Modelos avançados de pele humana 3D in vitro: epiderme bioimpressa e pele tricamada contendo hipoderme para avaliação de segurança e mimético de dermatite atópica nocaute de IL-13Rα2 para estudo da função barreira / Advanced in vitro 3D human skin models: bioprinted epidermis and trilayer skin containing hypodermis for safety assessment and atopic dermatitis mimetic with IL-13Rα2 knockout for barrier function study

A reconstrução de modelos avançados de pele tridimensional in vitro, que corresponda de forma mais fidedigna ao complexo microambiente da pele humana, depende da utilização de inovações tecnológicas e da adição de novos tipos celulares representativos da pele humana. Desta maneira, estes miméticos fornecem uma plataforma de alta relevância para estudos de fisiopatologia da pele, além de propiciar um sistema para a avaliação da segurança e eficácia de cosméticos e medicamentos alternativo ao uso de animais. Dessa maneira, o Capítulo I compara a performance de uma epiderme reconstruída humana (RHE) bioimpressa com a manual utilizando o teste in vitro de irritação cutânea descrito no guia OCDE número 439. Nossos resultados demonstram que ambos os modelos de pele exibiram morfologia estratificada e a função barreira epidérmica equivalente aos modelos validados. Nos testes de irritação in vitro, ambos modelos distinguiram corretamente as substâncias de referência, classificadas entre irritantes ou não-irritantes de acordo com o limiar de viabilidade de 50%. Esse resultado indica que a bioimpressora poderia ser de grande utilidade para a automação da reconstrução de modelos epidérmicos. O tecido hipodérmico possui importante papel na homeostase da pele humana. O Capítulo II aborda a reconstrução de uma pele tricamada, contendo a camada hipodérmica, além da epiderme e derme. Usando esferoides de adipócitos diferenciados in vitro, um modelo de pele tricamada em matriz de colágeno foi construído. Ao comparar este com a pele bicamada obtivemos maior expressão de loricrina e involucrina no modelo tricamada, indicando um potencial para maior função barreira, além de maior expressão de PPAR-γ. Testes de função barreira através da resistividade elétrica não demonstraram diferenças entre os modelos, mas a aplicação de SDS a 5 mg/ml por 18 horas induziu o aumento da viabilidade na pele tricamada. Além disso, após a aplicação de SDS a 2,5% para induzir uma irritação aguda, seguida de recuperação por 42h, obtivemos maior viabilidade na pele tricamada, indicando melhor recuperação pós-lesão irritativa induzida. A pele tricamada é promissora para estudos do metabolismo da pele humana e recuperação de lesões. A dermatite atópica (DA) é uma doença eczematosa de pele caracterizada por inflamação do tipo Th2 e alteração da barreira epidérmica. IL-13 e IL-4 são centrais no comprometimento da barreira epidérmica na DA. Entre os receptores de IL-13 em queratinócitos, o receptor IL-13Rα2, tem um papel controverso na alteração da barreira cutânea. O objetivo do Capítulo III foi estudar a deleção da expressão de IL-13Rα2 em RHE, que foram expostas a IL-4 e IL-13, e avaliadas conforme a expressão dos receptores e de proteínas alteradas na DA. As epidermes com knockout em IL-13Rα2 apresentaram redução da expressão de NELL2 (p<0,0021), tipicamente aumentadas na DA. Além disso, houve redução da expressão do receptor do IL-2Rγ. Assim, um possível papel de exacerbação da DA do receptor IL-13Rα2 deve ser estudado mais extensamente para ser caracterizado

The reconstruction of advanced three-dimensional in vitro skin models, which more reliably correspond to the complex microenvironment of human skin, depends on the use of technological innovations and the addition of new cell types representative of human skin.In this way, these mimetics provide a highly relevant platform for studies of skin pathophysiology, in addition to providing a system for evaluating the safety and efficacy of cosmetics and medicines alternative to animal use. In this way, Chapter I compares the performance of a bioprinted human reconstructed epidermis (RHE) with a manual one using the in vitro skin irritation test described in OECD guide number 439. Our results demonstrate that both skin models exhibited stratified morphology and the epidermal barrier function equivalent to validated models. In in vitro irritation tests, both models correctly distinguished the reference substances, classified as irritating or non-irritating according to the viability threshold of 50%. This result indicates that the bioprinter could be of great use for automating the reconstruction of epidermal models Hypodermic tissue plays an important role in the homeostasis of human skin. Chapter II addresses the reconstruction of a three-layer skin, containing the hypodermic layer, in addition to the epidermis and dermis. Using in vitro differentiated adipocyte spheroids, a trilayer skin model in collagen matrix was constructed. When comparing this with bilayer skin, we obtained greater expression of loricrin and involucrin in the trilayer model, indicating a potential for greater barrier function, in addition to greater expression of PPAR-γ . Barrier function tests using electrical resistivity did not demonstrate differences between the models, but the application of SDS at 5 mg/ml for 18 hours induced an increase in viability in the three-layer skin. Furthermore, after applying 2.5% SDS to induce acute irritation, followed by recovery for 42 hours, we obtained greater viability in the three-layer skin, indicating better recovery after induced irritant injury. Trilayer skin holds promise for studies of human skin metabolism and injury recovery. Atopic dermatitis (AD) is an eczematous skin disease characterized by Th2-type inflammation and alteration of the epidermal barrier. IL-13 and IL-4 are central to the impairment of the epidermal barrier in AD. Among the IL-13 receptors on keratinocytes, the IL-13Rα2 receptor has a controversial role in altering the skin barrier. The objective of Chapter III was to study the deletion of IL-13Rα2 expression in RHE, which were exposed to IL-4 and IL-13, and evaluated according to the expression of receptors and proteins altered in AD. Epidermis with IL-13Rα2 knockout showed reduced NELL2 expression (p<0.0021), typically increased in AD. Furthermore, there was a reduction in the expression of the IL-2Rγ receptor. Therefore, a possible AD exacerbation role of the IL-13Rα2 receptor should be studied more extensively to be characterized

Whole-body computed tomography is safe, effective and efficient in the severely injured hemodynamically unstable trauma patient / La Tomografía Computarizada Corporal Total es una herramienta segura, efectiva y eficiente en el paciente politraumatizado con inestabilidad hemodinámica

Abstract Trauma is a complex pathology that requires an experienced multidisciplinary team with an inherent quick decision-making capacity, given that a few minutes could represent a matter of life or death. These management decisions not only need to be quick but also accurate to be able to prioritize and to efficiently control the injuries that may be causing impending hemodynamic collapse. In essence, this is the cornerstone of the concept of damage control trauma care. With current technological advances, physicians have at their disposition multiple diagnostic imaging tools that can aid in this prompt decision-making algorithm. This manuscript aims to perform a literature review on this subject and to share the experience on the use of whole body computed tomography as a potentially safe, effective and efficient diagnostic tool in cases of severely injured trauma patients regardless of their hemodynamic status. Our general recommendation is that, when feasible, perform a whole body computed tomography without interrupting ongoing hemostatic resuscitation in cases of severely injured trauma patients with or without signs of hemodynamic instability. The use of this technology will aid in the decision-making of the best surgical approach for these patients without incurring any delay in definitive management and/or increasing significantly their radiation exposure.

Resumen El trauma es una compleja patología que requiere un equipo experimentado y multidisciplinario con una capacidad para la toma de decisiones Oportuna ya que en unos pocos minutos pueden representar la diferencia entre la vida y la muerte. Estas decisiones deben ser precisas para ser capaces de priorizar y controlar eficientemente las lesiones que puedan estar causando el compromiso hemodinámico. En esencia, este es el punto clave del concepto de control de daños en la atención del trauma. Con los nuevos avances tecnológicos, el equipo médico tiene a disposición múltiples herramientas imagenológicas de diagnóstico. Este artículo presenta una revisión de la literatura y descripción de la experiencia local con el uso de la tomografía corporal total como una herramienta diagnostica potencialmente segura, efectiva y eficiente en casos de pacientes con trauma severo sin importar su estado hemodinámico. La recomendación general, cuando sea posible, es que se debe realizar una tomografía corporal total sin interrumpir las maniobras de resucitación hemostática en casos de pacientes severamente traumatizados con o sin signos de inestabilidad hemodinámica. El uso de esta tecnología tiene como objetivo tomar decisiones pertinentes y definir el mejor abordaje quirúrgico para el paciente sin incurrir en tardanzas en el manejo definitivo o incrementar el tiempo de exposición a la radiación.

REBOA as a New Damage Control Component in Hemodynamically Unstable Noncompressible Torso Hemorrhage Patients / El REBOA como nuevo actor en el control de daños del paciente hemodinámicamente inestable con hemorragia no compresible del torso

Abstract Noncompressible torso hemorrhage is one of the leading causes of preventable death worldwide. An efficient and appropriate evaluation of the trauma patient with ongoing hemorrhage is essential to avoid the development of the lethal diamond (hypothermia, coagulopathy, hypocalcemia, and acidosis). Currently, the initial management strategies include permissive hypotension, hemostatic resuscitation, and damage control surgery. However, recent advances in technology have opened the doors to a wide variety of endovascular techniques that achieve these goals with minimal morbidity and limited access. An example of such advances has been the introduction of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which has received great interest among trauma surgeons around the world due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology. This article aims to describe the experience earned in the use of REBOA in noncompressible torso hemorrhage patients. Our results show that REBOA can be used as a new component in the damage control resuscitation of the severely injured trauma patient. To this end, we propose two new deployment algorithms for hemodynamically unstable noncompressible torso hemorrhage patients: one for blunt and another for penetrating trauma. We acknowledge that REBOA has its limitations, which include a steep learning curve, its inherent cost and availability. Although to reach the best outcomes with this new technology, it must be used in the right way, by the right surgeon with the right training and to the right patient.

Resumen La hemorragia no compresible del torso es una de las principales causas de muerte prevenibles alrededor del mundo. Una evaluación eficiente y apropiada del paciente traumatizado con hemorragia activa es la esencia para evitar el desarrollo del rombo de la muerte (hipotermia, coagulopatía, hipocalcemia y acidosis). Actualmente, las estrategias de manejo inicial incluyen hipotensión permisiva, resucitación hemostática y cirugía de control de daños. Sin embargo, los recientes avances tecnológicos han abierto las puertas a una amplia variedad de técnicas endovasculares que logran esos objetivos con una morbilidad mínima y un acceso limitado. Un ejemplo de estos avances ha sido la introducción del balón de resucitación de oclusión aortica; REBOA ( Resuscitative Endovascular Balloon Occlusion of the Aorta , por sus sigla en inglés ), el cual, ha tenido gran provecho entre los cirujanos de trauma alrededor del mundo debido a su potencial y versatilidad en áreas como trauma, ginecología y obstetricia, y gastroenterología. El objetivo de este artículo es describir la experiencia lograda en el uso del REBOA en pacientes con hemorragia no compresible del torso. Nuestros resultados muestran que el REBOA puede usarse como un nuevo actor en la resucitación de control de daños del paciente con trauma severo, para este fin, nosotros proponemos dos nuevos algoritmos para el manejo de pacientes hemodinámicamente inestables: uno para trauma cerrado y otro para trauma penetrante. Se reconoce que el REBOA tiene sus limitaciones, las cuales incluye un periodo de aprendizaje, su costo inherente y la disponibilidad. A pesar de esto, para lograr los mejores resultados con esta nueva tecnología, el REBOA debe ser usado en el momento correcto, por el cirujano correcto con el entrenamiento y el paciente correcto.

Vena cava inferior como factor predictor del shock en trauma: medición ecográfica / Inferior vena cava as a predictor of shock in trauma patients: sonographic measurement

Resumen Objetivo Establecer la medición ecográfica del diámetro de la vena cava inferior como factor predictor del shock en pacientes politraumatizados. Materiales y Método Estudio de corte transversal donde se determinó la medición ecográfica de la vena cava inferior a 40 pacientes que ingresaron a la Unidad de Politraumatizados (UPT) del Hospital General del Este "Dr. Domingo Luciani", en el período entre enero y abril de 2018. Se seleccionaron 2 grupos; el grupo 1: pacientes en shock , aquellos con tensión arterial sistólica menor a 90 mm Hg al ingreso, y el grupo 2: pacientes controles que mantuvieron cifras tensionales normales. El estudio de imagen de la vena cava inferior se realizó con el equipo de ecografía ALOKA prosound SSD-a5 y con el ultrasonido portátil MicroMaxx SonoSite , en el cual se midió el índice de colapsabilidad. Los hallazgos se registraron en la hoja de recolección de datos. El análisis estadístico se hizo con la prueba de t de student para muestras independientes y la valoración de puntos de corte diagnóstico se hizo con la prueba de ROC. Resultados La media del Índice de colapsabilidad (IC) de la VCI para el grupo control y de shock fue de 26 ± 12,7% y de 58,5 ± 5,9%, respectivamente; El índice de colapsabilidad fue > 50% en todos los pacientes del grupo de shock . Conclusiones La medición del diámetro de la VCI es un predictor de shock , siendo el IC el parámetro más sensible y específico.

Aim To establish the sonographic measurement of the diameter of the inferior vena cava as a predictor of shock in trauma patients. Materials and Method A cross-sectional study to determined the sonographic measurement of the inferior vena cava to 40 patients attended at Hospital Domingo Luciani trauma unit, in the period between January and April of 2018. Two groups were selected; group 1: shock patients, those with systolic blood pressure lower than 90 mm Hg, and the group 2: control patients that kept normal blood pressure. The image study of the inferior vena cava was carried out with the ALOKA prosound ultrasound equipment SSD a5 and with the portable ultrasound MicroMaxx SonoSite, in which the collapsibility index was measured. The findings were recorded in the data collection sheet. The statistical analysis proposed for the comparison of averages was made with the student's t-test for independent samples and the assessment of diagnostic cut-off points was made with a ROC curve. Results the mean of collapsability index of de IVC for control and shock group were 26 ± 12,7% and 58,5 ± 5,9%, respectively; The collapsability index (CI) was > 50% in all patients of shock group. Conclusions The measurement of the ICV diameter is a predictor of shock, being the IC the most sensitive and specific parameter.

Altered thalamic neurotransmitters metabolism and functional connectivity during the development of chronic constriction injury induced neuropathic pain

BACKGROUND: To investigate the thalamic neurotransmitters and functional connections in the development of chronic constriction injury (CCI)-induced neuropathic pain. METHODS: The paw withdrawal threshold was measured by mechanical stimulation the right hind paw with the von frey hair in the rats of CCI-induced neuropathic pain. The N-acetylaspartate (NAA) and Glutamate (Glu) in thalamus were detected by magnetic resonance spectrum (MRS) process. The thalamic functional connectivity with other brain regions was scanned by functional magnetic resonance image (fMRI). RESULTS: The paw withdrawal threshold of the ipsilateral side showed a noticeable decline during the pathological process. Increased concentrations of Glu and decreased levels of NAA in the thalamus were significantly correlated with mechanical allodynia in the neuropathic pain states. The thalamic regional homogeneity (ReHo) decreased during the process of neuropathic pain. The functional connectivity among the thalamus with the insula and somatosensory cortex were significantly increased at different time points (7, 14, 21 days) after CCI surgery. CONCLUSION: Our study suggests that dynamic changes in thalamic NAA and Glu levels contribute to the thalamic functional connection hyper-excitation during CCI-induced neuropathic pain. Enhanced thalamus-insula functional connection might have a significant effect on the occurrence of neuropathic pain.

Nursing team knowledge on care for patients with fungating wounds / Conocimiento del equipo de enfermería sobre cuidados con pacientes con úlceras neoplásicas / Conhecimento da equipe de enfermagem sobre cuidados com pacientes com feridas neoplásicas

ABSTRACT Objective: to evaluate the nursing team knowledge of a cancer hospital on care for patients with Malignant Fungating Wounds (MFW) and to analyze associated sociodemographic and educational factors. Method: an observational and cross-sectional study, conducted between September and October 2015, after approval by the Research Ethics Committee. A questionnaire was applied containing sociodemographic, educational and related components to the accomplishment of dressings, dressings choice and orientation. Data were analyzed by using Chi-square, Fisher's exact test, Student's t-Test and Pearson's correlation. Results: 37 professionals participated in the study, most of whom were technicians (56.8%), women (91.9%) and with a mean age of 32 years. The professionals presented 56.5% of correct answers. There were no statistically significant associations between sociodemographic/educational variables and number of correct answers. Conclusion: there was a lack of important knowledge about care for patients with MFW, which should guide strategies for the oncology staff training.

RESUMEN Objetivo: evaluar el conocimiento del equipo de enfermería de un hospital oncológico sobre el cuidado de pacientes con Úlceras Neoplásicas Malignas (UNM) y analizar factores sociodemográficos y educativos asociados. Método: estudio observacional y transversal, realizado entre septiembre y octubre de 2015, tras la aprobación por el Comité de Ética en Investigación. Se aplicó un cuestionario que contenía componentes sociodemográficos, educativos y relacionados con la realización de curativos, elección de coberturas y orientación. Los datos fueron analizados a través del Test Qui-Cuadrado, Exacto de Fisher, Test t de Student y correlación de Pearson. Resultados: en el estudio 37 profesionales, siendo la mayoría técnicos (56,8%), mujeres (91,9%) y con edad media de 32 años. Los profesionales presentaron un 56,5% de aciertos. No hubo asociaciones estadísticamente significativas entre variables sociodemográficas/educativas y número de aciertos. Conclusión: se observó déficit de conocimientos importantes sobre el cuidado de pacientes con UNM, lo que debió orientar estrategias para capacitación de los equipos actuantes en Oncología.

RESUMO Objetivo: avaliar o conhecimento da equipe de enfermagem de um hospital oncológico sobre o cuidado de pacientes com Feridas Neoplásicas Malignas (FNM) e analisar fatores sociodemográficos e educacionais associados. Método: estudo observacional e transversal, realizado entre setembro e outubro de 2015, após aprovação por Comitê de Ética em Pesquisa. Foi aplicado questionário contendo componentes sociodemográficos, educacionais e relacionados à realização de curativos, escolha de coberturas e orientação. Os dados foram analisados por meio do Teste Qui-Quadrado, Exato de Fisher, Teste t de Student e correlação de Pearson. Resultados: participaram do estudo 37 profissonais, sendo a maioria técnicos (56,8%), mulheres (91,9%) e com idade média de 32 anos. Os profissionais apresentaram 56,5% de acertos. Não houve associações estatisticamente significativas entre variáveis sociodemográficas/educacionais e número de acertos. Conclusão: observou-se déficit de conhecimentos importantes sobre o cuidado de pacientes com FNM, o que deve nortear estratégias para capacitação das equipes atuantes em Oncologia.

Qualidade de vida de pessoas com feridas crônicas / Calidad de vida de personas con heridas crónicas / Quality of life of people with chronic wounds

Resumo Objetivo: Avaliar a qualidade de vida de pessoas com feridas crônicas. Métodos: Estudo transversal realizado com 176 pessoas com feridas crônicas em acompanhamento ambulatorial e domiciliar em um serviço público de saúde. Foram utilizados: formulário para a caracterização sociodemográfica, clínica e terapêutica e o questionário Cardiff Wound Impact Schedule para a mensuração da qualidade de vida. As análises foram descritivas e inferenciais empregando-se os testes t de Student, ANOVA, Mann Whitney e Kruskal-Wallis. Resultados: Dentre as pessoas acompanhadas em domicílio, predominaram lesões de origem vasculogênicas, com tempo de existência superior a 12 meses e área de até 25 cm2. No ambiente ambulatorial, prevaleceram feridas vasculogênicas e traumáticas, com tempo máximo de seis meses e extensão de até 25 cm2. Os fatores clínicos associados à qualidade de vida foram: tempo de duração da lesão, etiologia da lesão, grande extensão, aspecto do exsudato, presença de odor e de dor. O domínio de QV "bem-estar" apresentou maior impacto negativo decorrente da presença de lesão. Conclusão: Os fatores clínicos influenciaram diretamente os domínios de QV, sendo necessária a utilização de estratégias diferenciadas com o intuito de reduzir o impacto na QV por se tratarem de aspectos que poderiam ser atenuados ou evitados mediante a avaliação da lesão e a escolha do tratamento adequado.

Resumen Objetivo: Evaluar la calidad de vida de personas con heridas crónicas. Métodos: Estudio transversal realizado con 176 personas con heridas crónicas con seguimiento ambulatorio y domiciliario en un servicio público de salud. Se utilizó: formulario para la caracterización sociodemográfica, clínica y terapéutica y el cuestionario Cardiff Wound Impact Schedule para la medición de la calidad de vida. Los análisis fueron descriptivos e inferenciales y se aplicaron las pruebas t de Student, ANOVA, Mann Whitney y Kruskal-Wallis. Resultados: Entre las personas con seguimiento domiciliario, predominaron lesiones de origen vascular, con tiempo de existencia superior a 12 meses y área de hasta 25 cm2. En el ambiente ambulatorio, prevalecieron heridas vasculares y traumáticas, con tiempo máximo de seis meses y extensión de hasta 25 cm2. Los factores clínicos asociados a la calidad de vida fueron: tiempo de duración de la lesión, etiología de la lesión, extensión grande, aspecto del exudado, presencia de olor y dolor. El dominio de CV "bienestar" presentó mayor impacto negativo como resultado de la presencia de la lesión. Conclusión: Los factores clínicos influyeron directamente los dominios de CV y es necesaria la utilización de estrategias diferenciadas con la intención de reducir el impacto en la CV por tratarse de aspectos que podrían ser atenuados o evitados mediante la evaluación de la lesión y la elección del tratamiento adecuado.

Abstract Objective: To evaluate the quality of life of people with chronic wounds. Method: Cross-sectional study carried out with 176 people with chronic wounds in outpatient and home care in a public health service. The following instruments were used: a sociodemographic, clinical and therapeutic characterization form and the Cardiff Wound Impact Schedule questionnaire for measuring quality of life. The analysis was descriptive and inferential and used the Student's t-test, the ANOVA test and the Mann Whitney and Kruskal-Wallis tests. Results: Among patients in home follow-up, the predominant characteristics were lower limb ulcers, persisting for more than 12 months and with an area of up to 25 cm2. In the outpatient environment, lower limb ulcers and traumatic wounds prevailed, with a maximum duration of six months and size of up to 25 cm2. The clinical factors associated with quality of life were: duration of wound, wound etiology, larger size, type of exudate, presence of odor and pain. The QoL domain "well-being" was the most affected by the presence of the wound. Conclusion: Clinical factors directly influenced the QoL domains, and it is necessary to use differentiated strategies in order to reduce the impact of wounds on QoL, since the factors can be attenuated or avoided by evaluating the wound and choosing the appropriate treatment.

Reanimación con control de daños en el trauma grave pediátrico / Damage control resuscitation in pediatric severe trauma

INTRODUCCIÓN: El trauma es una importante causa de morbimortalidad en la población pediátrica, alcanzando el primer lugar en mortalidad en nuestro país, sin considerar las patologías perinatales y las malformaciones congénitas. Un porcentaje importante de las muertes precoces y tardías secundarias a esta causa, así como sus secuelas, podrían prevenirse con una óptima y oportuna reanimación. OBJETIVOS: Revisar -a la luz de la evidencia existente- la atingencia de la reanimación con control de daños (RCD) en el trauma pediátrico grave, con énfasis en el manejo médico. MATERIAL Y MÉTODOS: Se usó la base de datos PubMed, Cochrane Library y Google académico, empleando como términos de búsqueda (MeSH): trauma, politrauma, reanimación, control de daños, líquidos de reanimación, hipotensión permisiva, coagulopatía, transfusión masiva y niños. RESULTADOS: El concepto de RCD puede ser aplicado en el trauma grave en niños, teniendo en cuenta sus particularidades anatomo-fisiológicas. El principio se basa en el manejo de la tríada letal (coagulopatía, acidosis e hipotermia) asociado a una cirugía con control de daños. En este contexto se analiza la limitación de cristaloides, la hipotensión permisiva y la reanimación hemostática en el manejo inicial del trauma pediátrico gra ve. CONCLUSIONES: Estudios futuros deberán establecer el verdadero rol de la hipotensión permisiva, la relación óptima de hemoderivados a transfundir y la mejor estrategia para predecir la activación de protocolos de transfusión masiva y su impacto en niños con trauma grave.

INTRODUCTION: Trauma is an important cause of morbidity and mortality in the pediatric population. It has the first place in mortality in our country without considering perinatal pathologies and congenital malformations. An important percentage of early and late deaths secondary to this cau se, as well as its sequelae, could be prevented with optimal and timely resuscitation. OBJECTIVE: To review the applicability of damage control resuscitation (DCR) in severe pediatric trauma, with emphasis on medical management. Material and Methods: The PubMed, the Cochrane Library and the Google academic database were used. Search terms (MeSH) were: trauma, polytrauma, resuscitation, damage-control, fluids, permissive hypotension, coagulopathy, massive transfusion and children. RESULTS: The concept of DCR can be applied to severe pediatric trauma, taking into account their anatomical and physiological characteristics. The principle is based on the management of the lethal triad (coagulopathy, acidosis and hypothermia) associated with damage control surgery. Limitation of crystalloids, permissive hypotension and hemostatic resuscitation are reviewed in the initial treatment of severe pediatric trauma. CONCLUSION: Future studies should establish the true role of permissive hypotension, the optimal relationship between blood products and the best strategy to predict the activation of massive transfusion protocols and their impact on children with severe trauma.

Hypothermia in trauma

The number of polytrauma patients in high energy accidents brought to trauma centers is increasing day by day. For their management we require a multidisciplinary team capable of performing lifesaving maneuvers following the sequence of resuscitation protocols. The physiological response in a patient with trauma is usually hypovolemic shock. The compensatory mechanisms are activated to improve redistribution of the flow and maintain systemic vascular resistance. During the transitional period rational and goal-directed fluid therapy and prevention of inadequate tissue perfusion and impaired metabolic exchange at the microcirculatory level take precedence. Trauma kills by acidosis, hypothermia and coagulopathy- together called the "mortal triad"- which develop as a consequence of the metabolic changes induced by polytrauma. Hypothermia as part of the triad in the polytrauma patient is an indicator of injury severity and is associated with an increase in mortality. In the case of trauma patients, the presence of hypothermia is related to inability of the body systems to maintain temperature in the face of increased heat loss, decreased production and/or alterations in thermoregulation. The hemodynamic response to the decrease in temperature begins with peripheral vasoconstriction, myocardial dysfunction and electrical instability develops as a consequence of the metabolic changes induced by polytrauma. The complications of hypothermia include activation of the coagulation cascade, triggering of acidosis, endothelial dysfunction, inflammatory cascade activation, consumption coagulopathy, hypoxia, cell death, multiple organ dysfunction etc. This review highlights the main aspects of the pathophysiological derangements occurring as a result of trauma

Cardiovascular Effects of Shock and Trauma in Experimental Models. A Review

Abstract Experimental models of human pathology are useful guides to new approaches towards improving clinical and surgical treatments. A systematic search through PubMed using the syntax (shock) AND (trauma) AND (animal model) AND (cardiovascular) AND ("2010/01/01"[PDat]: "2015/12/31"[PDat]) found 88 articles, which were reduced by manual inspection to 43 entries. These were divided into themes and each theme is subsequently narrated and discussed conjointly. Taken together, these articles indicate that valuable information has been developed over the past 5 years concerning endothelial stability, mesenteric lymph, vascular reactivity, traumatic injuries, burn and sepsis. A surviving interest in hypertonic saline resuscitation still exists.

Otimização hemodinâmica em trauma grave: uma revisão sistemática e metanálise / Hemodynamic optimization in severe trauma: a systematic review and meta-analysis

Objetivo: O trauma grave pode associar-se a ocorrência de importante choque hemorrágico e ao comprometimento da perfusão dos órgãos. Formulamos a hipótese de que o tratamento direcionado por objetivo conferiria benefícios em termos de morbidade e mortalidade, em casos graves de trauma. Métodos: Realizamos uma busca sistemática nas bases de dados MedLine, Embase e Cochrane Controlled Clinical Trials Register com relação a pacientes vítimas de trauma grave. A mortalidade foi o desfecho primário dessa revisão. Os desfechos secundários incluíram taxas de complicações, duração da permanência no hospital e na unidade de terapia intensiva, e o volume de fluidos administrados. A metanálise foi realizada utilizando o programa de computador RevMan, e os dados apresentados são as odds ratios (OR) para desfechos dicotomizados e as diferenças médias e diferenças médias padrão para desfechos contínuos. Resultados: Foram analisados quatro estudos clínicos randomizados e controlados, que incluíram 419 pacientes. O risco de mortalidade foi significantemente reduzido nos pacientes com tratamento direcionado por objetivo, em comparação ao grupo controle (OR=0,56; IC95%: 0,34-0,92). A duração da permanência na unidade de terapia intensiva (DM: 3,7 dias; IC95%: 1,06-6,5) e no hospital (DM: 3,5 dias; IC95%: 2,75-4,25) foi significantemente mais curta ...

Objective: Severe trauma can be associated with significant hemorrhagic shock and impaired organ perfusion. We hypothesized that goal-directed therapy would confer morbidity and mortality benefits in major trauma. Methods: The MedLine, Embase and Cochrane Controlled Clinical Trials Register databases were systematically searched for randomized, controlled trials of goal-directed therapy in severe trauma patients. Mortality was the primary outcome of this review. Secondary outcomes included complication rates, length of hospital and intensive care unit stay, and the volume of fluid and blood administered. Meta-analysis was performed using RevMan software, and the data presented are as odds ratios for dichotomous outcomes and as mean differences (MDs) and standard MDs for continuous outcomes. Results: Four randomized, controlled trials including 419 patients were analyzed. Mortality risk was significantly reduced in goal-directed therapy-treated patients, compared to the control group (OR=0.56, 95%CI: 0.34-0.92). Intensive care (MD: 3.7 days 95%CI: 1.06-6.5) and hospital length of stay (MD: 3.5 days, 95%CI: 2.75-4.25) were significantly shorter in the protocol group patients. There were no differences in reported total fluid volume or blood transfusions administered. Heterogeneity in reporting among the studies prevented quantitative analysis of complications. Conclusion: Following severe trauma, early goal-directed therapy was associated with lower ...

Implicación del traumatismo en la fisiopatología del pie diabético / Effect of traumatismo on the physiopathology of the diabetic foot

El pie diabético es el resultado de la interacción de factores sistémicos o predisponentes (neuropatía, microangiopatía y macroangiopatía), sobre los que actúan factores desencadenantes y agravantes. Con el objetivo de evaluar la implicación del traumatismo en la fisiopatología del pie diabético, se realizó una búsqueda bibliográfica en bases de datos nacionales e internacionales, se revisaron los trabajos hasta el 2011; los términos utilizados fueron: definición, concepto, traumatismo y fisiopatología del pie diabético, en idioma español e inglés. Se constató que el traumatismo en términos generales, solo es tratado en esta enfermedad como parte de los factores desencadenantes extrínsecos que se clasifican en mecánicos, térmicos o químicos; lo cual es avalado por cinco definiciones referidas a esta enfermedad. Se concluye que la limitada interpretación de la implicación del traumatismo en la fisiopatología del pie diabético, unida a una pobre interpretación de este factor en los diferentes conceptos conocidos, favorece la elaboración de una nueva definición de esta enfermedad.

The diabetic foot is the result of the interaction of systemic or predisposing factors (Neuropathy, Microangiopathy and Macroangiopathy) upon which unleashing aggravating factors also act. With the objective of evaluating the implications of traumatism in the physiopathology of the diabetic foot, literature review was made in national and international databases to analyze the papers published until 2011. The terms were definition, concept, traumatism and physiopathology of the diabetic foot in Spanish and English. It was verified that traumatism is generally addressed in this disease as part of the extrinsic unleashing factors that are classified into mechanical, thermal or chemical, which is supported on five definitions of this disease, one of them put forward by a domestic author. It was concluded that the restricted interpretation of the implication of traumatism for the physiopathology of the diabetic foot together with poor interpretation of this factor in the various concepts already known makes it possible to prepare a new definition of this disease.

Uso de métodos complementares na inspeção post mortem de carcaças com suspeita de tuberculose bovina / Use of complementary methods in post mortem inspection of carcasses with suspected bovine tuberculosis

O objetivo foi utilizar métodos complementares de diagnóstico (histopatológicos, bacteriológicos e moleculares), no julgamento de lesões suspeitas de tuberculose observadas durante a inspeção post mortem de rotina em abatedouros. Foi acompanhado o abate e a inspeção de 41.193 bovinos, sadios ao exame ante mortem, em sete abatedouros no estado de Mato Grosso. Carcaças de 198 (0,48%) animais apresentaram lesões, sendo 182 (92,0%) classificadas como granulomatosas ou piogranulomatosas na avaliação histopatológica. Entretanto, na baciloscopia, não foi evidenciada a presença de bacilo álcool-ácido resistente (BAAR). Mycobacterium bovis foi isolado em três (1,5%) lesões, provenientes de linfonodos retrofaringeanos de bovinos com até três anos de idade. Quando usado a PCR múltipla (m-PCR) diretamente nos fragmentos de tecido, detectou-se a presença de DNA de M. bovis em 14 (7,0%) lesões, incluindo as três amostras identificadas na análise bacteriológica. O julgamento das lesões pelo exame macroscópico concordou em 93,0% (184/198) com os resultados obtidos por meio da PCR. A fim de evitar equívocos durante a avaliação, principalmente das lesões paucibacilares, como as encontradas neste estudo, recomenda-se a utilização de testes complementares rápidos e confirmatórios. A m-PCR, associada à inspeção post mortem de rotina, demonstrou ser uma técnica promissora para a vigilância da tuberculose bovina em abatedouros, contribuindo para o sucesso do programa de erradicação da tuberculose bovina.

The aim of this study was used diagnostic methods (histopathological, bacteriological and molecular) in the trial of suspected tuberculosis lesions observed during routine post mortem inspection in abattoirs. A total of of 41,193 cattle, which appeared healthy in ante mortem examination, slaughtered in seven abattoirs in the state of Mato Grosso, Brazil were examined. The carcasses of 198 (0.48%) animals showed lesions, of which 182 (91.9%) were classified as granulomatous or pyogranulomatous by histopathological analysis. However, at bacilloscopy, the presence of acid-fast bacilli (AFB) was not detected. Mycobacterium bovis was recovered from 3 (1.5%) samples, all from retropharyngeal lymph nodes in cattle up to three years old. When multiplex PCR (m-PCR) was performed directly on fragments of injured tissue, M. bovis DNA was detected in 14 (7.0%) samples including the same 3 bacteriologically positive samples. Evaluation of lesions by macroscopic analysis agreed 93% (184/198) with bacteriological culturing and the molecular test. To avoid misinterpretation during the examination, mainly of paucibacillary lesions such as those found in the samples analyzed, the use of rapid and unequivocal complementary tests such as mPCR is recommended. Molecular diagnosis, combined with routine post mortem inspection, proved to be a promising technique to improve the surveillance of TB in abattoirs, contributing to the success of the bovine tuberculosis eradication program.

Tratamento clínico das feridas - curativos / Clinical treatment of wounds – dressings

O tratamento das feridas inclui métodos clínicos e cirúrgicos, entre os clínicos, o curativo é o mais frequentemente utilizado. Um vasto arsenal terapêutico, composto por curativos passivos, os com princípios ativos, inteligentes, biológicos e terapia por pressão negativa é capaz de auxiliar no reparo do tegumento em várias situações. Os curativos são utilizados para melhorar as condições do leito da ferida podendo ser, em algumas ocasiões, o próprio tratamento definitivo. Em muitas situações é apenas a etapa intermediária para o tratamento cirúrgico. A opção do tipo de curativo a ser utilizado deve ser baseada no conhecimento das bases fisiopatológicas da reparação tecidual sem nunca esquecer o quadro sistêmico do paciente...

The treatment of wounds includes clinical and surgical methods, among the clinical the dressings are the most often used. A vast therapeutic arsenal it is composed by passive, active, intelligent and biological dressings; negative pressure therapy - vacuum can also assist various situations in wound repair. Dressings are used to improve the conditions of the wound bed and in some occasions they can be considered the definitive treatment whereas in others, only an intermediate step to the surgical treatment. The choice of material for the bandage should included biochemical and physiopathological knowledge of the wound healing process, keeping in mind the existing systemic problems of the patient...

Úlceras venosas em membros inferiores / Venous ulcer in lower extremities

A úlcera venosa crônica de membros inferiores é extremamente desgastante para o paciente e familiares, deteriorando a qualidade de vida e a produtividade das pessoas. Apesar de ser um problema comum nas unidades de saúde, as úlceras venosas não possuem tratamento adequado na maioria dos serviços devido principalmente ao desconhecimentode sua fisiopatologia e dos métodos terapêticos. Entre as medidas terapêuticas complexas descrita na literatura, a prevenção e o diagnóstico precoce são as etapas primordiais para o tratamento adequado desses pacientes, minimizando as sequelas físicas e psicológicas de uma lesão ulcerada em membros inferiores...

The lower limbs chronic venous ulcers are extremely stressful for patients and their families due to the physical limitation and the need of special care caused by that disease, which is responsible for the decrease of their life quality and productivity. Despite being a common problem in health care units,venous ulcers do not have adequate treatment in most of these specialized services mainly because of the ignorance of pathophysiology and therapists. Among the complex therapeutic measures described inthe literature, prevention and early diagnosis are the primary steps of a proper treatment; minimizing, thus,the physical and psychological consequences brought to lower limb ulcerations...

Effects of platelet-rich plasma gel on skin healing in surgical wound in horses / Efeitos do gel de plasma rico em plaquetas na cicatrização de feridas cirúrgicas na pele de cavalos

PURPOSE: To establish a low-cost method to prepare platelet-rich plasma (PRP) and evaluates the potential of platelet derived factors to enhance wound healing in the surgical wounds in equine. METHODS: To obtain a PRP gel, calcium gluconate and autologous thrombin were added to platelet-rich plasma. For the tests six saddle horses were used and two surgical incisions were made in each animal. Wounds were treated with PRP gel or untreated. Sequential wound biopsies collected at Treatment 1: at days 5 and 30 and Treatment 2: at days 15 and 45 post wounding permitted comparison of differentiation markers and wound repair. RESULTS: The optimal platelets enrichment over 4.0 time's baseline values was obtained using 300 g for 10 min on the first centrifugation and 640 g for 10 min on the second centrifugation. CONCLUSION: Wounds treated with PRP gel exhibit more rapid epithelial differentiation and enhanced organization of dermal collagen compared to controls in equine.

OBJETIVO: Estabelecer um método econômico na preparação de plasma rico em plaquetas (PRP) e avaliar se os fatores derivados destas plaquetas aceleram a cicatrização de feridas cirúrgicas em cavalos. MÉTODOS: Gluconato de cálcio e trombina autógena foram adicionados ao PRP para a obtenção do gel de PRP. Foram usados seis cavalos de sela, cada um dos quais sofreu duas incisões cirúrgicas. Uma destas incisões foi tratada com gel de PRP e a outra suturada de maneira tradicional (controle). A biópsia das feridas foi coletada de maneira seqüencial; Tratamento 1. nos dias 5 e 30 e Tratamento 2. nos dias 15 e 45 do período pós-operatório permitindo uma comparação na diferenciação epitelial e no reparo das feridas. RESULTADOS: O enriquecimento das plaquetas obtido através de uma primeira centrifugação usando 300 g por 10 minutos e uma segunda 640 g por 10 minutos acelerou quatro vezes a reparação tecidual em relação ao controle. CONCLUSÃO: As feridas tratadas com gel de PRP apresentaram uma mais rápida diferenciação epitelial e acelerou a organização do colágeno da derme comparado ao grupo controle em cavalos.

Expression of FAP and alpha-SMA during the incised wound healing in mice skin / 法医学杂志

UNLABELLED@#OBJECTIVE To investigate the time-dependent expression of fibroblast activation protein (FAP) and alpha-smooth muscle actin(alpha-SMA) during the incised wound healing of the skin in mice.@*METHODS@#The expression of FAP and alpha-SMA in incised wound of mice skin was detected by immunohistochemistry and Western blot.@*RESULTS@#By immunohistochemistry, the expression of FAP and alpha-SMA in the normal skin and the skin 1 h after injury maintained at a very low level, but the positive cells expressing FAP and alpha-SMA started to elevate 6 h after injury and reached its peak on 5 d for FAP and on 3 d for alpha-SMA, then gradually decreased to the normal level on 14 d. The expression of FAP and alpha-SMA was observed throughout the wound healing stages 1 d after injuries by Western blot as well with a peak expression occurring on 5 d for FAP and on 3 d for alpha-SMA after injury.@*CONCLUSION@#FAP may be a potentially useful marker for wound age determination and alpha-SMA may be used as an effective indicator for the mid- and late stage incised wound of mice skin. The combination use of FAP and alpha-SMA may be potentially effective indicators for wound age determination.

Expression of calpain 1 and calpain 2 during the skin incised wound healing in mice / 法医学杂志

OBJECTIVE@#To investigate the expressions of calpain1 and calpain2 during the skin incised wound healing in mice.@*METHODS@#Expression of calpain1 and calpain2 was evaluated by immunohistochemical method.@*RESULTS@#Both calpain1 and calpain2 were expressed in the skin cells in the control groups. The calpain1 positive cells were remarkably increased and reached the maximal level in day 1 after skin incised wound, decreased after day 3, markedly increased again in day 5, and then gradually decreased from day 7 to 14; the calpain2 positive cells were significantly increased in day 1 and decreased to the minimum in day 3, markedly increased again in day 5, and then gradually decreased from day 7 to 10.@*CONCLUSION@#The changes of calpain1 and calpain2 expressions appear to be bimodal after incised wound of skin in mice.