André Oliveira Paggiaro

Massive Localized Lymphedema (MLL) in Bariatric Candidates

Background: Mild lymphedema of lower limbs and eventually abdomen is not exceedingly rare in morbid obesity. However, few large symptomatic masses have been reported. In a consecutive series of patients, all requiring resection of the lesion before bariatric treatment, clinical features and surgical findings are described, aiming to clarify the nature of this intricate problem. Methods: Subjects (n=4, 50% females, age 34.0±13.7 years (19-53), BMI 56.4±10.5 kg/m2 (44.1-73.1) displayed lesions on the anteromedial aspect of the thigh (n=3) and hypogastrium (n=1). All reported episodes of intertrigo of local skin-folds in the preceding years, managed by local care and antibiotics. The mass was described as a serious nuisance, impairing walking, dressing and personal hygiene. Results: The mass was surgically removed without requirement for blood transfusion except in the case of one huge mass. Complications were relatively minor and consisted of partial skin dehiscence and lymph leakage for 2-3 weeks. Histologically, a complex pattern was observed including skin hypertrophy, edema, fibrosis, foci of microabscesses and dilated blood vessels, along with the pathognomonic lymphangiectasia. On follow-up to 6 months, improvement or restoration of the ability to walk occurred, with no additional skin infection and no recurrence. Conclusions: 1) Surgical treatment was effective. 2) Functional rehabilitation was achieved. 3) No recurrence was observed within the follow-up period.

Substitutos cutâneos: conceitos atuais e proposta de classificação

Complex wounds are characterized by complete loss of cutaneous cover. The most common plastic surgery technique is the autogenous skin graft; however, the amount of material available from donor areas is often limited. The development of synthetic or biological products as skin substitutes is therefore an area of interest. The present study aimed to classify the different types of skin substitutes available based on three criteria: the skin layer to be replaced, which can be categorized into epidermal (E), dermal (D), and dermal-epidermal composites (C); the durability in the wound bed, which can be temporary (T) or permanent (P); and the origin of the material, subdivided into biological (b), biosynthetic (bs), and synthetic (s).

Negative pressure therapy (vacuum) for wound bed preparation among diabetic patients: case series

CONTEXT Complications from diabetes mellitus affecting the lower limbs occur in 40 to 70% of such patients. Neuropathy is the main cause of ulceration and may be associated with vascular impairment. The wound evolves with necrosis and infection, and if not properly treated, amputation may be the end result. Surgical treatment is preferred in complex wounds without spontaneous healing. After debridement of the necrotic tissue, the wound bed needs to be prepared to receive a transplant of either a graft or a flap. Dressings can be used to prepare the wound bed, but this usually leads to longer duration of hospitalization. Negative pressure using a vacuum system has been proposed for speeding up the treatment. This paper had the objective of analyzing the effects of this therapy on wound bed preparation among diabetic patients. CASE SERIES Eighty-four diabetic patients with wounds in their lower limbs were studied. A commercially available vacuum system was used for all patients after adequate debridement of necrotic tissues. For 65 patients, skin grafts completed the treatment and for the other 19, skin flaps were used. Wound bed preparation was achieved over an average time of 7.51 days for 65 patients and 10 days for 12 patients, and in only one case was not achieved. CONCLUSIONS This experience suggests that negative pressure therapy may have an important role in wound bed preparation and as part of the treatment for wounds in the lower limbs of diabetic patients.

Pentoxifylline modifies three-dimensional collagen lattice model contraction and expression of collagen types I and III by human fibroblasts derived from post-burn hypertrophic scars and from normal skin

Fibroblasts are thought to be partially responsible for the persisting contractile forces that result in burn contractures. Using a monolayer cell culture and fibroblast populated collagen lattice (FPCL) three-dimensional model we subjected hypertrophic scar and non-cicatricial fibroblasts to the antifibrogenic agent pentoxifylline (PTF - 1mg/mL) in order to reduce proliferation, collagen types I and III synthesis and model contraction. Fibroblasts were isolated from post-burn hypertrophic scars (HSHF) and non-scarred skin (NHF). Cells were grown in monolayers or incorporated into FPCLs and exposed to PTF. In monolayer, cell number proliferation was reduced (46.35% in HSHF group and 37.73% in NHF group, p<0.0001). PTF selectively inhibited collagen III synthesis in the HSHF group while inhibition was more evident to type I collagen synthesis in the NHF group. PTF also reduced contraction in both (HSHF and NHF) FPCL.

Clinical trial comparing 3 different wound dressings for the management of partial-thickness skin graft donor sites.

PURPOSE: A review of the literature reveals a lack of consensus regarding local management of skin graft donor sites. This study was undertaken to determine the effects of 3 different dressings on healing of donor sites and patient discomfort related to donor sites. DESIGN: This study is a comparison cohort study. SUBJECTS AND SETTING: We recruited 34 burn patients scheduled for partial-thickness skin grafts; their mean age was 36 ± 18 years (mean ± SD, range 20 to 54 years), and 63% were male. All subjects were managed at Burn Unity Care, located in Sao Paulo, Brazil. MATERIALS AND METHODS: Subjects were randomly allocated to 1 of 3 groups: (1) a study group (group A) whose donor sites were dressed with a bovine collagen calcium-alginate dressing covered with transparent polyurethane film; (2) a second intervention group (group B), whose donor sites were dressed only with transparent polyurethane film dressing; and (3) a control group whose donor sites were dressed with rayon soaked in 0.9% saline (group C). Two independent observers assessed donor site wounds for epithelialization, scabbing, quantity and characteristics of exudate, and complications. Pain was measured using the visual analog scale, the brief pain inventory, and Index of Pain Management. RESULTS: Subjects managed with the bovine collagen calcium-alginate dressing covered with transparent polyurethane film (group A) achieved the greatest epithelialization (6.3 vs 8.2 for thin film dressing only P < .02 and 6.3 vs 11.7 days for control group P < .01). Patients managed with the bovine collagen calcium-alginate dressing covered with transparent polyurethane film also reported less pain that subjects allocated to the control (group C) or thin film only group (group B), (P < .05). Ninety percent of subjects allocated to the calcium alginate covered with thin film dressing reported mild pain intensity on the Visual Analog Scale, 85% of did not report pain localized to the donor site on the brief pain inventory, and scores on the Index of Pain Management ranged from 23 to 11. CONCLUSION: Study findings suggest that use of a collagen calcium-alginate dressing with a transparent film covering reduces the time for complete epithelialization and may reduce pain related to skin graft donor sites.

Intralesional pentoxifylline as an adjuvant treatment for perioral post-burn hypertrophic scars

Pentoxifylline (PTF), a methylxanthine derivative, has therapeutic use as an antifibrotic agent. In vitro, PTF inhibits the production of collagen and reduces the proliferation of fibroblasts in hypertrophic scars. This study aimed to evaluate changes in the elasticity of hypertrophic scars in the peribuccal area in burned patients, who presented with mouth-opening limitation. Eighteen patients were divided into two groups. The case group (n=10) was treated with PTF 1 mg ml(-1), while in the control group (n=8) no treatment was performed. Measurements of mouth opening (lip-to-lip and tooth-to-tooth distances in mm) were taken, before and after five therapeutic sessions with pentoxifylline with weekly intervals. The variations of these measures (Delta%) were calculated and submitted to statistical analyses. There was a significant improvement in the opening of the mouth, in vermilion distance (V=3.20 mm) as much as the dental distance (DD=4.19 mm) in the treated group, than in the control group. It was noted that pentoxifylline increases the elasticity of hypertrophic scars in the perioral area.

Registry of Hospital das Clínicas of the University of São Paulo Medical School: first official solid organ and tissue transplantation report - 2008

OBJECTIVE: The aim of this study was to report a single center experience of organ and tissue transplantation INTRODUCTION: This is the first report of organ and tissue transplantation at the Hospital das Clínicas of the University of Sao Paulo Medical School. METHODS: We collected data from each type of organ transplantation from 2002 to 2007. The data collected were patient characteristics and actuarial survival Kaplan-Meier curves at 30 days, one year, and five years RESULTS: There were a total of 3,321 transplants at our institution and the 5-year survival curve ranged from 53% to 88%. CONCLUSION: This report shows that solid organ and tissue transplants are feasible within the institution and allow us to expect that the quality of transplantation will improve in the future.

Role of keratinocytes in wound contraction: an impact assessment using a model of collagen matrix populated with fibroblasts

BACKGROUND: The possible participation of keratinocytes in wound remodeling has been widely studied. This study investigated the impact of keratinocytes in wound contraction. METHODS: Murine type I collagen gels populated by human fibroblasts and seeded with human keratinocytes on the surface to form a dermo-epidermal equivalent were used as the study group. Collagen gels populated by only fibroblasts were used as the control group. The criteria for the preparation and storage of gels were similar for both groups. RESULTS: An evident and statistically significant increase in gel contraction was observed in samples populated by keratinocytes compared to the control group. CONCLUSIONS: These results suggest that keratinocytes not only modulate fibroblast proliferation but also play an active role in wound contraction per se. Further research on the mechanisms involved in the communication pathways between cells and between cells and the matrix shall be assessed from the perspective of keratinocyte participation in wound healing and pathologic scarring.

Replacement of fetal calf serum by human serum as supplementation for human fibroblast culture

INTRODUCTION: Fetal calf serum (FCS) is commonly used as a supplement in the culture medium for fibroblast cells. This supplementation is far from ideal as sample quality varies from batch to batch and the composition of FCS is not completely known. In addition, FCS may be contaminated with viruses and/or prions and may also cause adverse immunologic responses in humans. Due to these facts, a worldwide effort is being made to find alternatives for xenobiotic elements in cell cultures. Human serum could be a safer alternative, especially for clinical application. METHODS: We investigated human serum as a substitute for FCS in human fibroblast culture. Fresh human serum was obtained from 10 healthy volunteers. Fibroblasts were cultivated in multiwell plates containing either Dulbeccos modified Eagles medium (DMEM) plus 10% FCS (D10) or DMEM plus 10% human serum (D10H). Cell counts were obtained between 24 and 264 hours of cultivation; results were expressed as the mean number of cells ± standard error of the mean to create cell proliferation curves. RESULTS: There was no statistical difference in fibroblast proliferation between the two groups. Human serum supported human fibroblast growth and proliferation, suggesting that it may be a potential substitute for FCS in human cell culture. Cells cultivated with human serum presented a different morphology, appearing smaller and more rounded as compared to cells cultivated in D10. CONCLUSIONS: These results demonstrate that human serum can be substituted for FCS in human fibroblasts culture and that fibroblasts cultivated in the presence of human serum have a morphology that is similar to in vivo fibroblasts.

Construção de substituto da pele composto por matriz de colágeno porcino povoada por fibroblastos dérmicos e queratinócitos humanos: avaliação histológica

Background: In the case of extensive lesions, the use of autologous grafts is limited by the extent of the donor area and the clinical condition of patients. Allografts collected from cadavers or volunteers are usually rejected after 1 to 2 weeks, thus serving only as temporary cover for these lesions. Treating major cutaneous lesions with reconstructed autologous skin is an attractive alternative, because it is possible to obtain cultures of cells that multiply rapidly and can be cryopreserved from a small fragment of the patient’s skin, thereby facilitating its indefinite use in new treatments. This study evaluated the