Dinker R Pai

Cellular events and biomarkers of wound healing

Researchers have identified several of the cellular events associated with wound healing. Platelets, neutrophils, macrophages, and fibroblasts primarily contribute to the process. They release cytokines including interleukins (ILs) and TNF-α, and growth factors, of which platelet-derived growth factor (PDGF) is perhaps the most important. The cytokines and growth factors manipulate the inflammatory phase of healing. Cytokines are chemotactic for white cells and fibroblasts, while the growth factors initiate fibroblast and keratinocyte proliferation. Inflammation is followed by the proliferation of fibroblasts, which lay down the extracellular matrix. Simultaneously, various white cells and other connective tissue cells release both the matrix metalloproteinases (MMPs) and the tissue inhibitors of these metalloproteinases (TIMPs). MMPs remove damaged structural proteins such as collagen, while the fibroblasts lay down fresh extracellular matrix proteins. Fluid collected from acute, healing wounds contains growth factors, and stimulates fibroblast proliferation, but fluid collected from chronic, nonhealing wounds does not. Fibroblasts from chronic wounds do not respond to chronic wound fluid, probably because the fibroblasts of these wounds have lost the receptors that respond to cytokines and growth factors. Nonhealing wounds contain high levels of IL1, IL6, and MMPs, and an abnormally high MMP/TIMP ratio. Clinical examination of wounds inconsistently predicts which wounds will heal when procedures like secondary closure are planned. Surgeons therefore hope that these chemicals can be used as biomarkers of wounds which have impaired ability to heal. There is also evidence that the application of growth factors like PDGF will help the healing of chronic, nonhealing wounds.

Qualities of an effective teacher: what do medical teachers think?

BackgroundEffective teaching in medicine is essential to produce good quality doctors. A number of studies have attempted to identify the characteristics of an effective teacher. However, most of literature regarding an effective medical teacher includes student ratings or expert opinions. Furthermore, interdisciplinary studies for the same are even fewer. We did a cross-sectional study of the characteristics of effective teachers from their own perspective across medicine and dentistry disciplines.MethodsA questionnaire comprising of 24 statements relating to perceived qualities of effective teachers was prepared and used. The study population included the faculty of medicine and dentistry at the institution. Respondents were asked to mark their response to each statement based on a 5-point Likert scale ranging from strongly disagree to strongly agree. These statements were grouped these into four main subgroups, viz. Class room behaviour/instructional delivery, interaction with students, personal qualities and professional development, and analysed with respect to discipline, cultural background, gender and teaching experience using SPSS v 13.0. For bivariate analysis, t-test and one way ANOVA were used. Multiple linear regression for multivariate analysis was used to control confounding variables.ResultsThe top three desirable qualities of an effective teacher in our study were knowledge of subject, enthusiasm and communication skills. Faculty with longer teaching experienced ranked classroom behaviour/instructional delivery higher than their less experienced counterparts. There was no difference of perspectives based on cultural background, gender or discipline (medicine and dentistry).ConclusionThis study found that the faculty perspectives were similar, regardless of the discipline, gender and cultural background. Furthermore, on review of literature similar findings are seen in studies done in allied medical and non-medical fields. These findings support common teacher training programs for the teachers of all disciplines, rather than having separate training programs exclusively for medical teachers. Logistically, this would make it much easier to arrange such programs in universities or colleges with different faculties or disciplines.

Role of simulation in arthroscopy training.

Summary Statement Arthroscopy uses a completely different skill set compared with open orthopedic surgery. Hitherto, arthroscopy had not been given enough emphasis in the core orthopedic curricula. Simulation has been seen as an excellent way to teach the skills required in arthroscopy. The simulators used for arthroscopy training can be broadly classified into physical simulators such as cadavers, animals, models and box trainers, virtual-reality simulators, and hybrid simulators that combine virtual-reality simulation with physical components that allow real tactile feedback. The advantages and disadvantages of each of these types have been described in this article. The factors that determine skill acquisition using these simulators have been highlighted. In conclusion, simulation seems to be a valuable tool for arthroscopy training, although further studies are needed to state whether this translates into better operative skill on real patients.

Injury to ulnar collateral ligament of thumb

Injury of the ulnar collateral ligament (UCL) of thumb can be incapacitating if untreated or not treated properly. This injury is notorious for frequently being missed by inexperienced health care personnel in emergency departments. It has frequently been described in skiers, but also occurs in other sports such as rugby, soccer, handball, basketball, volleyball and even after a handshake. The UCL of the thumb acts as a primary restraint to valgus stress and is injured if hyperabduction and hyperextension forces are applied to the first metacarpophalangeal joint. The diagnosis is best established clinically, though MRI is the imaging modality of choice. Many treatment options exist, surgical treatment being offered depending on various factors, including timing of presentation (acute or chronic), grade (severity of injury), displacement (Stener lesion), location of tear (mid‐substance or peripheral), associated or concomitant surrounding tissue injury (bone, volar plate, etc.), and patient‐related factors (occupational demands, etc.). This review aims to identify the optimal diagnostic techniques and management options for UCL injury available thus far.

Diabetic Foot Ulcer-Diagnosis and Management

Diabetes Mellitus is known to have many complications and one of the most distressing is diabetic foot ulcer which affects 15% of people with diabetes. It puts enormous financial burden on the patient and the health care services, even though it is preventable. Diabetic foot ulcer is characterized by a classical triad of neuropathy, ischemia, and infection. Each of these has a multifactorial aetiopathogenesis. These factors are compounded by mechanical stress created by foot deformities. The most commonly used classification systems are the Wagner-Ulcer Classification system and the University of Texas Wound Classification. These classifications help to predict the outcome of this condition. Prevention of this condition is paramount to prevent long term morbidity and sometimes mortality. This can be achieved by patient self-awareness and emphasis on regular foot examinations during follow-up. Care of the diabetic foot should be multidisciplinary. Debridement, dressings and offloading are the pillars of local management. Simultaneous glycemic and infection control is also essential. Amputations are usually the treatment of last resort but occasionally can be considered early to allow for faster mobilization and rehabilitation. Causative factors like peripheral vasculopathy and neuropathy must also be appropriately treated.

Charcot Neuroarthropathy of the Foot and Ankle

Charcot neuroarthropathy (CN) is a rare, progressive, deforming disease of bone and joints, especially affecting the foot and ankle and leading to considerable morbidity. It can also affect other joints such as the wrist, knee, spine and shoulder. This disease, described originally in reference to syphilis, is now one of the most common associates of diabetes mellitus. As the number of diabetics increase, the incidence of CN is bound to rise. Faster initial diagnosis and prompt institution of treatment may help to reduce its sequelae. There should be a low threshold for ordering investigations to assist coming to this diagnosis. No single investigation is the gold standard. Recent studies on pathogenesis and development of newer investigation modalities have helped to clarify the mystery of its pathogenesis and of its diagnosis in the acute phase. Various complementary investigations together allow the correct diagnosis to be made. Osteomyelitis continues to be confused with acute CN. Hybrid positron emission tomography has shown some promise in differentiating these conditions. A multispecialty approach involving diabetologists, orthopaedists and podiatrists should be used to tackle this difficult problem. The aim of this article is to describe current knowledge about CN with particular reference to the status of diagnostic indicators and management options.

Diabetic Foot Ulcer â Diagnosis and Management

Diabetes Mellitus is known to have many complications and one of the most distressing is diabetic foot ulcer which affects 15% of people with diabetes. It puts enormous financial burden on the patient and the health care services, even though it is preventable. Diabetic foot ulcer is characterized by a classical triad of neuropathy, ischemia, and infection. Each of these has a multifactorial aetiopathogenesis. These factors are compounded by mechanical stress created by foot deformities. The most commonly used classification systems are the Wagner-Ulcer Classification system and the University of Texas Wound Classification. These classifications help to predict the outcome of this condition. Prevention of this condition is paramount to prevent long term morbidity and sometimes mortality. This can be achieved by patient self-awareness and emphasis on regular foot examinations during follow-up. Care of the diabetic foot should be multidisciplinary. Debridement, dressings and offloading are the pillars of local management. Simultaneous glycemic and infection control is also essential. Amputations are usually the treatment of last resort but occasionally can be considered early to allow for faster mobilization and rehabilitation. Causative factors like peripheral vasculopathy and neuropathy must also be appropriately treated.

A unique case of non- traumatic asymmetric shoulder dislocation with four-part fractures of proximal humeri following seizures

DOI: 10.4103/0974-2700.115357 dislocations are rare. To the best of our knowledge only five cases of asymmetric shoulder dislocations have been reported worldwide.[1‐5] None of these cases were associated with four‐part fracture of proximal humeri. Musculoskeletal injuries following seizures are frequently missed.[1] The case presented here is of a post‐seizure asymmetric fracture dislocation of shoulder with missed initial diagnosis. A 50 year old man presented to us in the outpatient department with complaints of pain and restriction of movements of both shoulders three weeks subsequent to seizures. The patient was seen at a nearby health care facility where apparently, the shoulder injury was missed. Radiograph of both shoulders showed anterior dislocation with four‐part fracture of the proximal humerus on the right side and posterior dislocation with four‐part fracture of the proximal humerus on the left side. A computed

Medical simulation: Overview, and application to wound modelling and management

Simulation in medical education is progressing in leaps and bounds. The need for simulation in medical education and training is increasing because of a) overall increase in the number of medical students vis-à-vis the availability of patients; b) increasing awareness among patients of their rights and consequent increase in litigations and c) tremendous improvement in simulation technology which makes simulation more and more realistic. Simulation in wound care can be divided into use of simulation in wound modelling (to test the effect of projectiles on the body) and simulation for training in wound management. Though this science is still in its infancy, more and more researchers are now devising both low-technology and high-technology (virtual reality) simulators in this field. It is believed that simulator training will eventually translate into better wound care in real patients, though this will be the subject of further research.

Figures, Tables and Supporting Material

Tables, illustrations, and graphs represent data in a format that is easy to understand and grasp at a glance. They are a substitute for, and not an addition to, voluminous descriptions in the body of the article. They can be used in all sections of the article, not just for results. All tables, illustrations, and graphs must be appropriately labeled and referenced in the text. Tables are best when there is more text to display and the data is qualitative. They organize data into understandable classifications. The commonest used charts are bar charts, pie charts, histograms, line charts, and scatter diagrams. Charts are especially useful when the relationship between data sets is more important than the actual numbers. Flow charts help to depict the overall scheme of methodology. Illustrations may take the form of photographs or line diagrams and are usually used to support clinical presentations, operative findings, or investigation findings.