Wound Disruption Following Caesarean Delivery in Women With Class III Obesity: A Retrospective Observational Study.

BACKGROUND: This study sought to identify risk factors associated with wound disruption following Caesarean section (CS) in women with class III obesity and to determine the value of individualized perioperative care plans in reducing its incidence. METHODS: The study included women with class III obesity who underwent CS after 24 weeks of gestation at Mount Sinai Hospital, Toronto, Ontario between 2011 and 2015 and collected data on demographics, clinical history, and perioperative details. Multivariable logistic regression analysis was performed to identify factors likely to contribute to a higher incidence of wound disruption (level of evidence II-3B). RESULTS: Of the 334 identified cases, in women with a mean BMI of 48.20 ± 7.52 kg/m2, there were 60 cases of wound disruption (18%). The most common perioperative interventions involved Pfannenstiel skin incisions (75.6%), subcutaneous tissue closure (65.4%), use of pressure dressings (65%), and thromboprophylaxis (71.8%). On bivariable analysis, surgical time >1 hour (24.2% vs. 13.5%; OR 2.03; P = 0.017) and the use of thromboprophylaxis (20.1% vs. 10.6%; OR 2.22, P = 0.031) were associated with increased wound disruption, but these associations were attenuated on multivariable regression analysis. CONCLUSIONS: No single risk factor or perioperative intervention was independently associated with wound disruption. However, the use of individualized perioperative care plans resulted in fewer wound disruptions in our cohort when compared with published literature.

Intrinsic curvature in wool fibres is determined by the relative length of orthocortical and paracortical cells.

Hair curvature underpins structural diversity and function in mammalian coats, but what causes curl in keratin hair fibres? To obtain structural data to determine one aspect of this question, we used confocal microscopy to provide in situ measurements of the two cell types that make up the cortex of merino wool fibres, which was chosen as a well-characterised model system representative of narrow diameter hairs, such as underhairs. We measured orthocortical and paracortical cross-sectional areas, and cortical cell lengths, within individual fibre snippets of defined uniplanar curvature. This allowed a direct test of two long-standing theories of the mechanism of curvature in hairs. We found evidence contradicting the theory that curvature results from there being more cells on the side of the fibre closest to the outside, or convex edge, of curvature. In all cases, the orthocortical cells close to the outside of curvature were longer than paracortical cells close to the inside of the curvature, which supports the theory that curvature is underpinned by differences in cell type length. However, the latter theory also implies that, for all fibres, curvature should correlate with the proportions of orthocortical and paracortical cells, and we found no evidence for this. In merino wool, it appears that the absolute length of cells of each type and proportion of cells varies from fibre to fibre, and only the difference between the length of the two cell types is important. Implications for curvature in higher diameter hairs, such as guard hairs and those on the human scalp, are discussed.

Three-dimensional architecture of macrofibrils in the human scalp hair cortex.

Human scalp hairs are comprised of a central cortex enveloped by plate-like cuticle cells. The elongate cortex cells of mature fibres are composed primarily of macrofibrils-bundles of hard-keratin intermediate filaments (IFs) chemically cross-linked within a globular protein matrix. In wool, three cell types (ortho-, meso- and paracortex) contain macrofibrils with distinctly different filament arrangements and matrix fractions, but in human hair macrofibril-cell type relationships are less clear. Here we show that hair macrofibrils all have a similar matrix fraction (∼0.4) and are typically composed of a double-twist architecture in which a central IF is surrounded by concentric rings of tangentially-angled IFs. The defining parameter is the incremental angle increase (IF-increment) between IFs of successive rings. Unlike the wool orthocortex, hair double-twist macrofibrils have considerable inter-macrofibril variation in IF increment (0.05-0.35°/nm), and macrofibril size and IF increment are negatively correlated. Correspondingly, angular difference between central and outer-most IFs is up to 40° in small macrofibrils, but only 5-10° in large macrofibrils. Single cells were observed containing mixtures of macrofibrils with different diameters. These new observations advance our understanding of the nano-level and cell-level organisation of human hair, with implications for interpretation of structure with respect the potential roles of cortex cell types in defining the mechanical properties of hair.

Multi-center experience with outpatient total hip arthroplasty via a standard posterolateral approach.

BACKGROUND: This study sought to evaluate the safety, efficacy, and resource utilization of a pilot outpatient surgery program for total hip arthroplasty compared to traditional inpatient total hip arthroplasty performed via the posterolateral approach. METHODS: A cohort of 68 patients from two sites were enrolled in a regional pilot project for outpatient total hip arthroplasty (THA) and matched 1:1 against a cohort of patients undergoing routine inpatient THA. Data was extracted retrospectively from patient and hospital charts including adverse events (AE), readmission within 90 days, emergency room (ER) visits, patient calls, patient-reported outcome measures, length of stay, and multiple surgical variables. RESULTS: The outpatient group had a mean hospital stay of 13 hours, whereas the inpatient group had a mean of 58 hours (p<0.001). Three outpatients and four inpatients experienced post-op complications. Three inpatients and one outpatient visited the ER within 8 weeks of surgery. No difference in pre-operative hemoglobin (p = 0.210), or surgical blood loss (p = 0.550) was found between study groups. There was no difference found between groups regarding Oxford-12 Hip Score improvement, nor satisfaction at six months, one and two years (p>0.125). CONCLUSION: This study demonstrates that outpatient THA using the posterolateral approach is as safe and effective as inpatient THA for overall healthy and carefully screened patients, based on the low rate of AEs observed and similar patient outcomes reported. Significantly reduced time in hospital demonstrates the reduced healthcare resources associated with outpatient THA.

Histopathological effects of the Yen-Tc toxin complex from Yersinia entomophaga MH96 (Enterobacteriaceae) on the Costelytra zealandica (Coleoptera: Scarabaeidae) larval midgut.

Yersinia entomophaga MH96, which was originally isolated from the New Zealand grass grub, Costelytra zealandica, produces an orally active proteinaceous toxin complex (Yen-Tc), and this toxin is responsible for mortality in a range of insect species, mainly within the Coleoptera and Lepidoptera. The genes encoding Yen-Tc are members of the toxin complex (Tc) family, with orthologs identified in several other bacterial species. As the mechanism of Yen-Tc activity remains unknown, a histopathological examination of C. zealandica larvae was undertaken in conjunction with cultured cells to identify the effects of Yen-Tc and to distinguish the contributions that its individual subunit components make upon intoxication. A progressive series of events that led to the deterioration of the midgut epithelium was observed. Additionally, experiments using a cell culture assay system were carried out to determine the cellular effects of intoxication on cells after topical application and the transient expression of Yen-Tc and its individual components. While observations were broadly consistent with those previously reported for other Tc family members, some differences were noted. In particular, the distinct stepwise disintegration of the midgut shared features associated with both apoptosis and necrotic programmed cell death pathways. Second, we observed, for the first time, a contribution of toxicity from two chitinases associated with the Yen-Tc complex. Our findings were suggestive of the activities encoded within the subunit components of Yen-Tc targeting different sites along putative programmed cell death pathways. Given the observed broad host range for Yen-Tc, these targeted loci are likely to be widely shared among insects.

Sutures versus staples for wound closure in orthopaedic surgery: a randomized controlled trial.

BACKGROUND: A recently published meta-analysis comparing metallic staples to sutures in orthopaedic procedures revealed three fold increase in risk for infection in stapled wounds. The studies included in the meta-analysis are at risk of bias due to experimental design limitations. A large randomized controlled trial is proposed to direct orthopaedic surgeons in their choice of wound closure material. METHODS/DESIGN: A parallel group randomized controlled trial with institutional review board approval will be conducted. Patients will be randomized intraoperatively to have skin wounds closed with sutures or staples. Dressings will be used to maintain blinding outcome assessors. The primary outcome measure will be a composite all-cause wound complication outcome measure composed of: infection, wound drainage, wound necrosis, blistering, dehiscence, suture abscess and material sensitivity reaction. An independent review board blinded to treatment assignment will adjudicate suspected complications based on clinical data. All deceased patients will also be reviewed. An interim analysis of complications will take place after half of the patients have been recruited. All data will be analyzed by a blinded statistician. Dichotomous primary and secondary outcome measures will be analyzed using the Chi-squared statistic. Continuous outcome measures will be analyzed using Student's t-test. Subgroup analysis will compare infection rates using sutures versus staples in each anatomic area (upper extremity, pelvis/acetabulum, hip/femur, knee, ankle). A further subgroup analysis will be conducted comparing trauma patients to elective surgery patients. Non-infected revision surgery will also be compared to primary surgery. DISCUSSION: Wound closure material is an afterthought for many orthopaedic surgeons. The combined results of several comparative trials suggests that the choice of wound closure materials may have an impact on the rate of surgical site infections. However, the strength of the evidence is poor given the heterogeneity of the methods employed in previous studies. The following study protocol aims to guide surgeons in their choice of wound closure material by determining if there is a difference in complication rates in sutured and stapled wounds. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov under the identifier NCT01146236 (registered June 14, 2010).

The wool proteome and fibre characteristics of three distinct genetic ovine breeds from Portugal.

Wool properties and commodity value vary considerably between breeds. In Portugal, three major ovine groups exist: Churros, Bordaleiros and Merinos. This work studies the effect of the ovine genotype on the wool proteome of such groups. Wool was collected from 15 ewes/breed and genetic groups: Churra da Terra Quente (CTQ) or Churro, Serra da Estrela (SE) or Bordaleiro and Merino Branco (MB) or Merino. Proteins were extracted and subjected to label-free proteomics analysis. A total of 50 keratinous protein groups were identified in all the samples, divided into type I and II keratins and the keratin associated proteins: high-glycine-tyrosine proteins, ultra-high sulphur proteins and high-sulphur proteins. Major differences were found between MB and CTQ with respect to K75 and K38, both medullar proteins and to a lesser extent between SE and CTQ suggesting that these might be good markers for this trait in wool. Partial least squares discriminatory analysis proved MB to be readily distinguishable from the other two breeds. Further differences were noted in keratin associated protein levels between the three breeds, normally an indicator of higher levels of orthocortex and also their relationship to high curvature, high crimp fibres like Merino. BIOLOGICAL SIGNIFICANCE: The ovine genetic type has strong effects on wool productivity parameters and quality traits. In this work, we compare the proteomes and the microscopical characteristics of the wool from three distinct ovine genetic types from Portugal: Merino, Bordaleiro and Churro. Important differences were found regarding keratin associated proteins and keratins K75 and K38, suggested as putative markers for quality traits in the wool proteome such as the average curvature.

Cortical cell types and intermediate filament arrangements correlate with fiber curvature in Japanese human hair.

Naturally straight and curved human scalp hairs were examined using fluorescence and electron microscopy techniques to determine morphological and ultrastructural features contributing to single fiber curvature. The study excluded cuticle and medulla, which lack known bilateral structural asymmetry and therefore potential to form curved fibers. The cortex contained four classifiable cell types, two of which were always present in much greater abundance than the remaining two types. In straight hair, these cell types were arranged annularly and evenly within the cortex, implying that the averaging of differing structural features would maintain a straight fiber conformation. In curved fibers, the cell types were bilaterally distributed approximately perpendicular to fiber curvature direction with one dominant cell type predominantly located closest to the convex fiber side and the other, closest to the concave side. Electron tomography confirmed that the dominant cell type closest to the convex fiber side contained discrete macrofibrils composed of helically arranged intermediate filaments, while the dominant cell type closest to the concave side contained larger fused macrofibrils composed of intermediate filament arrangements varying from helical to hexagonal arrays approximately parallel to the longitudinal fiber axis. These findings concur with the current hypothesis of hair curvature formation and behavior.

Differences between ultrastructure and protein composition in straight hair fibres.

Mammalian hairs are internally patterned from both a morphological and proteomic perspective to exhibit specific functional traits, including curvature, which is important for coat structure affecting thermo-insulation. Most functional traits in mammalian coats are complex emergent phenomena associated with single-fibre properties that are themselves multi-variate and poorly understood. Here we compare hair curvature, ultrastructure, microstructure, protein composition and felting (a functional attribute) between fibres from natural straight-wool mutants of domestic sheep (felting lustre-mutant sheep), their wild-type relatives and also with a straight-haired semi-lustrous breed, English Leicester. Proteomic and structural results confirmed that the straight lustre mutant fibres had a normal cuticle and the same cortical protein and ultrastructural building blocks as wild-type fibres, but differed from equivalent fibres from wild-type relatives and English Leicester in layout and relative proportions. While curved wild-type fibres had bilaterally arranged orthocortex and paracortex, and English Leicester fibres had a scatter of paracortex on a background of orthocortex, lustre mutant fibres typically had a complete or partial ring of orthocortex surrounding a paracortex core, and sometimes a central orthocortex (similar to straight human and goat hairs). Lustre mutant fibres also had a reduced abundance of some high glycine-tyrosine proteins, normally associated with the orthocortex, with a possible relationship between the protein expression of the KAP8 and KAP16 protein families and fibre felting properties. We conclude that through control of the internal fibre patterning, multiple-solutions to hair curvature are possible, and variation may affect mechanical phenotype differently. Felting lustre mutant sheep will be a useful tool for discriminating cause and effect from non-causative correlation in mammalian fibre development.

Oxidative Modification in Human Hair: The Effect of the Levels of Cu (II) Ions, UV Exposure and Hair Pigmentation.

Protein oxidative degradation is implicated in a wide range of deleterious effects. For human hair, this oxidative damage can lead to significant observable changes in fiber physical and visual properties. A redox proteomic approach was applied to map molecular modification in human hair proteins and correlate this modification with the abundance of copper (II) ions, the levels of UV exposure and the general level of hair pigmentation. An increase in oxidative modification was observed with increasing copper (II) ion levels, regardless of the pigmentation level. Significantly, increased protein oxidative modification was also observed to occur in both lightly and darkly pigmented hair tresses even in the absence of irradiation, albeit at lower relative levels. Modification levels increased with increased copper (II) ion concentration. This new finding indicates that the level of copper (II) ions in human hair plays a key role in mediating protein oxidation, with or without exposure to UV light. Overall, these results strongly suggest that minimization of the level of copper (II) ions in human hair will mitigate and/or slow protein oxidative modification and therefore lower overall hair damage.

Sutures versus staples for wound closure in orthopaedic surgery: a pilot randomized controlled trial.

BACKGROUND: In the spectrum of surgical decision-making, wound closure material is often an afterthought. However, the findings of a recent meta-analysis suggest that the rate of surgical site infections (SSIs) is increased by using staples to close surgical wounds. Less clear is the effect of closure material on the incidence of non-infectious wound complications.The aim of this study was to compare sutures and staples in terms of: incidence of wound complications to determine the sample size for a definitive trial comparing wound closure methods. METHODS: Eligible adult orthopaedic patients were randomized to have wounds closed with sutures or staples. Time for skin closure was recorded. Wounds were assessed for complications for six weeks. The incidence of complications was compared using Fisher's exact test. Time to close and pain with removal of closure material were compared using a Student's t-test. RESULTS: The total number of patients reporting a wound complication was 59 of 148 patients completing six-week followup (41%), with no differennce between sutures and staples (RR = 0.77, CI = 0.52-1.14). The time to close wounds was shorter in the staple group (mean=4.8 min, CI = 2.6-7.1) than the suture group (mean=12 min, CI = 7.9-16). Patients in the staple group (mean=3.7, CI =2.8-4.6) reported more pain with removal than suture group (mean=2.5, CI =1.6-3.4). CONCLUSIONS: This study suggests that 42% of patients report a wound complication with no difference between sutures and staples. It was demonstrated that suturing skin requires more time and staples are more painful to remove. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT01146236 (registered June 14, 2010).

Interspecies comparison of morphology, ultrastructure, and proteome of mammalian keratin fibers of similar diameter.

Sheep wool has traditionally been viewed as the representative mammalian keratin fiber for the purposes of describing morphology and protein composition. We have investigated narrow fibers from the under-hairs of a range of species both closely and distantly related to sheep, comparing structure and protein composition. Within this group, curvature was negatively correlated with diameter for all but mohair. The cortical cell types present in alpaca, rabbit, and mohair fibers differed structurally from wool, primarily in terms of their macrofibril architecture. Except for rabbit, each species' fibers contained three cell types, and except for mohair, cell types were distributed asymmetrically across the cortex. In mohair, the cell types were distributed annularly, and each cell type had regions in which intermediate filaments were packed into highly aligned hexagonal mosaics, much like the mesocortex in wool. Coupled with this, were differences in the protein profiles; the rabbit fiber contained extra keratins and keratin associated proteins, while only subtle differences were noted between mohair and Merino fibers. In both rabbit and mohair fibers, the relative abundance of keratin K85 was lower than that of Merino. These results suggest that there may be links between relative protein composition and fiber morphology, albeit complex ones.

Characterization of the exocuticle a-layer proteins of wool.

The outermost protein layer of wool cuticle cells is known as the exocuticle a-layer. This layer is a resistant barrier to the degradation of the fibre and, as a result, little is known of its proteinaceous composition. Merino wool fibres were subjected to both proteolytic and chemical digestion and the resulting material was found by transmission electron microscopy to be highly enriched in a-layer. Amino acid analysis revealed a high cysteine and glycine content, with a close, but not exact, match to the Allwörden membrane. Subsequent digestion of the a-layer preparation by 2-nitro-5-thiocyano-benzoic acid produced a large number of short peptides, and analysis by mass spectrometry revealed peptides with strong homologies to cuticular ultra-high sulphur proteins of sheep wool and cuticular ultra-high and high-sulphur proteins of human hair, thus supporting other evidence for the presence of these sulphur-rich proteins in the a-layer.