Bulldog Scalp Syndrome.

Bulldog scalp syndrome or cutis verticis gyrata (CVG) is a rare cutaneous disorder with an incidence of just 0.026 to 1 per 100,000 population and cosmetic problems should not be ignored as they can affect the quality of life of patients in social and psychological aspects. In CVG the scalp thickens to form folds resembling sulci and gyri just as the skin fold of bulldog. It is a clinical diagnosis with various etiologies. It is classified as primary essential or nonessential and secondary CVG. It can manifest with symptoms ranging from mild to severe intensity. Cosmetic problems are the major concern that can affect patients' social and psychological health. If the folds are heavy, they can cause mass symptoms. Thus, surgery remains the definitive treatment option for improving the cosmetic appearance. Both our cases have different etiologies, however, were managed surgically with removal of skin folds (gyrae) and scoring of aponeuroses of the scalp followed by stretching of the scalp and closure to improve appearance. The surgical team as well as patients were satisfied with the appearance of the scalp after healing. CVG though a rare disease with various etiologies is a benign condition with good prognosis with no reports of malignant transformation so far.

Wound pH and Surface Temperature as a Predictive Biomarker of Healing in Diabetic Foot Ulcers.

AIM: To monitor wound pH and surface temperature as predictors of wound healing in diabetic foot ulcers (DFU). METHODS: Prospective, observational, time-bound study of 18 months, enrolling patients aged 18 to 60 years with uninfected DFU. The wound was assessed at baseline and after that, every week for 4 weeks according to the leg ulcer measurement tool (LUMT). Concurrently, wound surface pH and temperature were measured. The data were analyzed using descriptive statistics, and a P-value < .05 was considered statistically significant. RESULTS: Fifty-four patients with DFU were included in the study with a mean age of 55 years and a male to female ratio of 1.57. The wound showed progressive improvement, a maximum mean LUMT score of 48.89 (± 2.81) at the initial evaluation and decreased progressively to the mean of 19.80 at week 4 (± 3.43), both of which were statistically significant (P-value < .001). Similarly, the median wound pH progressively reduced from 7.7 at baseline to 7.20 in the fourth week, and median wound temperature decreased from 90°F (32.22 °C) at baseline to 85°F (29.44 °C) in the fourth week, both of which were statistically significant (P-value < .001). CONCLUSION: Progressive and significant change in wound pH to acidic and drop in wound surface temperature, both corresponding to improvement in the status of DFU, maximum at 4 weeks, make them valuable predictors of wound healing. However, further, more extensive studies are required to establish a concrete relationship.

Poor Glycemic Control Is Associated With Lower Interleukin-2 (IL-2) Levels and Low Macrophage Viability in Chronic Diabetic Foot Ulcers (DFUs).

Low macrophage viability in chronic diabetic foot ulcers (DFUs) may lead to inadequate interleukin (IL) expression and the persistence of infection. This study evaluates the association between macrophage function, IL-2 expression, and wound microflora in chronic DFUs. Diabetic patients with DFUs (group 1, n = 40) and without DFUs (group 2, n = 40) were compared for macrophage function in serum by viability testing. Immunological response was measured by serum IL-1ß, IL-2ß, and IL-10 levels. The aerobic and anaerobic microflora of the DFUs were assessed by culture and molecular methods. Demographic, clinical, and biochemical factors were statistically analyzed by χ2 test and Student t test. Multiple correspondence analysis (MCA) was used to detect the pattern of association between glycosylated hemoglobin (hemoglobin A1c), serum IL-2 levels, and macrophage viability. Of the total DFU cases, 22 (55%) showed the presence of polymicrobial microflora. Low macrophage viability with predominant Gram-negative flora was seen in 10 (25%) cases in group 1. Serum IL-2 levels were significantly lower (P = .004) in patients in group 1 along with elevated levels of hemoglobin A1c (P = .038). MCA showed an association between low viability of macrophages and lower IL-2 levels and elevated hemoglobin A1c levels with lower serum IL-2 levels. As compared to group 2, the low viability of macrophages was significantly associated (P = .007) with lower IL-2 levels in group 1. Elevated hemoglobin A1c levels are strongly associated with lower IL-2 levels and low macrophage viability. This might be a contributing factor to the persistence of infections in chronic DFUs.

Superior Mesenteric Artery Syndrome as a Rare Cause of Postoperative Intractable Vomiting: A Case Report.

Background: Superior mesenteric artery syndrome is a very rare cause of proximal intestinal obstruction. The objective of this clinical case report is to highlight that this unusual condition can occur in the early postoperative period and medical management may completely cure the condition. Clinical Case: A middle-aged female who was being treated for pulmonary tuberculosis underwent exploratory laparotomy with limited ileal resection and a loop ileostomy for multiple ileal perforations. Postoperatively, she was restarted on anti-tubercular drugs (ATD) but developed a drug reaction, recurrent bilious vomiting, and jaundice and ATD had to be stopped. But her vomiting did not abate and she progressively developed septicemia. An abdominal CT scan diagnosed Wilkie's syndrome, and she was managed non-operatively by decubitus, parenteral nutrition, and nasojejunal tube feeding supplemented with prokinetics and antibiotics. But her sepsis did not resolve. Intraoperative histopathology suggested Candida infection, and she recovered only after systemic antifungal therapy. Discussion: Debilitation conditions like tuberculosis cause weight loss and loss of intra-abdominal fat pad, which is known to precipitate SMA syndrome. However, its presentation in the early post-operative period is rare. Symptoms may vary from non-specific abdominal fullness and weight loss to features of acute bowel obstruction. CECT of whole abdomen can help in confirming the diagnosis. SMA syndrome is often not considered in differential diagnosis and can delay treatment. Medical management is the mainstay treatment option, although surgery is reserved for cases, which fail medical treatment. Conclusion: High suspicion is needed to diagnose SMA syndrome in the postoperative period, which precipitates with intractable bilious vomiting. Medical management may be curative. The precipitating factor for SMA syndrome should also be addressed to improve the overall patient outcome.

Successful management of delayed postoperative lung collapse secondary to spillage of aspergilloma.

Aspergilloma usually grows in lung cavities, although some may present with intrabronchial masses. Bronchial spillage during surgery is a known and disastrous complication of cavitary aspergilloma with bronchial communication. We present a case of a man in his 40s who developed a cavitary aspergilloma with recurrent haemoptysis almost a decade after his pulmonary tuberculosis. Following a segmentectomy for the same, the patient was extubated on table with well-expanded lung fields. Six hours later, he developed respiratory distress, and X-ray showed a complete lung collapse. An emergency bronchoscopy revealed a fungal ball obstructing the left main bronchus. The mass was successfully removed through bronchoscope, and the patient had lung expansion and uneventful recovery.

Biofilm and wound healing: from bench to bedside.

The bubbling community of microorganisms, consisting of diverse colonies encased in a self-produced protective matrix and playing an essential role in the persistence of infection and antimicrobial resistance, is often referred to as a biofilm. Although apparently indolent, the biofilm involves not only inanimate surfaces but also living tissue, making it truly ubiquitous. The mechanism of biofilm formation, its growth, and the development of resistance are ever-intriguing subjects and are yet to be completely deciphered. Although an abundance of studies in recent years has focused on the various ways to create potential anti-biofilm and antimicrobial therapeutics, a dearth of a clear standard of clinical practice remains, and therefore, there is essentially a need for translating laboratory research to novel bedside anti-biofilm strategies that can provide a better clinical outcome. Of significance, biofilm is responsible for faulty wound healing and wound chronicity. The experimental studies report the prevalence of biofilm in chronic wounds anywhere between 20 and 100%, which makes it a topic of significant concern in wound healing. The ongoing scientific endeavor to comprehensively understand the mechanism of biofilm interaction with wounds and generate standardized anti-biofilm measures which are reproducible in the clinical setting is the challenge of the hour. In this context of "more needs to be done", we aim to explore various effective and clinically meaningful methods currently available for biofilm management and how these tools can be translated into safe clinical practice.

Locally Advanced Rectal Cancer: What We Learned in the Last Two Decades and the Future Perspectives.

The advancement in surgical techniques, optimization of systemic chemoradiotherapy, and development of refined diagnostic and imaging modalities have brought a phenomenal shift in the treatment of the locally advanced rectal cancer. Although each therapeutic option has shown substantial progress in their field, it is finding their ideal amalgamation which has baffled the clinician and researchers alike. In the effort to identifying the perfect salutary treatment plan, we have even shifted our attention from the trimodal approach to non-operative "watchful waiting" to more recent individualized care. In this article, we acknowledge the scientific progress in the management of locally advanced rectal cancer and compare the opportunities as well as the obstacles while implementing them clinically. We also explore the current challenges and controversies surrounding the multidisciplinary approach and highlight the new trends and recent advances with an ultimate goal to improve the patients' quality of life.

An appraisal of vascular endothelial growth factor (VEGF): the dynamic molecule of wound healing and its current clinical applications.

Angiogenesis is a critical step of wound healing, and its failure leads to chronic wounds. The idea of restoring blood flow to the damaged tissues by promoting neo-angiogenesis is lucrative and has been researched extensively. Vascular endothelial growth factor (VEGF), a key dynamic molecule of angiogenesis has been investigated for its functions. In this review, we aim to appraise its biology, the comprehensive role of this dynamic molecule in the wound healing process, and how this knowledge has been translated in clinical application in various types of wounds. Although, most laboratory research on the use of VEGF is promising, its clinical applications have not met great expectations. We discuss various lacunae that might exist in making its clinical application unsuccessful for commercial use, and provide insight to the foundation for future research.

Psychological Stress on Wound Healing: A Silent Player in a Complex Background.

Stress is hard to define and is further complicated by varied perceptions in the population and differing responses in different situations. Psychological stress brings about certain physiological changes through manipulation of the neural, humoral and immunological systems. Observational studies have showed that fear and anxiety before surgery can complicate normal wound healing. Two different pathways appear to be involved: one directly through hypothalamic-pituitary-adrenal axis and sympathetic-adrenomedullary axis, and another indirectly through negative psychological stressors such as anxiety, depression and social isolation. The pathogenesis includes decreased expression of pro-inflammatory cytokines, resulting in poor angiogenesis, matrix regeneration and delayed healing. Prolonged immunological activation in itself is a stressor and can precipitate a sickness behaviour syndrome manifested by disturbed sleep, anorexia, reduction in activity, increased responsiveness to pain and addiction to alcohol and tobacco. It has been observed that cortisol release suppresses pro-inflammatory cytokine release, while down-regulation of cortisol causes unabated inflammatory response. In individuals with chronic wounds, on the other hand, it is thought that physical stress has different effects such as foul odor, pain, exudate and social and familial isolation, which may act independently as psychological stressors. This article attempts to appraise the influence of psychological stress on the immunological system and its effect on wound healing.

Wound Healing in the Golden Agers: What We Know and the Possible Way Ahead.

While "population aging" is an accomplishment that deserves acclamation, it is in itself a tremendous challenge. Age-related skin changes, impaired wound healing, and concurrent comorbidities are the deadly triad that contribute most to the development of nonhealing chronic wounds in the elderly. This imposes enormous medical, social, and financial burden. With the rising trend in the aging population, this problem is likely to exacerbate unless multidisciplinary, rapt wound care strategies are developed. The last decade was dedicated to understand the basic biology underlying the wound healing process but most in vitro and animal model studies translated poorly to human conditions. Forthcoming, the focus is on the development of diagnostic and therapeutic strategies to improve healing in this vulnerable age group. Further, understanding the complex pathobiology of cellular senescence and wound healing process is required to develop focused therapy for these "problem wounds" in the elderly.