Acute wound healing has been studied extensively, and infor- mation learned over time has been extrapolated and applied to chronic wound healing based on the assumption that chronic wound healing is “abnormal.” Research has identifi ed chronic wound healing as a different process in many ways, as described in this chapter. The current thinking is that imbal- ances exist in the molecular environment of healing and nonhealing wounds. When the scales are tipped toward low levels of infl ammatory cytokines and proteases, and mitoti- cally competent cells are present, the balance will produce high mitogenic activity and healing. When high levels of infl ammatory cytokines and proteases are present along with
RESEARCH WISDOM
Hypergranulation in Horses
In the veterinary community, there has been signifi - cant interest in hypergranulation because it is a frequent complication of wound healing on the legs of horses.
Predisposing factors for hypergranulation in horses include tissue hypoperfusion, infection, trauma, and ban- daging of wounds.115–118 In horses, the initial infl amma- tory reaction tends to be protracted, and this leads to the perseverance of TGFβ-1 well into the proliferative phase;
this is suggested as the predisposing factor that leads to production of excessive granulation tissue. One study of horses reported fi ndings that TGFβ-1 and TGFβ-3 expres- sion in normal and exuberant wound healing are different.
The latter tend to have higher concentrations of fi brogenic TGFβ-1 and lower concentrations of antifi brotic, antiscar- ring TGFβ-3. However, the differences were not statistically signifi cant. Based on the study results, the authors suggest that production of exuberant granulation is related to ban- daging (dressing) of the wound, which is associated with higher concentration of fi brogenic TGFβ-1 and decreased expression of antifi brotic TGFβ-3. Healing appeared nor- mal in wounds in which the TGFβ-3 concentrations were higher.117
Different dressing types appear to be related to hyper- granulation formation.119 Silicone gel dressings were found to prevent hypergranulation and improve tissue quality.
Possible rationale includes
1) Microvessel occlusion, which occurs signifi cantly more often in wounds that were dressed with silicone
2) Gradual decrease in oxygen tension in the tissue until the point of anoxia, when fi broblasts no longer function ade- quately and undergo apoptosis, and the ratio of collagen synthesis to degradation is altered in favor of degradation minimizing fi brosis
3) Diminished expression of mutant p53, an indirect inhibitor of apoptosis also found in these wounds.
Exuberant granulation typically does not go on to wound closure.48
CLINICAL WISDOM
Wound dressings appear to play a signifi cant role in exu- berant granulation tissue formation and hypertrophic scarring, in humans, related to prolonged contact of the wound tissue with wound fl uid. Dressings are described in Chapter 20.
Twelve Possible Wound Healing Phase Diagnoses 1. Acute Infl ammation
2. Chronic infl ammation 3. Absence of infl ammation 4. Proliferation
5. Chronic proliferation 6. Absence of proliferation 7. Epithelialization
8. Chronic epithelialization 9. Absence of epithelialization 10. Remodeling
11. Chronic remodeling 12. Absence of remodeling
EXHIBIT 2.2
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REVIEW QUESTIONS
1. The erupting volcano effect is attributed to which type of pressure ulcer?
A. Deep Tissue Injury B. Stage II
C. Stage III D. Stage IV
2. Experts agree that fetal tissue is different from adult tissue.
Which of the following statements is true regarding fetal tissue and healing?
A. Contraction is a usual event along with minimal scar- ring.
B. Low levels of adrenal steroids and an immature immune system affects cellular activity.
C. Amniotic fl uid surrounding the fetus has no effect on the healing response of the fetus.
D. When amniotic fl uid is removed there is an abrupt transition to adult like healing.
3. The shape of the myofi broblast “picture frame” beneath the skin can be predictive of the speed of wound contrac- tion. Which statement is true?
A. Linear wounds contract moderately.
B. Circular wounds contract slowly.
C. Rectangular wounds contract rapidly.
D. Square wounds contract slowly.
4. Chronic wound fl uid has been shown to:
A. Inhibit proliferation of endothelial cells.
B. Promote proliferation of keratinocytes.
C. Inhibit proliferation of proinfl ammatory cytokines.
D. Promote proliferation of fi fi broblasts.
5. High levels of matrix metalloproteinases (MMPs) can result in:
A. Excessive tissue degradation.
B. Maintenance of growth factor levels.
C. Promotion of cell surface receptors.
D. Promotion of tissue inhibitors of metalloproteinase (TIMPS)
senescent cells, there is low mitogenic activity, and the result is a chronic wound.53 Understanding the differences between acute and chronic wound healing is a work in progress; as
scientists demonstrate new fi ndings, this information is being used to customize treatment interventions. Other chapters in this book are devoted to those interventions.
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