Digital imaging analysis to assess scar phenotype

In order to understand the link between the genetic background of patients and wound clinical outcomes, it is critical to have a reliable method to assess the phenotypic characteristics of healed wounds. In this study, we present a novel imaging method that provides reproducible, sensitive, and unbiased assessments of postsurgical scarring. We used this approach to investigate the possibility that genetic variants in orofacial clefting genes are associated with suboptimal healing. Red‐green‐blue digital images of postsurgical scars of 68 patients, following unilateral cleft lip repair, were captured using the 3dMD imaging system. Morphometric and colorimetric data of repaired regions of the philtrum and upper lip were acquired using ImageJ software, and the unaffected contralateral regions were used as patient‐specific controls. Repeatability of the method was high with intraclass correlation coefficient score > 0.8. This method detected a very significant difference in all three colors, and for all patients, between the scarred and the contralateral unaffected philtrum (p ranging from 1.20^?05 to 1.95^?14). Physicians’ clinical outcome ratings from the same images showed high interobserver variability (overall Pearson coefficient = 0.49) as well as low correlation with digital image analysis results. Finally, we identified genetic variants in TGFB3 and ARHGAP29 associated with suboptimal healing outcome.     

Small bowel obstruction in the virgin abdomen: the need for a mandatory laparotomy explored

Background

A laparotomy is still considered mandatory for patients without previous abdominal surgery presenting with a small bowel obstruction (SBO) because of a perceived high incidence of underlying lesions. However, there is no evidence in literature to support this assumption. We analyzed the etiology of SBO in this subgroup of patients to establish the need for a mandatory laparotomy.

Methods

A retrospective analysis was conducted over a 5-year period. Basic demographics, radiology results, operative findings, and outpatient investigations were analyzed.

Results

Of 689 patients presenting with an SBO, a total of 62 patients, 9.0%, had a virgin abdomen. A known underlying disease (inflammatory bowel disease, malignancy) was the cause in 13 patients. The remaining 49 patients had adhesions in 75.5% and a newly diagnosed malignancy in 10.2% as a cause.

Conclusions

Adhesions are by far the most likely cause of SBO in patients without previous abdominal surgery followed by a small number of newly diagnosed malignancies. Both prevalences are in equal proportion to patients with previous abdominal surgery. A trial of nonoperative management may therefore be justified.     

Technical aspects of the syndesmotic screw and their effect on functional outcome following acute distal tibiofibular syndesmosis injury

Introduction

Much of the currently available data on the technical aspects of syndesmotic screw placement are based upon biomechanical studies, using cadaveric legs with different testing protocols, and on surgeon preference. The primary aim of this study was to investigate the effect of the level of syndesmotic screw insertion on functional outcome. Further, the effects of number of cortices engaged, the diameter of the screw, use of a second syndesmotic screw and the timing of removal on functional outcome were tested.

Material and method

All consecutive patients treated for an ankle fracture with concomitant acute distal tibiofibular syndesmotic injury that had a metallic syndesmotic screw placed, between 1 January 2004 and 31 December 2010, were included. Patient characteristics (i.e., age at injury and gender), fracture characteristics (i.e., affected side, trauma mechanism, Weber fracture type and number of fractured malleoli), and surgical characteristics (i.e., level of screw placement, screw diameter, tri- or quadricortical placement, number of syndesmotic screws used and the timing of screw removal) were recorded. Outcome was measured using validated questionnaires, which were sent by post, and consisted of the American Orthopaedic Foot and Ankle Society ankle-hindfoot score (AOFAS), the Olerud–Molander Ankle Score (OMAS) and a single question Visual Analog Scale (VAS) for patient satisfaction with outcome.

Results

During the 7-year study period, 122 patients were treated for syndesmotic injury. A total of 93 patients (76%) returned the questionnaire. The median follow-up was 51 months. The outcome scoring systems showed an overall score for the entire group of 92 points for the AOFAS, 77 for the OMAS and 8.2 for the VAS. Outcome was statistically significantly influenced by the number of fractured malleoli, age, trauma mechanism and the level of screw insertion.

Conclusion

Overall, the functional outcome of acute syndesmotic injuries treated with a syndesmotic screw was good and mainly influenced by patient and fracture characteristics. Most different technical aspects of placement appeared not to influence these results. Only screw placement above 41 mm negatively influenced outcome.     

Dehydroepiandrosterone modulates T-cell response after major abdominal surgery

Background

The immune balance controlled by T-helper (Th)1 and Th2 cells is critical in protecting the host from pathogenic invasion, and its imbalance may increase susceptibility to infection in patients undergoing major surgery. The differentiation of naive T cells to Th1 and Th2 cells is largely driven by cytokines. In addition, steroid hormones have been shown to affect Th1/Th2 balance, particularly in autoimmune diseases. The regulation of Th1/Th2 balance in patients undergoing surgery and its potential clinical relevance remain unclear.

Materials and methods

Blood samples were obtained from patients both before and 2 h after major abdominal surgery. Peripheral blood mononuclear cells were isolated and cultured in wells coated with either anti-CD3 (direct T-cell stimulation) or phytohemagglutinin (PHA) (indirect T-cell stimulation), with or without 10⁻⁵ M dehydroepiandrosterone (DHEA). The release of interleukin (IL)-2, interferon gamma, and IL-10 was measured by an enzyme-linked immunosorbent assay, and the expression of CD4, CD8, and CD69 was determined by flow cytometry.

Results

DHEA decreased the release of IL-2 and IL-10 in directly (anti-CD3) and indirectly (PHA)-stimulated T cells from postoperative samples, whereas the release of interferon gamma in PHA-stimulated T cells was not affected. The distribution of CD4/CD8 was not significantly different after surgery or DHEA. DHEA was associated with a decrease in the expression of the activation marker CD69 on CD4⁺ T cells, whereas the activation of CD8⁺ T cells remained unchanged.

Conclusions

These results demonstrate that DHEA plays a critical role in controlling Th1/Th2 balance in the immediate postoperative period. Attenuation of both the Th1 and Th2 responses has been suggested to have immunoprotective effects. The role of DHEA in the regulation of Th1/Th2 balance in patients undergoing major abdominal surgery may, therefore, also be of significant clinical relevance and warrants further investigation.