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Literature Review: Connective Tissue Repair

Abstract
The paper proceeds as a literature based review on repair mechanisms in connective tissue. Factors influencing tissue repair mechanisms are estimated. The current paper broadly examines published data on factors that affect aspects of connective tissue repair. The review covers wound healing and tendon healing in particular

Introduction
The issue connective tissue repair stands nowadays rather acute, as along with development of medicine it becomes vivid, how many issues remain unresolved. Keeping in mind that a human body is a complicated and sophisticated mechanism where nothing remains without due attention, it is necessary to appraise the impact of various factors ranging from local (e.g. wound infection) to behavioral (depression) on the healing process. Literature on the subject is not abundant, however, there is enough publications on virtually any sphere of the issue. The current paper proceeds as a literature based review of publications that deal with connective tissue repair issue. Five publications are appraised in the paper and their analysis is provided.

Surgical physiology of wound healing: a review

An article by Deodhar A.K. and Rana R.E. published in Postgraduate Medicine Journal “Surgical physiology of wound healing: a review” is a general review on the subject. However, it provides a reader with strong understanding of the process of healing and its importance in surgical practice. In brief and to the point the importance of the issue is explained: “any breach in continuity of skin or mucous membrane exposes the deeper tissues to the danger of infections… today wound healing abnormalities are among the greatest causes of disability and deformity”. At first, the article proceeds with a description of the healing stages, which are: vascular and inflammatory response, reepithelization, granulation tissue formation, and matrix and collagen remodeling. This part features brief explanation of the processes, indicating their importance. At the same time, the role of each cell-type and description of possible deviations from the normal process is explicated.

The description of various factors affecting wound healing takes up a considerable part of the article. Authors have classified the factors into two categories: local and systemic factors affecting wound healing. First among local factors is infection. It is the most common cause among local ones for prolonged healing. Clinical infection takes place when a critical amount of pathogenic bacteria is present. Pathogenic organisms prolong healing as they activate alternate pathway and reinforce inflammation, thus prolonging inflammatory phase of the repair process, which in certain cases may last up to one week. Bacteria also produce toxins, which are sometimes damaging to cells. Finally, microorganisms need nutrients and oxygen, thus drawing some of the latter away from body cells. Extraneous bodies also contribute to the possibility of infection. All these effects could be avoided or minimized by using proper surgical techniques.

Among other important local factors affecting wound healing are surgical technique, hematoma formation, foreign body reaction, tissue ischemia, and topical medications and dressings. The use of improper surgical technique, aside from infection risk, may also result in devitalization of tissue if skin edges are crushed.

Among systemic risk factors the authors mention various deficiency states, aging factor, disease states, and influence of medication. Abnormalities in carbohydrate and fat metabolism decelerate wound healing. Deficiency of insulin, which acts as a factor for fibroblast growth, may restrain collagen disposition. Deficiency of protein and/or nitrogen sometimes occurs after major traumas and also negatively affects repair process as it increases inclination towards infection.

There are two vitamins that significantly impact healing process: A, C, and K. Vitamin K deficiency leads to clotting malfunction, which results in hematoma formation and other adverse effects. As ascorbic acid (Vitamin C) is an essential factor for collagen biosynthesis, its deficiency may lead to collagen lysis and it being unstable. Slow down in re-epithelization, malfunction of collagen synthesis and increased danger of infection may be caused by lack of vitamin A. Among minerals and trace elements deficiencies the most dangerous is zinc deficiency as it results in impaired immune responses, malfunction of collagen synthesis etc.

Aging is a very important factor in wound healing. It was observed, that foetal wounds tend to heal faster and without formation of scar tissue. Probably, the fact that collagen is produced in foetal wounds much more rapidly than in adults, could be one of the reasons for high age importance in healing process. However, this statement is controversial and the authors do not take any stance in this issue and just state the facts.

The article lists over 25 diseases that greatly influence healing processes. Among most important are: Ehlers-Danlos syndrome, coagulation disorders, hemophilia, Von Willebrand’s disease, Werner’s syndrome, vascular disorders, atherosclerosis, vasculitis, lymphoedema, chronic renal failure, diabetes, Cushing’s syndrome, immunologic deficiency states, cirrhosis, myelofibrosis and other chronic hematologic disorders associated with thrombocytopenia.

Among medicinal causes that cause impaired wound repair authors mention glucocorticoids, glucocorticoids, anticoagulants, antineoplastic medication, cyclosporin A, and many others. Unfortunately, authors do not discuss the ways medication and disease states influence the healing process and do not provide any supportive evidence while just stating facts. They claim, that only effects of anticoagulants and glucocorticosteroids are sufficiently explored. These drugs decrease inflammation and simultaneously decrease collagen and protein synthesis, interfere with most body defence mechanisms.

The “Surgical physiology of wound healing: a review” article completely justifies its title, as it is a review and does not provide much details on the matter. It is impossible to argue with the authors, as they do not provide any backing to their statements. However, the value of the article should not be underestimated, as it gives a clear understanding of all the basic healing processes and provides a reader with a starting point for further research.

Physiologic, Behavioral Factors Affect Wound Healing

The editorial by John H. Bowker “Physiologic, Behavioral Factors Affect Wound Healing” is significant as it discusses physiological problems along with behavioral component of wound healing processes. Generally, the reason for the author to undertake the research is purely practical. Also, an attempt to evaluate the literature on the matter is undertaken. In the very introduction the author makes a discovery, that literature reports on wound healing methods and systems control or at least consider only one or two influencing factors.

As the article proceeds, the author asks a series of questions, which at the same time serve as subheadings: “Is tissue oxygen perfusion adequate?”, “Is nutritional status normal?”, “Is there evidence of persistent bacterial infection versus mere colonization?”, “Is locomotor function impaired?”, “Have vasoconstrictors been prohibited? Is the patient abstaining from nicotine and caffeine?” etc.

To answer the question of oxygen perfusion in tissues being adequate, which surely affects healing process greatly, Bowker provides rather detailed description of procedures to be carried out in order to answer the question. It is argued, that poor oxygen perfusion in tissues against a background of anemia and diabetic nephropathy may be treatable. The argument is indeed dependable, as it is stated practicing expert. Bowker, along with Deodhar and Rana mention malnutrition as an important factor influencing healing. Bowker emphasizes that in his practice the greatest evidence of malnutrition was deficiency of serum albumin. The problem is rather easily solvable with high-caloric feeding, as the author suggests.

With the passage of time protective sensation may gradually decrease causing serious problems with healing. The decrease is in some cases so gradual, that the patient might be unaware of it, thus, it is suggested to use Semmes-Weinstein for sensation estimation.

Persistent bacterial infection might be caused by cellulites and osteomyelitis. This diseases result in warm wounds producing purulent exudate. This factor definitely slows the healing process down and might be dealt with using antibiotics.

It is often assumed, that behavioral factor is completely in patient’s competence. Yet, Bowker lays responsibility on caregivers too. First, weight-relief devices need to be appropriately chosen and then fitted. This is, indeed, the caregiver’s duty. The problem arises also when examination of the wound was not through enough to ensure that the bone was not penetrated (in this case surgical intervention is strongly recommended).

Another important question the author raises is whether the patient properly uses the plantar weight-relief devices. A study shows, that an opportunity to relief weight results in patients abusing this option. The patient might proceed to undertaking all the usual activities not taking his wound into account. This is a serious problem, as it may lead to additional ulceration and eventually to amputation. The author discusses various means of dealing with this problem including the use of various devices that would limit misuse and proper patient education.

As for the weight-relief shoes, it is emphasized that their use should not exclude following other wound-care procedures on the part of the patient as well as physician.

A more common behavioral issue in wound healing is smoking. Substances like coffee and vasoconstrictors result in the same: constriction of blood vessels with the latter being, probably, less harmful. Uncontrolled habits can greatly influence the process of recovery. Pernicious habits are also very hard to overcome, which may result in considerable problems in the course of treatment. Indeed, taking vasoconstrictors is not a habit, yet this factor could be overlooked in the course of treatment and these drugs not prohibited. It is the responsibility of the physician to control this factor.

It is very important to keep patients informed and educated on importance glucose control programs. The program cannot be comprehensive without patient being well informed.

Among other reasons for inadequate patient’s compliance are depression, denial, etc. the research have shown that noncompliance is related rather to the above mentioned factors than intelligence. Significant results in dealing with the problem can be achieved if proper education is introduced to the patient. However, patients with psychological abnormalities or personality disorders may experience significant problems overcoming denial.

To conclude, the author refers to teamwork as one of the most important factors in wound healing, as well as any other highly complicated activity.

To emphasize on the point stated above, the article is practical and gives valuable information on factors affecting wound healing. It is highly dependable, as the author is a practicing expert and is a well-known specialist in his sphere.

Nutritional factors affecting wound healing

Nutritional factors have already being mentioned in works by Deodhar and Bowker, while Thomas in “Nutritional factors affecting wound healing” addresses the problem directly. The controversy around this subject arises from inability of nutritional improvements to reduce complications or actually improve healing, while the negative effects of malnutrition have already been proved.

The first problem in the scope is diagnosing malnutrition. Patients need not only abundance of nutrients: they need to be appropriately balanced in each specific case. Even if the diet is appropriate it would not necessarily lead to improvements in healing process, as the overall health condition of the patient might be poor.

Treatment needs integrated approach and the role and weight of nutrition in it has not yet been proved. The vast majority of nutrition-related studies are animal-based, which results in deviations of results. Even in clinical settings, various approaches to nutrition such as parenteral nutrient delivery may result in treatment outcome being very hard to estimate. The importance of specific nutrients as vitamins, minerals and trace elements such as zinc, amino acids etc. have been appraised, however, their importance in each individual case varies greatly making it hard to set the individual nutrient supplementation up. However, despite the fact that all the abovementioned issues have not yet being resolved, any patient requires a well-balanced therapeutic diet.

The article proceeds as a discussion of up-to-date knowledge in the sphere of nutrition and sheds light on the scope of problems in the field. The use of examples by the author improves information perception and understanding of the issue.

Factors affecting the strength of flexor tendon repair
The research by Bhatia and others is different from the least of the articles in the current review, as it reports on the research on cadaveric tissue. The objective of the research was to determine the effect of core sutures on flexor tendon repairing. In the course of experiments different types and configurations of core sutures was explored. Some attention was also given to variable thickness of sutures. Various tests including straight and cyclic load were utilized. The researchers used four locked single knots as the most appropriate to their opinion. The publication is characterized by presentation of the research results and absence of broad generalizations. However, the results it yields are deeply practical as they allow for surgeons to choose their technique basing on dependable evidence. The research is important as it sheds light on some aspects of strength of 4/0 suture material.

Is Full Weightbearing Safe Following Achilles Tendon Repair?
The most recent study (2001) in the current review is by Akizyki and others titled “Is full Weightbearing Safe Following Achilles Tendon Repair?” It is believed that immediate weight bearing and neutral plantar flexion following immediately after repair may limit atrophy and stiffness.

However, it may also place some harmful stress on the repair. The study seeks resolves the problem and estimate the strain on the Achilles tendon during weight bearing in different degrees of plantar flexion and with immobilization. In the course of the study, the EMG from plantar flexors of 10 participants without any ankle deviations was recorded. Then, different walking conditions such as immobilized foot walking with neutral or some degree of flexion freedom was applied. It is unnecessary to list all the procedures in the current review. However, it is worth mentioning, that a wide scope of different preconditions was appraised and sophisticated methods of EMG results calculation were used. the result of the study is as follows: “In the immobilized ankle, the addition of a 1" heel lift was sufficient to minimize plantarflexor activity during walking”. The study is significant indeed, as it provides practical guidelines for physicians in applying weight bearing treatment method and proves it to be safe in certain limits. It is valuable that these limits are specifically determined.

Conclusion
The research shows, that there is enough publications and researches behind them on the subject of connective tissue repair and their scope is impressive. a conclusion could be drawn, that this field of study is growing rapidly now, as new technology and advancements in medicine allow for researches to seek new aspects of the issue and ways of dealing with them.

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Essay on School-based Clinics

Introduction
This paper will evaluate the advantages and traits of three different school-based clinics information on which was retrieved in the process of a web search. These clinics, based on the information available online have features that can form the basis for a successful school-based medical establishment.

St. Barnabas School-Based Clinic
One example is the St. Barnabas school-based clinic that aims at servicing those teenagers who are underprivileged in access to quality health care due to lack of insurance and under-insurance. This focus on serving less privileged classes seems one of the noble goals for a school-based clinic.

St. Barnabas School-Based Clinic concentrates on preventing risky behaviors that cause drug and alcohol abuse and lead to sexually transmitted diseases and undesired pregnancies. To curb risky behaviors, the clinic presents an «an ideal focal point for integrating comprehensive health education with the provision of basic primary and preventive health and mental health services» (St. Barnabas School-Based Clinic).

The experience of the clinic indicates that its efforts were able to contribute to the improvement in adolescents’ health state in the area.

One of the clinic’s advantages is its concern with offering advanced health care, as the clinic adds new services every year. Now is service range includes «a full range of primary care, dental screening and counseling services» , supplemented with  WIC counselors for pregnant students and a program on education and treatment of Chlamydia.

In 1998 alone, the clinic was able to attract 1,000 new enrollees.

The School-Based Clinic Program: Duke University Medical Center
The School-Based Clinic Program at Duke University Medical Center offers a wide range of services at several schools ranging from elementary to high school level.

The clinic operated by the program boast the determination to serve the needs of every student regardless of the ability to pay. Thus, students are offered assistance in filing insurance claims. In case the student is not covered by insurance, the student is then charged a modest fee based on the ability to pay.

This clinic is able to take conventional school service to a new level as it functions in partnership with Duke University Hospital, Durham Regional Hospital, Durham Public Schools and Center for Child and Family Health. 

Denny Wellness Center
Denny Wellness Center that has been offering health care services in Seattle schools since 1992, operates in five schools of the middle and high school level. The Puget Sound Neighborhood Health Centers (PSNHC) that serves as parent for Denny Wellness Center has been functioning in the Seattle community for over 30 years. Thus, the ability to draw on the well-established culture is one of the distinct benefits of the clinic.

The positive feature of the clinic is the close cooperation between the staff of the clinic and the school nurse, the school guidance counselors and other school staff.

Features of the listed school-based clinics to be incorporated in the creation of a new clinic
In my view, partnership with other healthy care institutions is of great importance for a school-based clinic. At the stage of the clinic formation, it is of special importance to be able to find the establishments that will be able to help the clinic to keep abreast of the latest developments in medical science as it happened at Duke University Health Center.

Besides, the school needs to constantly monitor the effects of the school program so as to be able to measure the effectiveness of the clinic’s efforts directed at the preservation and improvement of the youth’s health. Thus, St. Barnabas School-Based Clinic was able to report positive results in this area.

The school-based clinic has to function in close cooperation with the other school staff, which would enable it to work out effective solutions to improving the youth’s health.