in what clinically appears to be an otherwise normal gland. Histologically, the nodules are irregular some are poorly circumscribed while others are surrounded by scarring and condensation of thyroid stroma, creating the appearance of complete encapsulation. They are composed of follicles of variable size and shape. Some follicles are large, with abundant colloid surrounded by flattened, cuboidal or columnar epithelial cells, often with cellular areas composed of small follicles lined by crowded epithelium with scant colloid in a small lumen, alone or pushing into large colloid-filled follicles as...

Inoculation of G mellonella Larvae

Larvae of G. mellonella are easy to inoculate via injection into the haemocoel through the last left proleg (Cotter et al., 2000). The base of the proleg can be opened by applying gentle pressure to the sides of the leg and this aperture will reseal after removal of the syringe needle without leaving a scar. Inoculation of larvae with test micro-organisms must be accompanied by inoculation of larvae with the buffer used to re-suspend the test micro-organisms to ensure that this has no impact on larval viability. A number of workers also suggest the 'mock-inoculation' of a number of larvae per experiment to ensure that the handling and inoculation procedures are not deleterious to the health of the larvae (Dunphy & Webster, 1984 Cotter et al., 2000). Larvae can be stored at 15 C prior to use and, once inoculated, may be maintained at temperatures up to 37 C, as long as appropriate controls are implemented to quantify the effect of temperature on survival. Larvae should be handled...

Robert M Herndon MD

Strocytes play a far more important role in multiple sclerosis (MS) than has been generally recognized. Not only do they form the dense firm scars in areas of demyelination, which led to the term plaque in MS, but they also have important functions in the development and control of the immune response in the nervous system. They are typically stellate, or star shaped cells, although some have highly specialized shapes. They are derived from the neuroectoderm and phyloge-netically are closely related to ependymal cells. Their developmental origin and relationship to precursor cells and oligodendrocytes is discussed in Chapter 2. Historically, they were regarded primarily as supporting cells that provide structural support for other cells in the central nervous system and react to injury by forming scars. Their main role relative to MS was seen as scar formation. Beginning in the 1960s, it became clear that astrocytes are far more complex than previously suspected. They perform a large...

Assessing The Diagnostic Capability Of Ctu Preliminary Results

CTU has also been utilized to evaluate patients after urinary diversion. In one study (20), CTU was able to detect 9 abnormalities in 24 patients following such surgery, including four ureteral strictures, and single cases of renal parenchymal scarring, bilateral renal collecting system and ureteral dilatation, vascular compression of a ureter, a calculus in a urinary reservoir, and tumor recurrence in the afferent limb of a neobladder.

Cellular Composition And Organization Of The Adult Mouse

Epithelial layers with a stem cell component often display a remarkable regenerative capacity in pathological conditions. If the lateral ventricle ependyma contains a stem cell, then one might expect this epithelium to regenerate after injury. However, there is at present no convincing evidence that the lateral ventricle ependyma regenerates after injury. Interestingly, injury to the ependymal cells stimulates the subependymal astrocytes to proliferate and form a gliotic scar, which appears to substitute for the missing ependyma (55,59). Again, ependyma of more caudal regions may behave differently and have some capacity to proliferate, and comparisons of the molecular characteristics of the ependyma throughout the neuraxis would be revealing.

Etiology and risk factors

The second important factor for epilepsy is the epileptogenic abnormality itself. Epilepsies attributable to identifiable brain defects are referred to as symptomatic epilepsies. Symptomatic epilepsies can be caused by a variety of disorders, including brain malformations, infections, vascular disturbances, neoplasms, scars from trauma, including strokes, and disorders of cerebral metabolism. Treatment for symptomatic epilepsy is most effective if it is directed at the underlying cause. The most common symptomatic epilepsy is temporal lobe epilepsy, usually associated with a characteristic lesion called hippocampal sclerosis. Hippocampal sclerosis appears to be caused by cerebral injury within the first few years of life in individuals with a genetic predisposition to this condition. Some forms of epilepsy are unassociated with identifiable structural lesions or diseases and are usually unassociated with other neurological or mental deficits. These are genetically transmitted,...

Local Complications After Radiation Synovectomy

More severe complications are local skin and needle track ulcerations which may occur if drops of the radionuclide flush back out of the needle during retraction from the joint. This can be easily avoided by flushing the needle with steroids or 0.9 saline after application of the radionuclide, as described before. Savaser et al. (48) report on a needle track ulceration after radiation synovectomy of an ankle joint with Re-186, which showed healing by scar formation after a few weeks without any further treatment. Necrosis of periarti-cular tissue is the worst local complication in radiation synovectomy and is caused by accidental para-articular injection of the radionuclide. A very low frequency of two cases of necrosis out of 11,000 treatment procedures was reported by Kolarz and Thumb in 1982 (49). With at least 23,000 radiation synovectomy

Mucous Membrane Pemphigoid

Mucous membrane pemphigoid is an uncommon, chronic blistering disorder affecting the mouth 186 . Other sites of involvement include the eyes, skin, and mucosa of the nasopharynx, anogenital region, oesophagus and larynx 32 . It has been defined as a group of putative autoimmune, chronic inflammatory, subepithelial blistering diseases predominantly affecting mucous membranes and characterised by linear deposition of IgG, IgA and C3 along the epithelial basement membrane 33 . It has also been called benign mucous membrane pemphigoid and cicatricial pemphigoid. However, it can be a severely disabling condition, and rarely causes scarring except in the eye and oesophagus larynx, so these terms are not appropriate. Mucous membrane pemphigoid is more common in women than men and most patients are in the 40-60-year age range. The mouth is often the first and only site of involvement. Oral lesions can be intact blisters that may contain clear or sero-sanguinous fluid, er-ythematous patches or...

Recurrent Aphthous Ulceration

There are three main clinical forms of the condition minor, major and herpetiform ulceration, although a minority of patients may show various combinations of these types. Minor aphthae are by far the most common manifestation ( 85 ) and are characterised by the formation of one or several superficial ulcers, usually 28 mm in diameter with a yellowish-grey, fibrinous floor and an erythematous halo. The ulcers tend to involve the non-keratinised mucosa such as the lips, buccal mucosa, ventrum of the tongue and floor of the mouth. They usually heal within 7-10 days by regeneration of the epithelium across the floor of the ulcer, and without scarring. The ulcers frequently recur at regular intervals, typically of 2-3 weeks. Some patients, however, are virtually never ulcer free, as new crops appear before pre-existing ones have healed. A minority of cases are menstruation-related and the ulcers appear monthly in the premenstrual week. Major aphthae are less common ( 10 ) and ulcers can...

Imaging of tumour tissue

Thallium-201 is widely used for myocardial perfusion imaging. Over the past few years there has been growing interest in the use of 201T1 in oncology. It may be useful in the differentiation between low-and high-grade glial tumours and between tumour recurrence and scar tissue. Thallium-201 scintigraphy can assess residual tumour viability after chemotherapy in bone and soft-tissue sarcomas.

Indications for free flaps

Mutilating, high-energy injuries that lead to extensive soft tissue destruction can preclude any possibility of using local pedicled flaps for coverage. Free tissue transfer is warranted when local flaps cannot be harvested outside the zone of injury or when soft tissue defects are extensive and involve exposed vital structures such as bone, tendons, nerves, and vessels. Other major indications for free flap coverage include coverage following extensive scar contracture release due to trauma or burn, and coverage following tumor excision 1,2,8,14,23 . Mutilating hand injuries are particularly amenable to free flap reconstruction because of the ability to transfer multicomponent

Tissue Response To Gdc Histopathological Findings

Neck has been demonstrated as early as 36 h after coiling and has been suggested to serve as a substrate for endothelialization (30). Complete isolation of the aneurysm from the parent vessel can promote scar formation and stabilization of the thrombus (Fig. 2). Ishihara et al. (31) showed endothelialization of platinum coils at the orifice of human cerebral aneurysms at 2 wk and at 20 mo after embolization in five cases of small neck aneurysms. Bavinzski et al. (32) studied the histopathological changes in 18 human cerebral aneurysms treated with GDC and concluded that endothelialization of the aneurysm orifice after coiling can occur but seems to be the exception rather than the rule. They found tiny gaps between the coils at the aneurysm neck in 50 of densely packed aneurysms that appeared completely occluded on angiography. Small neck size and dense coil packing across the aneurysm neck are important factors to induce endothelialization, which excludes the aneurysm from the parent...

General Laboratory Screening Tests

In addition to assessing the airways and lung parenchyma, the chest radiograph should be reviewed for the absence or presence of a thymus in infants and for the possibility of a thymoma, which may be associated with hypogammaglobulinemia in adults (39). Hyperinflation with patches of atelectasis, suggestive of asthma, might suggest that additional details of the past history should be carefully reviewed in patients, particularly small children, referred because of cough or recurrent pneumonia, because similar densities seen on previous films may not have actually been due to infection. The presence of old scars and active disease should be documented. Hilar adenopathy may be seen in cellular and humoral immune defects. Abnormalities of the ribs resembling those seen in rickets might suggest ADA deficiency (13), and cardiovascular abnormalities may suggest asplenia (40) or DiGeorge syndrome (41) or may steer the workup away from immune deficiency and toward Kartagener syndrome (situs...

Clinical Characteristics of Probable Chorea Acanthocytosis from 25 Early Cases

The disease onset varied from 18 to 42 years old with the mean age of onset at 30.5 years. The male female ratio was 18 7. No X-linked family pedigree of disease inheritance was reported in these male patients. Choreiform involuntary movements were noted in 23 of 25 cases, with mainly oro-lingual-buccal dyskinesia and choreiform limb movements. The knee-buckling gait (flamingo-like walk), often seen in patients with Huntington's disease (HD), was noted in four cases among 25 22, 33, 42 . Twenty-two patients of 23 had decreased deep tendon reflexes suggesting polyneuropathy. Self-mutilation was noted in 22 patients of 24. Among 14 cases of MLS reported in Japan, self-mutilation was not noted except for one patient with a tongue scar due to a bite 35 . Severe oro-facial dyskinesia with lip-biting was considered to most likely indicate a diagnosis of ChAc. WAIS-IQ less than 80 was reported in ten cases of 25. Seizures were seen in ten, and of those, generalized seizures of the grand mal...

Discontinuity And Recovery Developmental discontinuities

What do these differences mean Clearly, the association with age, puberty, or both suggests that maturational factors could play an important part. For example, perhaps the relative cognitive immaturity of younger children protects them from the development of cognitive scars arising from an episode of depression. Or, it may be that the massive

Immediate Questions

Is patient taking any new medication(s) or herbal supplements) Has there been any exposure to toxins Food refusal can be secondary to acute ingestion of poisons that ulcerate or scar the mucosal lining of the mouth. Some decrease in appetite may be seen with medications or herbal supplements that directly cause disordered taste sensations or exacerbation of GI upset.

Need for vigorous treatment of the first episode

The finding that the first episode of depression can lead to scarring is important because it suggests that much greater attention should be paid to the recognition and treatment of the first episode of depression. Since late adolescence is a common period for the onset of adult depressive disorders (Smith & Weissman, 1992), the implication is that child and adolescent psychiatry could have an important part to play in the prevention of depression in adulthood. Indeed, there are plenty of developmental examples of the ways in which early disorders that are not managed appropriately can lead to permanent changes in both the biology of individuals and their psychosocial functioning (Wolkind & Rutter, 1985).

Burch Colposuspension

After all four sutures are placed in the vagina and through the Cooper's ligaments, the assistant ties first the distal sutures and then the proximal ones, while the surgeon elevates the vagina with the vaginal hand. In tying the sutures, one should leave a suture bridge between the vaginal wall and Cooper's ligament, so as not to place too much tension on the vaginal wall. After the sutures are tied, one can easily insert two fingers between the pubic bone and the urethra, thus avoiding compression of the urethra against the pubic bone. Vaginal fixation and urethral support depend more on fibrosis and scarring of periurethral and vaginal tissues over the obturator internus and levator fascia than on the suture material itself.

Specific Conditions 2631 Mydriasis

Whether caused by central (third nerve palsy) or local (i.e., sphincter muscle damage, retroiridal scarring) pathology or other etiologies 6 , the condition requires surgical correction if it results in photophobia that compromises vision. If mydriasis represents a major cosmetic problem for the patient, this is also an indication for corrective surgery. Scarring usually occurs in the context of anterior PVR, and treatment of the mydriatic pupil should be addressed during vitrectomy. The goal is to remove the scar tissue that lines the pars plana, ciliary body, and the back surface of the iris. If the lens is present, it must be sacrificed. Endoscopy-assisted vitrectomy offers several advantages traditional viewing cannot match (see Chap. 2.20). Complete scar removal is not always possible, and even if it is, return of iris pupil mobility is not guaranteed.

Prevention opportunities

In still another group of patients, low-grade chronic depressive developments occur in the setting of disabling systematic medical and neurological disorders, and are best categorized as 'secondary dysthymias' 78 For instance, poliomyelitis may not only lead to deformities in musculoskeletal structures in children, but could permanently scar the sufferer's sense of enjoyment, fulfilment, and outlook of life. Likewise, low-grade chronic depressive development often complicates neurodegenerative cerebrovascular disease later in life. In both situations, psychological factors might be operative, yet the contribution of specific cerebral lesions to

General Clinical Considerations of Brain Computer Interfaces

In addition to the processing issues that define the requirements of a BCI system, there is a unique set of factors that a clinician must consider about a given platform when considering application to a patient population. The most fundamental issue is that a BCI system is safe. First, surgical placement must have acceptable clinical risk, and then subsequently over time the implant must be reliable and durable in its ability to acquire signals. Understanding the risks of initial surgical application is reasonably straightforward as they will most likely utilize variants of standard neurosurgical practices. There are equivalent types of technical procedures, which include the placement of deep brain stimulators, placement of cortical stimulators for pain, and placement of grid electrodes. What will require closer examination is the construct's likelihood for ongoing function. This can be affected by how the device is designed (i.e., will the construct break down in a couple years )...

Upper limb bone defectindications for vascularized bone transfer

In general, most authors suggest that the strongest indications for the use of vascularized bone graft include situations that are prone to failure or complications with technically less demanding techniques such as nonvascularized bone autografts or allografts. These situations include massive defects and or an unfavorable surrounding soft tissue milieu related to prior failure of conventional bone grafting failure, infection, radiation, or other causes of extensive scarring.

Issues In Minimally Invasive Surgery

The first laparoscopic cholecystectomy (gall bladder removal) was performed on a human patient in 1987 (Mouret, 1991 see also Reddick et al., 1989). Just over one decade later, almost all abdominal surgical procedures are performed laparoscopically. For such surgery, the patient requires general anesthetic, and as with Mrs. Sanders' case, the abdomen is insufflated with carbon dioxide. Small keyhole-size incisions are made for ports of entry of the camera and surgical instruments. These are inserted with the operative ends inside the abdominal cavity and the handles the surgeons use to control the instruments outside the patient's abdomen. Laparoscopic cholecystectomy has gained universal acceptance as the procedure of choice for gall bladder removal because of a high rate of success and rapid recovery in most cases. MIS procedures are used frequently for appendectomies, inguinal hernia repairs, and Nissen fundoplications, a procedure to alleviate severe heartburn. Compared to...

Watersoluble b vitamins what impact do they have on wound healing

Although the role of nutrition in the various phases of wound healing is well recognized, the action of each of the B vitamins in this regard is still being defined. It is clear that the B vitamins have specific metabolic functions, and that they interact with one another in order to ensure that wound-related energy metabolism and tissue synthesis occur appropriately. Studies have shown that B vitamins play initial coen-zymatic roles during the inflammatory phase and during the removal of dead tissue and bacteria. B vitamins also have critical roles in the proliferative and remodeling phases of wound healing in that they participate in the synthesis and interlinking of collagen and, therefore, the synthesis of new tissues and blood vessels. During the third or final phase of wound healing, myofibroblasts are dependent on B vitamins when they pull the edges of wounds inward and continue to strengthen the scar for up to 2 yrs.2 During all phases of wound healing, substantial amounts of...

Molecular Basis of Disease

Ducts and subsequent scarring and destruction of exocrine functions. Neonatal meconium ileus occurs in approximately 15 of newborns with CF. Other manifestations include chronic sinusitis, nasal polyps, liver disease, pancreatitis, and congenital bilateral absence of the vas deferens (CBAVD). Males with CBAVD are azoospermic and have an increased frequency of mutations in one or both CFTR alleles or an incompletely penetrant mutation (the intron 8 variant 5T allele) in a noncoding region of CFTR. These men usually have no pancreatic disease and may have normal, borderline, or elevated sweat electrolytes. A small subset of patients with atypical CF have chronic Pseudomonas bronchitis, normal pancreatic function, and normal or intermediate sweat electrolytes.

Canal WallDown Mastoidectomy

When CWD mastoidectomy is indicated, the posterior border of the ear canal is to be removed. The medial border of the dissection is the floor of the facial recess, which is the lateral wall of the fallopian canal at the external genu. After the sigmoid sinus and middle fossa tegmen are skeletonized, the fossa incudis and horizontal SCC are identified. The anterior buttress, where the posterior auditory canal meets the tegmen, is removed to open up the epitympanum to the mastoid antrum. Next, the facial nerve is delineated by lowering the facial ridge laterally. The posterior buttress is where the posterior canal wall meets the floor of the auditory canal lateral to the facial nerve. It has to be removed well to open up the mastoid tip. The final step is an adequate meatoplasty. Considering future scar contraction, it needs to be at least twice its future size.

Phototherapeutic Keratectomy Fig 518c

Principle Superficial corneal scars can be ablated with an excimer laser (wavelength of 193 nm).The lesion is excised parallel to the surface of the cornea to avoid refractive effects. The edges of the ablated area are merged smoothly with the rest of the corneal surface, eliminating any irregularities.

Sacral Nerve Stimulation

Foramina are located using bony landmarks. The acute phase test is performed under local anesthesia using a 20-gauge spinal insulated needle (Medtronic Inc., Minneapolis, MN) attached to an external neurostimulator (Medtronic Inc.). The needle is placed in the sacral foramina, and an electrical current is gradually applied to the needle until a visual muscle response is obtained. Muscle responses include movement of the external sphincter and lateral rotation of the leg (S2), contraction of pelvic floor and plantar flexion of the big toe (S3), or contraction of the anus (S4). The chronic phase of PNE involves placement of a temporary stimulator lead into the same position as the testing needle. This lead is left in place for a trial period of 1 to 2 weeks to allow evaluation of functional response. The decision to proceed from temporary to permanent stimulation is made on the basis of 50 functional improvement in either the number of episodes or incontinence-free days. For placement...

Subretinal Hemorrhage

The photoreceptors may start dying as early as within 24 h 36 , and early photoreceptor death ensues if the blood is not evacuated 57 . Late sub-retinal scarring is another threat that should force the ophthalmologist to consider fairly acute intervention if the blood is thick and submacular.

Umanganese For Pimples

Acne is a common disorder of the oil glands in the skin and can appear on the face, back, shoulders, chest, and arms. In adolescents during puberty, sex hormones stimulate the sebaceous glands resulting in excess secretion of sebum, a fatty oil that lubricates the skin. The glands become blocked and inflamed, which causes blackheads and pimples. If the glands become infected, sebum and pus build up under the skin and larger pimples and cysts appear which can eventually lead to scarring and pitting. It is important to keep the skin clean and free from oil. Facial steaming opens blocked skin pores and clears out sebum. Do not squeeze acne spots as they may become infected and leave scars. Reduce stress and avoid refined sugar and foods. For mild cases of acne, topical exfoliants and face washes are usually sufficient for medium cases, beneficial preparations should contain benzoyl peroxide or salicylic acid for severe acne, topical or oral antibiotics may be necessary or vitamin A...

Tigaro Theory and the New Hypotheses

Severe acute pancreatitis induces severe fibrosis after repair of acute inflammation. Recurrent acute pancreatitis may produce chronic pancreatitis through a necrosis-fibrosis sequence. However, little evidence of acute pancreatitis, such as scarring, has been histologically observed in chronic pancreatitis.

Translaminar Epidural Injection Technique

The patient is placed in a prone position, with the neck slightly flexed and the forehead supported on a small sponge. The target site is the lamina at C7-T1 because there is less likely to be central stenosis at this level and a larger epidural space. The lamina of C7 is easily seen with C-arm fluoroscopy. No injection is attempted at the site of previous posterior surgical laminectomy due to epidural scarring. Following aseptic preparation and sterile draping, a 22-gauge spinal needle is directed under fluoroscopy to impact the posterior lamina using a paramidline approach (Fig. 10). The depth of the needle is marked with a small forceps attached to the needle at the junction of the skin, while injecting 2 to 3 cc of local anesthetic into the adjacent lamina and the posterior cervical muscles as the needle is withdrawn. A 20- or 22-gauge epidural needle is then inserted into the anesthetized skin and down to the bone margin of the lamina adjacent to the interlaminar space. The...

Use of Antifibrotic Agents

Intra- or postoperative application of topical mitomycin C or 5-fluorouracile in young children with a long life expectancy is associated with the risk of late toxicity and potential muta-genicity of these antimetabolites, even though the filtering procedures combined with the use of mitomycin are becoming increasingly routine in antiglaucomatous surgery. Further possible deleterious complications of filtering procedures with mitomycin C are rupture of thin-walled blebs, wound leakage, late endo-phthalmitis, and long-standing hypotony. Owing to extreme scleral thinning in buph-thalmia, the potential risk of localized retinal necrosis has also to be considered. However, in refractory cases the use of antimetabolites or other methods to prevent scarring seems unavoidable where goniosurgery and ab-externo procedures without antimetabolites have failed.

Behavioural expression and selfconcept

Reckless behaviour unaffected by punishment is typical of antisocial individuals, who are also exploitative, manipulative, demanding, and lacking in a sense of responsibility. An easy-going hedonistic attitude may be interrupted by rage, cruelty, and violence. Lying, truancy, running away from home, thefts, fights, substance abuse, and illegal activities may be typical experiences, beginning in early childhood. Tattoos and scars from self-mutilation are common, as well as a propensity towards substance abuse, delinquency, and criminality.

Integration of the Peritoneal Transport System

On the other hand, chronic inflammation occurs at a very slow rate and is due to the exposure of the peritoneum to noncompatible dialysis solutions. It is not known whether any solutions other than an isotonic salt solution could be truly compatible with these cells. The macrophages and the mesothelial cells are both stimulated by dialysis solutions to produce a myriad of cytokines, prostaglandins, and matrix proteins, such as collagen and hyaluronan. Hyaluronan is secreted into the peritoneal cavity and is deposited within the tissue. This along with fibronectin and other macromolecules that escape the inflamed endothelium results in a thickening and scarring of the submesothelial peritoneum. Stimulation of tissue fibrob-last results in greater deposition of matrix materials with further scarring. Parenchymal cells such as skeletal muscle may just be innocent bystanders, but their true role has not been elucidated. It is anticipated that the system in Figure 5...

Mitral Valve Replacement

Mitral valve surgery in patients with heavily calcified mitral annulus, mitral annulus abscess due to infective endocarditis, or destroyed mitral annulus because of previous MVR can be technically very demanding and associated with high operative mortality and morbidity. We believe that the best approach is to completely excise the diseased mitral annulus (calcium bar, abscess, or scar with old pledgets) and reconstruct it with either autologous pericardium or glutaral-dehyde fixed bovine pericardium. When the entire mitral annulus needs reconstruction, a strip of pericardium 2 cm wide and 10-12 cm long is sutured to the endocardium of the left ventricle posteriorly and to the intervalvular fibrous body superiorly. The other end of the pericardial patch is sutured to left atrial wall (care

Pantothenic acid and wound healing

In a number of animal studies, oral pantothenic acid or topically applied panthenol was shown to accelerate the closure of skin wounds.28-31 Most of the mechanistic research done in this area involves looking at the impact pantothenic acid has on fibroblast function and concomitant wound closure and scar formation. Substantial amounts of work have also focused on how pantothenic acid enhances both collagen synthesis and collagen cross-linking and the role this vitamin plays in altering trace elements that have an impact on wound healing. Studies have also been done with subjects who have had tattoos removed to determine the impact pantothenic acid has on the actual strength of scar tissue.35 In this study, 18 of 49 patients were supplemented for 21 d with both pantothenic acid (0.2 g d) and vitamin C (1.0 g d) prior to the removal of tattoos by successive resection. Hydroxyproline and trace element concentrations were measured in both skin and scar tissue. Fibroblast counts and...

Operative technique of functioning muscle transplantation to the extensor aspect of the forearm

A gradual weakening of her finger and thumb extensors, with progressive loss of function, particularly when eating and playing the piano. MRI revealed a large tumor of the posterior inteross-eous nerve. The proximal part just distal to the elbow appeared normal, however. Thus, it would be available to innervate a transplanted muscle. Rather than transfer a regional tendon, the decision was made to replace the nonfunctioning muscle. The procedure would be fairly straightforward, because the origin, insertion, and appropriate motor nerve would be readily available with no scarring.

Pathomorphological Features and Diagnostic Imaging

The abdomen may help to distinguish between GP scarring and neoplastic proliferation. The benign narrowing of the common bile duct in GP may be confirmed by endoscopic retrograde cholangiopancreatography (ERCP). The mass located on the upper surface of the pancreas is whitish yellow with an elastic hard surface. Morphologically, various features such as fibrous scarring of the groove area and pericholedochal fibrosisis with inflammatory infiltrates are commonly seen. The Santorini duct is dilated and contains protein plugs. The biliary stricture is produced by fibrous scarring and chronic inflammation around the distal common bile duct. Because of scarring of the groove and thickening of the duodenum, the common bile duct bends to the left. An ultrasound endoscopy shows a dilated duct in the pancreatic head. ERCP shows that a stricture of the intra-pancreatic common bile duct is smooth, symmetrical and tapering, and that a stricture of the main pancreatic duct is occasionally...

Extragastrointestinal manifestations

A desmoid is a mass of firm pale tissue, characteristically growing by expansion, usually rounded in shape. Desmoids begin as small scar-like foci of fibrosis in the retroperitoneal fat and, when large, typically extend around and between other structures such as the small or large bowel, ureters and major blood vessels. Histologically, these lesions are composed of sheets of elongated myofibrob-lasts, arranged in fascicles and whorls. The lesions have a dense, tough consistency and there is a variable amount of collagen. They are well vascularized and contain numerous small blood vessels that bleed profusely when incised.

Postoperative Imaging

These postsurgical changes can include perinephric fluid, fat necrosis, urine leak, scarring, or a defect at the operative site (Figs. 21 and 22). Hemostatic agents, such as oxidized cellulose (Surgicel, Johnson & Johnson, Arlington, Texas), may be present (51) and can mimic abscess formation (Fig. 23).

The Patient Who Cannot Be Fit with a Pessary

Not all female candidates can be successfully fit with a pessary. Typical reasons for inability to be fit include vaginal scarring with loss of vaginal caliber or length from previous surgery, severe urogenital atrophy, vaginal pain, and markedly restricted or enlarged vaginal introitus. In those with significantly increased vaginal caliber, performing a perineoplasty and subsequent refitting with a pessary should be considered. For elderly women with severe genital prolapse who are not, and will not become, sexually active, and cannot be fit with a pessary, consideration should be given to a colpocleisis performed under regional or local anesthesia.

Microscopic Findings in Idiopathic Myocarditis

Reparative changes within the interstitium range from loose granulation tissue with minimal alteration of the myocardial architecture to replacement by collagenous scar tissue. Increased vascularity suggesting angiogenesis may also be seen, along with compensatory hypertrophy of residual myocytes. The findings on the follow-up biopsies should be graded as persistent, healing (resolving), or healed (resolved) myocarditis according to the Dallas criteria. The progression to dilated cardiomyopathy should also be recorded.

Macular Degeneration

A 63-year-old man with age-related macular degeneration noted a gradual decrease in vision in his left eye. He had undergone indocyanine green enhanced diode laser photocoagulation 15 months earlier for choroidal neovascularization- On examination, his visual acuity in this eye was 20 160. Slit-lamp biomicroscopy (A) revealed an atrophic chorioretinal scar superonasal to the fovea and a neurosensory detachment extending inferotemporally passing beneath the fovea. The sub retinal fluid appeared cloudy with mild subretinal fibrosis.

Surgical Approaches

We will typically perform an abdominal sacro-colpopexy in a patient with advanced prolapse in which the vaginal apex reaches significantly above the ischial spines on vaginal examination, for whom maintaining normal sexual activity is very important, someone who will require another abdominal procedure for their vaginal prolapse such as an abdominal paravaginal repair, and someone with significant vaginal wall scarring, large apical fascial defects, or significant foreshortening of the vaginal canal. Vaginal approaches are typically performed in post-menopausal women for whom sexual activity may not be as important and in whom other reconstructive procedures can be appropriately performed vaginally. Obliterative procedures are performed in elderly women who are not, and will not, be sexually active, and who request the least invasive procedure for advanced vaginal prolapse. Laparo-scopic approaches are reserved for surgeons request laparoscopic skills adequate enough to...

Postoperative Problems

There are four types of postoperative problems injuries to vessels or nerves, inflammatory or infectious conditions (superficial and deep), bad scars or defacing, or joint stiffness. - Screws covered with sleeves of PMMA (polymethylmethacrylate) soaked in antibiotic (tobramycin) to prevent local infections 47 . The scars at the site of previous points of passage of wires or screws (Fig. 19) are an almost unavoidable inconvenience when dealing with axial or circular external fixation. These can be (within certain limits) avoided by a precise preoperative planning and by correctly performing the operation (insertion of the bone fixation elements avoiding tension of the soft tissues when no important modifications of the configuration in the postoperative phase are planned, and on the contrary, applying wires or screws by creating a reserve of soft tissues in cases of internal or external lengthening of the limb or correction of serious deformities, so an overload of tension of the soft...

New Developments In Imaging

Ples of microscopic functional changes are an increased ratio of cells to extracellular matrix, increased ratio of apoptotic to normal cells, increased concentration of the amino acid choline, oxygen perfusion, and increased capillary flow. Changes in all these variables have been imaged successfully in patients, and some of them in the orbit. Examples of macroscopic functional changes in the orbit are changes in tissue motion, or increased attachments to other tissues caused by scarring or invasive growth, which have also been imaged successfully in the orbit.

Acute Rheumatic Fever

The myocardial lesions consist of nonspecific lymphocytic myocarditis and Aschoff nodules. The latter may be found within the endocardium, myocardium, pericardium, and conduction system and are pathognomonic of acute rheumatic fever. They represent oval collections of histiocytes, lymphocytes, plasma cells, and giant cells (Aschoff cells) located within the interstitium adjacent to small blood vessels (Fig. 14-11 see color plate 31). This granulomatous stage of Aschoff nodules arises 1 to 2 months after the onset of clinical symptoms and develops within or near foci of fibrinoid necrosis. They are eventually replaced by collagenous scar tissue.

Bodily preoccupations

Individuals with BDD are preoccupied with the idea that some aspect of their appearance is unattractive, deformed, or 'not right' in some way. Concerns usually focus on the face or head but can involve any body area. (5,10> The skin, hair, and nose are most often disliked (e.g. acne, scarring, lines, or pale skin, hair thinning, or a large or crooked nose). Concern with bodily asymmetry (e.g. 'uneven' buttocks) is common. Although the concern usually focuses on specific areas, it may involve overall appearance. An example of this is muscle dysmorphia, in which patients think that their body build is small and puny, when in reality it is large and muscular. BDD by proxy consists of a preoccupation with supposed flaws in another person's appearance, which may lead to insistence that the person have surgery or dermatological treatment.

Practical management issues

Psychiatrists may need to interface with dermatologists, plastic surgeons, and other non-psychiatric physicians from whom patients have requested or are receiving treatment. Although no one can predict how a given patient will respond to such treatment, available data indicate that patients usually do not improve and may become worse. In some cases, such treatment precipitates psychosis, suicidal behaviour, or violence. For these reasons, it seems wise to advise patients to try psychiatric treatment before obtaining surgery, and to avoid treatment such as dermabrasion or isotretinoin. Patients who damage their skin by picking it often require and benefit from a combination of dermatological and psychiatric treatment, in which case it is important and beneficial for the psychiatrist and dermatologist to collaborate.

Divergence Of Small Gtpase Pathways In Dendrites

Actin nucleation may also be achieved by rac, through homologs of the WASP family termed WAVE Scar proteins. WAVE proteins do not possess a rac-binding motif, and therefore require intermediate factors. One such intermediate is the formation of a pentameric complex consisting of the rac-target Sra1 CYFIP1, together with Nap, Abi, HSPC300 and WAVE38. The relevance of this complex in dendrites is not known yet (however, see below and Figure 17.2 Colorplate 10). The other possibility for rac to activate WAVE is via the insulin receptor substrate of 53 kDa (IRSp53) which was shown by Miki et al.39 to bind and control of WAVE, thereby initiating actin nucleation in vitro. IRSp53 is prominently expressed in neurons where it is a major constituent of the postsynaptic density40, indicating that the IRSp53 WAVE pathway is likely to be involved in rac-dependent control of spine morphology. IRSp53 is targeted to synapses by interaction with PSD-9541-43. By siRNA and expression of dominant...

Modified McCall Culdoplasty

The remnants of uterosacral ligaments are found posterior and medial to the ischial spines. They can be identified more easily by using Allis or Kocher clamps attached to the vaginal epithelium at approximately 4 o'clock and 8 o'clock (at the old hysterectomy scar) to place tension on structures of the pelvic sidewall. The clamp is elevated straight upward placing tension on the uterosacral ligament. The contralateral index finger is simultaneously used to palpate the connective tissue condensations along the side of the pelvis (uterosacral ligaments). A long Allis clamp is placed high on each uterosacral ligament.

Differential Diagnosis in Cardiac Sarcoidosis

The differential diagnosis includes granulomatous and giant cell lesions of the heart. Granulomatous infections are uncommon in immunocompetent patients, but we routinely perform histochemical stains for fungal and mycobacterial microorganisms. In general, necrotizing granulomas are found in infectious lesions. Giant cell myocarditis is characterized by the presence of giant cells but, by definition, granulomas are absent. In hypersensitivity myocarditis, the histiocytic lesions are poorly formed and are centered on collagen fibers. Eosinophils are numerous, but multinucleated giant cells and fibrosis are not found. The granuloma-like lesions of acute rheumatic fever are poorly formed, and the giant cells are generally smaller and do not resemble Langerhans type. Foreign body-type giant cells surrounding catheter sheath fragments can be found in biopsy specimens of patients undergoing repeated biopsy procedures (Fig. 14-5 A). The edge of healing ischemic infarcts can contain giant...

Morphologic Findings in IGCM

At postmortem examination or at transplantation, confluent or multifocal areas of necrosis are easily observed in the heart. The weight of the heart is usually normal or slightly increased. The 4 chambers of the heart are uniformly involved in most cases. In the late or healed stages of the disease, the ventricular wall may appear thin, but this reflects diffuse scarring and not aneurysmal changes because islands of myocytes are found within the collagenous scar tissue (Fig. 14-15 C and 15 D see color plate 35). Endocardial and pericardial involvement have been described but the process is primarily centered on the myocardium. Litovsky and colleagues150 proposed classification of IGCM into acute, healing, and healed phases. The acute or active phase is described above and is distinguished by the abundant inflammatory response, loose connective tissue stroma, and numerous giant cells of macrophage origin. In the healing or resolving stage, granulation tissue and immature fibrosis...

Central Serous Chorioretinopathy Definition

Diagnostic considerations Ophthalmoscopy will reveal a serous retinal detachment, usually at the macula. In chronic cases, a fine brown and white pigment epithelial scar will develop at the site of the fluid effusion. Swelling in the central retina shortens the visual axis and produces hyperopia. The site of fluid effusion can be identified during the active phase with the aid of fluorescein angiography (Fig. 12.26a and b).

Femoral Vein Approach

The femoral vein approach has some advantages and disadvantages relative to the jugular vein approach. Advantages include freedom from risks inherent in the jugular approach such as inadvertent carotid puncture. In addition, some patients prefer the femoral approach it is less unpleasant than to have procedures through the neck. If multiple prior biopsies have been performed from the neck, scar tissue may begin to limit access and create more discomfort with sheath placement, in which case moving to the femoral approach may help. Disadvantages of the femoral approach include the need for a long sheath in which clots may develop, risk of deep venous thrombosis, and need for patients to remain supine for approximately 30 minutes after sheath removal. In addition, directing the bioptome across the tricuspid valve and to the appropriate region of the ventricle is difficult sometimes. The bioptomes used from the femoral approach may yield smaller samples than those from the neck, but...

Degenerative Retinal Disorders 337 1245 Age Related Macular Degeneration Definition

Serous detachment of the retina and or retinal pigment epithelium hemorrhages (Fig. 12.27 b). Fibrous scar (Fig. 12.27 c) c Late age-related macular degeneration The fibrous scar is a typical sign. c Late age-related macular degeneration The fibrous scar is a typical sign.

Animal models of Parkinsons disease based on the use of neurotoxins

Given the behavioral limitations of MPTP-intoxicated mouse model, species more closely related to humans have been used to mimic the symptoms of PD. We recently developed a model of PD in green monkeys with progressive MPTP intoxication at very low doses. After a few MPTP injections, the monkeys were assessed as normal on a monkey parkin-sonian rating scale but already displayed subtle behavioral changes in a reach and grasp test (Pessiglione et al., 2003). Indeed, whereas control animals had a fully appropriate trajectory when asked to take some food with or without an obstacle in front of their hand, MPTP-intoxicated monkeys had aberrant initial trajectories which were corrected by visual guidance. This suggests that at the early phase of the disease, some compensatory mechanisms may occur. Then, with further MPTP injections, the animals became symptomatic recovered and after more injections became parkinsonian with a stable disease. Neurochemical...

Adverse Effects of Recovery

The process of recovery of neural tissue sometimes results in several undesirable consequences. In the brain, epilepsy may follow scar formation. Central pain syndromes such as post-stroke pain, dystonia and abnormal posturing - possibly a sequel to abnormal neural connections - can be difficult to treat. Injury to the spinal cord may result in paraplegic pain and autonomic dysreflexia, which may also be from abnormal neural connections. Flexor spasms may follow hyperexcitability of damaged neurons. Phantom limb pain may result from abnormal central organization and reflex sympathetic dystrophy and causalgia may follow abnormal neural connections. In peripheral nerves, neuroma formation may result in neuropathic pain.

Strategy changes of neurotization before and after 2000

For shoulder abduction, nerve reconstruction is always superior to local muscle(s) transfers. The donor nerves include the Ph nerve, XI nerve, CMB nerve, XII nerve, and some from C5 or C6 in three- or four-root avulsion injury. The priority choice for recipient nerves is first the distal C5 if it is available. If distal C5 is not healthy because of scarring, the suprascapular nerve, the dorsal division of the upper trunk, or finally the axillary nerve are considered for neurotization. From the author's experience, if the distal C5 is well reinnervated, the suprascapular, dorsal division of the upper trunk, axillary nerve, and some radial nerve function (especially ECRL) can be all

Postmeningitic Hydrocephalus

Hydrocephalus may occur as the result of a range of infectious or inflammatory processes. The effects of chronic inflammation - organization of the inflammatory exudate with scarring or gliosis - can produce obstruction to CSF flow, both within the ventricular system and in the basal cisterns and cortical subarachnoid spaces. Bacterial, parasitic and granulomatous infections are much more likely to lead to hydrocephalus than viral infections. Ventricular enlargement rather than hydrocephalus may occur due to an ex-vacuo phenomenon. This is a result of the severe white matter damage or encephalomalacia that is commonly seen in the

Ts in Organ Specific Microvascular Alterations in Diabetes

ETs have been shown to be produced by both cardiomy-ocytes and endothelial cells. We have previously demonstrated upregulation of ET-1 along with ETA and ETB receptor expression in heart tissues of diabetic rats. Such alterations were associated with focal apoptosis of car-diomyocytes, scarring of the myocardium, and increased expression of ECM proteins. Inhibition of ET receptor signaling completely prevented these structural abnormalities. Furthermore, a duration-dependant alteration of chronotropic and inotropic responses to ET-1 has been demonstrated in isolated atria of diabetic rats. Recently, we have demonstrated that ET-1 may interact with sodium-hydrogen exchanger-1 (NHE-1) in mediating diabetes-induced structural and functional changes. NHE-1 may act as the downstream mediator in the development of ET-mediated functional and structural changes in diabetic myocardium.

Tuberculosis and Other Mycobacteria Donald E Gardner PhD Fellow ATS

TB is a particularly good illustration of an infectious disease process that involves an ecological lifelong balance between a host and a microbe. TB in humans is predominately an airborne infection of the lungs that is almost always initiated by inhalation. Once the organisms have been inhaled and deposited in the lung, these organisms can be found in the lung's phagocytic cells (alveolar macrophages) that tend to protect them from antibodies and other host immune defenses. Individual susceptibility to TB and the severity of the disease are based on the virulence of the organism, the duration of exposure, concomitant exposure to other toxicants, medication for treatment of other diseases, and the nutritional status of the host. Once the organism has survived the transport through the environment and has infected a susceptible host, the TB infectious process can be divided into two stages that are commonly referred to as primary and secondary infections. During the primary phase,...

Selected Bibliography of Journal Articles

Garg HG, Lippay EW et al. (1993) Comparison of the effects of interleukin-1 beta on proteoglycan synthesis by human skin and post-burn normal scar explant cultures. Biochem Mol Biol Int 31(3) 583-591 11. Clayman MA, Clayman SM et al. (2006) The use of collagen-glycosaminoglycan (Integra) for the repair of hypertrophic scars and keloids. J Burn Care Res 27(3) 404-409 12. Ward RS, Hayes-Lundy C et al. (1994) Evaluation of topical therapeutic ultrasound to improve response to physical therapy and lessen scar contracture after burn injury. J Burn Care Rehabil 15(1) 74-79

Sensorimotor Cortex Model

The central sulcus of either adult or adolescent monkeys is exposed through a frontal craniotomy under general anesthetic, taking great care not to damage the cortex. After opening the dura, the hand-face region of the sensorimotor cortex is identified with cortical stimulation and injected with alumina gel. Although different injection patterns have been used, one of the most successful is the Ward modification of the Kopeloff technique (Bakay and Harms, 1981). In this method, two injections are made 4mm apart in the precentral gyrus and two injections in the postcentral gyrus, paralleling each other. A 27-gauge needle is used for the injection, which is placed into the cortex to a depth of approximately 4 mm. A volume of 0.1ml of aluminum hydroxide (fully saturated solution) in the form of alumina gel is injected at each site. Each injection is made quite slowly to allow time for volume equilibrium to be reached before removing the needle. In general an injection under the pia is...

Chorioretinal Inflammatory Diseases

Case 9-12, Chorioretinal Scar from Previous Toxoplasmosis A 23-year-old man had a history of toxoplasmosis in both eyes. The left eye (A) was notable for an atrophic and hyperpigmented chorioretinal scar involving the central macula. The visual acuity in this eye was 20 80. An OCT image (B) taken through the scar displayed a complete loss of neurosensory retinal tissue consistent with an old, focal necrotizing retinitis. Increased reflectivity was observed from the retinal pigment epithelium (RPE) and choroid corresponding to epithelial hyperpigmentation and alteration of the choroidal architecture. The reflection from the choroid was fragmented due to shadowing by the hyperpigmented RPE.

Longterm Care and Outcome in Open Myelomeningocele

Re-operation to release the cord should be considered in any child with a significant clinical deterioration. There are often dense adhesions and thick scar, making surgery difficult, and consideration to expanding the dura with a patch should be given. The results of surgery are reported to be gratifying in that most children can be stabilized and pain is often improved 12 .

Autoimmune Disease Mechanisms

AD is thought to result from the aberrant activation of the immune system together with the failure of immunoregulatory mechanisms that normally maintain immune tolerance. Despite the heterogeneous clinical expression of AD in humans, it seems clear that most ADs share several or all of the following features. They are polyclonal, with rarely a defined inciting single antigenic epi-tope and by the time of clinical disease expression, there has been extensive epitope spreading and effector cell recruitment (Davidson and Diamond, 2001). The innate immune system and tissue environment probably play a vital role in determining whether an antigen will evoke an immune reaction or anergy toler-ance (Medzhitov and Janeway, 2002) and a genetic component is present, but not sufficient. Some genes encode for major histocompatibility complex (MHC) molecules, but multiple other genes on different chromosomes play a role. In insulin-dependent diabetes mellitus for example, at least 19 such regions...

Urethral Dilatation Incision or Reconstruction

Urethral dilatation has been used for many years as a treatment for recurrent cystitis, pelvic or bladder and ure-thral pain, and for nonspecific voiding dysfunction including bladder emptying dysfunction in women. Although frequently used to treat urethral syndrome or primary bladder neck obstruction in the female, this procedure often results in only temporary symptomatic relief and over time it may result in bladder outlet obstruction secondary to transmural urethral stenosis or stricture formation. The obstruction is caused by periurethral fibrosis and scarring of the urethral wall that results from multiple episodes of postdilatation bleeding or extravasation of urine into the periurethral tissues. This may result in rigidity of the urethral wall and narrowing of the urethral lumen. weighed against the complication of developing urinary incontinence. Curative therapy ranges from transurethral incision of the urethra to various forms of urethral reconstruction depending on the...

Urinary Tract Infection In Children

The ''classical'' teaching is that acute pyelonephritis is a serious disease that needs treating urgently, not only because the child is sick but also because it may lead to permanent renal scarring and eventually to chronic renal disease. This, in turn, is thought to lead to raised blood pressure and renal failure. The argument is then that early detection and treatment will lead to a reduced incidence of these major complications. Regardless, there is now good evidence that this late study should be performed at least five months after the acute episode, and most units now perform this late study at six months. If this study is abnormal, there is a consensus that the child is at risk of deterioration in renal function. Defects seen at this stage are traditionally referred to as scars. This is based on animal studies, showing that in acute pyelonephritis produced by direct intrarenal injection of bacteria (or similar models), a permanent scar may be produced. This takes us to the...

Vesicoureteric Reflux

The consensus here is that the indirect radionuclide cystogram is the method of choice for follow-up of proven reflux in children who are old enough to cooperate. Because it cannot supply morphological imaging, it cannot exclude abnormal anatomy, especially posterior urethral valves in boys. Therefore it is felt that at least one structural study micturating cystourethrography (MCUG), with or without urody-namics should be performed at first presentation. The rationale for follow-up (often not clearly formulated) is that if there is persisting reflux-accompanied urinary tract infections, surgical correction is indicated and will prevent infections, scarring, and deterioration in renal function. It is also often felt necessary to give long-term antibiotic prophylaxis as long as reflux persists. This is based on the experimental work of Risdon and Ransley, which showed that pyelonephritis developed in the setting of reflux, infection, and compound calyces.

Long Term Passive Implantation

After all tested survival times, implant sites were evaluated histologically in fixed sections stained using haematoxylin and eosin, and in frozen sections reacted for adenosine triphosphatase activity (Figure 3.4). None of the implanted articles were found to change the enzyme reactivity of surrounding muscle fibers. No obvious difference could be found in the degree of inflammatory reaction around the devices and the negative control articles when the implant sites were evaluated according to their contents of inflammatory cells of different types and the extent of fibrotic and necrotic change using scales similar to those described elsewhere.17 In addition, the thicknesses of capsules around the implants were measured and found to be similar around devices and control articles (Figure 3.5). In the first few months, implants were surrounded by a loosely structured connective tissue capsule about 100-500 microns thick that contained many inflammatory cells. In longer-term implants of...

Physical Examination

During vaginal examination, periurethral scarring may become apparent through observation and palpation. A lighted speculum is very helpful in the vaginal examination, especially in the detection of signs of erosion. The entire urethra should be palpated carefully for any tender area or mass. In cases of excessive scarring, the urethra will

Epithelial Downgrowth or Fibrous Ingrowth

The spreading epithelial blanket or scar tissue covers the outflow channels. The condition may develop due to the injury itself or from surgery the IOP elevation can be fairly high and difficult to treat. Prevention is crucial, avoiding full-thickness sutures in limbal wound repair (see Chap. 2.2) and placing the paracentesis slightly central to the limbus (see Chap. 2.5). Regarding therapy, surgery is the primary weapon cyst cell scar tissue removal cryopexy and endodiathermy 25, 37 . Removal of a scar must be done very carefully to avoid tissue rupture and bleeding (see Chap. 2.5).

Peripheral And Cranial Nerve Injury

Sir Sydney Sunderland's classification is another scheme that is often utilized and involves his proposed five grades of degree of injury 3 (Table 32.2). The first- and second-grade degrees of injury in Sunderland's scheme correspond to neurapraxic and axonotmetic injuries, respectively. The third-grade degree of injury is characterized by endoneurial damage, in addition to Wallerian degeneration. Recovery occurs at a similar rate to a second-grade-degree injury but is not as complete, because the compromised endoneurium no longer provides a clear conduit that the regenerating axons can follow. A fourth-grade-degree injury involves a nerve with continuity maintained, but with scar tissue disrupting the endoneurium and perineurium. Fascicular disorganization leads to minimal spontaneous functional recovery, because regenerating axons no longer reach their original targets. A fifth-grade-degree injury is complete transection of a nerve. This degree of injury is typically easy to...

Cardiac Retransplantation

Cardiac transplantation has evolved as the best therapeutic option for those with end-stage heart disease.1 However, despite improvements in selection processes, organ preservation, and immunosuppression, a percentage of patients still experience rejection of their graft necessitating a second transplant. Clinically, rejection is diagnosed and graded according to endomyocardial biopsy. In addition to acute and chronic rejection, some cardiac transplant patients are plagued by transplant coronary artery disease. This form of accelerated atherosclerosis differs from traditional atherosclerosis in that it is a concentric and diffuse hyper-plastic process. The internal elastic lamina remains intact, calcification of the vessels is rare, and intramyocardial vessels are involved as well. While coronary angiogra-phy is useful for the diagnosis of progressive narrowing, coronary angioplasty is seldom effective as discrete stenoses are unusual. Graft failure is the inevitable result. In...

Rodney K Chan Perry H Liu and Dennis P Orgill

Unlike amphibians, humans lack tissue regenerative abilities and generally respond to injury through scarring and contraction. Some exceptions, such as regeneration of liver tissue after partial hepatectomy, suggest that the capacity for regeneration exists. The skin also has the potential for repair and regeneration. In fact, wounds in the second trimester not only heal in utero with minimal scarring, but also achieve the strength of unwounded skin. Yet, in adults, chronic non-healing wounds are becoming a major problem, one made worse by our growing elderly population and a dramatic rise in the incidence of diabetes.

Evaluation And Planning

Figure 3 End result (three years postoperative) of granulation scarring of defect from transoral resection of verrucous carcinoma (Fig. 2). Figure 3 End result (three years postoperative) of granulation scarring of defect from transoral resection of verrucous carcinoma (Fig. 2).

Wound Reepithelialization

TGF-b is a multipurpose growth factor expressed ubiquitously during wound healing, but its major roles are the stimulation of endothelial cell migration and matrix deposition. There are several different TGF-b isoforms, but they interestingly all bind to the same receptor. TGF-bl is expressed early on in wound healing, whereas TGF-P3 is expressed late. TGF-P3 has also been shown to decrease scarring. Despite the expectedly decreased matrix deposition in TGF-b-receptor 1 deficient animals, increased wound angiogenesis is observed. This apparent paradox highlights the apparently contradictory effects of TGF-b in a wound and in culture. TGF-b inhibits angiogenesis in vitro, whereas the opposite occurs in vivo.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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