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Healing, Part 2



Bone healing problems can be divided into: technical failures, when treatment problems have impaired normal biologic potential; biologic failures, when biologic malfunctions have made the correct treatment ineffective; and combinations of the two. Biologic failures include inadequate callus formation or lack of a normal regional acceleratory phenomenon (RAP), normal modeling or remodeling, or maldifferentiation of the healing tissues, plus combinations. The most common biologic failures involve the inability to form callus and/or a normal RAP. When an inadequate RAP combines with inadequate callus production, then chronic infection, nonunion, multiple failed bone grafts and fixation procedures, and even amputation can ensue. Accumulating evidence suggests that most biologic failures stem from problems attributable to mitogens, differentiating and priming agents, growth factors, and other labile biochemical and biophysical messengers and signals in the region of the fracture itself. The ability of bone to heal can differ in different parts of the bony skeleton at a given moment. Until the basic causes of such problems can be corrected, present-day clinicians must manage them by presently available treatments while conducting research that might resolve them. The causes of most biologic failures probably act within the first weeks after the fracture, although it may take months for clinical roentgenograms to show their effects.




Healing, part 2


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Multiple platelet-rich preparations have been reported to improve wound and bone healing, such as platelet-rich plasma (PRP) and platelet rich fibrin (PRF). The different methods employed during their preparation are important, as they influence the quality of the product applied to a wound or surgical site. Besides the general protocol for preparing the platelet-rich product (discussed in Part 1 of this review), multiple choices need to be considered during its preparation. For example, activation of the platelets is required for the release and enmeshment of growth factors, but the method of activation may influence the resulting matrix, growth factor availability, and healing. Additionally, some methods enrich leukocytes as well as platelets, but others are designed to be leukocyte-poor. Leukocytes have many important roles in healing and their inclusion in PRP results in increased platelet concentrations. Platelet and growth factor enrichment reported for the different types of platelet-rich preparations are also compared. Generally, TGF-β1 and PDGF levels were higher in preparations that contain leukocytes compared to leukocyte-poor PRP. However, platelet concentration may be the most reliable criterion for comparing different preparations. These and other criteria are described to help guide dental and medical professionals, in large and small practices, in selecting the best procedures for their patients. The healing benefits of platelet-rich preparations along with the low risk and availability of simple preparation procedures should encourage more clinicians to incorporate platelet-rich products in their practice to accelerate healing, reduce adverse events, and improve patient outcomes.


Estrogen deprivation is associated with delayed healing, while estrogen replacement therapy (ERT) accelerates acute wound healing and protects against development of chronic wounds. However, current estrogenic molecules have undesired systemic effects, thus the aim of our studies is to generate new molecules for topic administration that are devoid of systemic effects. Following a preliminary study, the new 17β-estradiol derivatives 1 were synthesized. The estrogenic activity of these novel compounds was evaluated in vitro using the cell line ERE-Luc B17 stably transfected with an ERE-Luc reporter. Among the 17β-estradiol derivatives synthesized, compounds 1e and 1f showed the highest transactivation potency and were therefore selected for the study of their systemic estrogenic activity. The study of these compounds in the ERE-Luc mouse model demonstrated that both compounds lack systemic effects when administered in the wound area. Furthermore, wound-healing experiments showed that 1e displays a significant regenerative and anti-inflammatory activity. It is therefore confirmed that this class of compounds are suitable for topical administration and have a clear beneficial effect on wound healing.


Large experimental evidence demonstrated that the sex steroid estrogen protects against developing a chronic wound1, delays delayed healing, particularly in the elderly2, and estrogen replacement accelerates healing in aged humans and hormone-deprived animal models3, 4. Several studies addressed the mechanisms underlying such an effect and showed that estrogenic compounds play a prominent role in promoting the healing processes by modulating the inflammatory response, accelerating re-epithelialization, inducing granulation, and modifying proteolysis in skin cells, especially keratinocytes5, 6.


Considering the necessity to find efficacious therapeutic means for healing of wounds, particularly in the elder population, estrogens should be taken in consideration, yet the serious, undesired side effects, particularly cancer promotion, associated with the use of these hormones prevents their therapeutic application. Therefore, to exploit the beneficial effects of estrogens on wound healing, while avoiding their undesired side effects, we attempted to obtain locally active estrogens.


In the present study we have prepared a family of compounds active through the ER characterized by a structure that should ensure their rapid metabolism and limited systemic action when administered in vivo. Most of compounds tested, and in particular 1e and 1f, showed a significant affinity for ERs and were able to efficiently induce ER transcriptional activity.


This work was supported by a grant from EUTICALS SpA to Dipartimento di Chimica, Università La Sapienza, Roma. A.M. was supported by European Research Council (WAYS-2012-ADG322977) and Frame Program 7 of European Union (INMiND-278859). The authors are indebted to Finlombarda and the TOPsrl research team for conceiving and carrying out a large part of the experimental work.


When it comes to physical healing, often confusion reigns. To combat it, I'd like to point out five "laws" of suffering. These "laws" will do more to help the hurting and erase their confusion than perhaps anything else they could read.


When it comes to physical healing, often confusion reigns. To combat it, I'd like to point out five "laws" of suffering. These "laws" will do more to help the hurting and erase their confusion than perhaps anything else they could read. Yesterday, we looked at laws one through four. Today we'll look at number five.


Updated by: Linda J. Vorvick, MD, Clinical Associate Professor, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.


Of particular interest is that patients who exhibited non concordant behaviour but who never the less continued to make progress did not generate the same level of anxiety in participants. Generally speaking, community nurses tolerated non concordance as long as healing and progression was evident.


There was evidence that the role of the specialist leg ulcer nurse was complex. Frequently she was used to endorse the decisions made by the nursing teams, and to provide reassurance that every possible aspect had been considered. However, there was also evidence that practitioners felt undermined by her role, particularly with patients who expressed particular trust in her decisions and specifically requested her intervention. One team leader feared that this was a reflection upon her and her team and that patients believed they did not have the knowledge and skill required to treat the ulceration effectively.


The same team frequently showed great understanding of the suffering of this particular patient who had a long and complex history of unhealed leg ulcers and deteriorating general health because of comorbidity. Strenuous efforts were made to continue the highest quality of care despite conflict over resourcing in an ever more stretched community service. Accepting the continuing deterioration of this patient was extremely painful for this team.


Mark Graban (2s):Welcome to Habitual Excellence, presented by Value Capture. This podcast. And our firm is all about helping you and your organization achieve Habitual Excellence via one unifying focus, one value-based structure, and one performance system. In other words, it's about helping you capture dramatically more value through achieving perfect care and perfect safety for patients and staff. To learn more about Value Capture and our services visit www.valuecapturellc.com. Hi, this is Mark Graban. Welcome to episode 65 of Habitual Excellence. Today is part two of the discussion that we started last week in episode 64 with Theresa Brown author of books, including her most recent healing.Mark Graban (51s):So I hope you enjoyed part one of the episode. Here is again, Theresa Brown, part two...


And the case you referenced RaDonda Vaught is, is the name of, of the nurse. And I wasn't there, I'm not an expert on the case, but my, from my reading of it, I mean, I've, I've seen commentary a lot, especially online, even in nurse forums. Some nurses say, well, if you just read the label on the medication, like the there's this hard line that says, you know, it was egregious, then you know, you, you raise different levels of punishment, losing your job, losing your license. Then there's the whole prosecution and conviction layer and like reading what happened there.Mark Graban (1m 35s):I mean, it seemed like there were many, many systemic factors she was working in and she was helping out by working in an area she was unfamiliar with. I think it was in re I believe radiology, and it was somewhat unusual to have to sedate a patient for that. There were time pressures from the doctor and others. And then there was this culture of just kind of ignoring the need for overrides and the factor, like you said about the couple of letters, like there could have been, there were maybe there were cultural factors that could have been better error proofing in place to not set her up to fail.Mark Graban (2m 16s):And I'm not a lawyer, but it seems like there's often like, you know, kinda mitigate relative legal liability where I don't think anyone is saying she's blamed less, but it seems like the system and society is punishing her. And I don't know where, where, where the, where the hospital is. And it assume like they're, they're blaming the nurse when the, it begs questions of, so what are you doing to prevent this from happening again?Theresa Brown (2m 48s):Right, right. And too right. Two points that you brought up one again, there's that very hard line culture, you know, it's clearly marked as a paralytic her mistake. I would never make that mistake. No one, no one, except someone who's really stupid and doesn't care would make that mistake. And that's it. And there is that strain in nursing. I know that. And it's PR it's probably there among physicians also, and it's just, it's so problematic. And like you just said, we can admit this was a very, very serious error.Theresa Brown (3m 32s):And she knows that like she never denied that she reported it and that's the other issue. And that actually, I just got my, my COVID booster last night and the pharmacist was talking to me about this just totally off the cuff about, we do not want a system that encourages people to lie and hide things.Mark Graban (3m 57s):And it sounds like from, from my reading of the reports and everything that happened there, that this error could have been covered up. And I'm not saying people should cover it up, but I think that fear factor now will prevent people from speaking up in ways that would prevent future errors. That's why I think, you know, this, this, this transparency and this focus on learning and improvement more so than retribution and punishment is something people talk about in the patient safety movement. A lot of groups, the Institute for safe medication practices and the Institute for healthcare improvement and, and, and, and some bleeding voices in the healthcare quality movement has spoken up very loudly about how this conviction is a big setback for future patient safety.Theresa Brown (4m 48s):Yeah, definitely because if you think, wow, if I make a mistake and I report this, okay, it's one thing to lose your job, to lose your license, to go to jail. Right. And I read the da said, well, it, that the DA went out of his way to say, this is not about nurses. This is about this nurse, but also said, it's like she was driving drunk. And I thought, it's absolutely not like she was driving drunk. She was at work. Like, I mean, if she was drunk at work, okay, that's different. But she was working. She made a mistake, a very bad mistake within an incredibly chaotic system.Theresa Brown (5m 34s):And to get back to you saying, if she could have said, I have a concern, this looks very different from when I've given this drug before I have to reconstitute it. It says, you know, but it is very familiar to feel like, even though everyone says, oh, you know, ask if you have a question ask, but then it can be, you don't know that, like what, what are you thinking?Mark Graban (6m 3s):Sure. The, the, the shaming that comes from speaking up and you, you, you write a lot Theresa about maybe the word pride applies. You wrote in "Healing" how it, wasn't easy to write about a mistake that you disclose you wrote about in your book, "The Shift" giving an injection of a steroid. Can you tell that story briefly? And like some of the, your reflection of why it was difficult to even put that into writing?Theresa Brown (6m 37s):Yeah. So very quickly that I was working outpatient oncology at that point, and someone had been ordered, I'll just make this up. Let's say 45 milligrams of, let's say 60 milligrams of dexamethasone. And so I don't remember the exact details and it comes in 20 milligram vials. So I went and pulled up three 20 milligram vials into a syringe and gave it slowly to the patient.Mark Graban (7m 5s):And I think you said it was like three times what the normal injection might be, might normally be a viral,Theresa Brown (7m 12s):Right? Yes. And so I thought this is really weird. I've never done this before, but we were working with a bunch of different doctors and, you know, that's the other thing that the problem of lack of standardization. So you just kind of felt like, well, this is weird, but we do a lot of weird. So, and then I was looking at the order, which I think had been faxed in and written over on the side. Very, very pale was to put the dexamethasone in a small bag and run it over 15 minutes. So I literally, when I saw that one, I literally wanted the ground to open up and swallow me.Theresa Brown (7m 58s):I felt so terrible and told the supervisor, and she said, go call the doctor. And the doctor was fabulous. It's like he said, oh yeah, I don't think that's going to, you know, my cause her pressure to drop. So monitor that. Yeah, fine. Very reassuring. Just really wonderful because I felt so, so bad. And that's the other problem in nursing. At least there's this culture of, you can never make a mistake.Theresa Brown (8m 38s):And the reality is we're human. We're gonna make mistakes. And so then you need to create a system that makes mistakes a lot less likely. So like I say, why can't we have a standardized order form? Why does every doctor use own for...Mark Graban (8m 58s):Well, and why are we relying? I mean, it seems like such a vivid illustration of a system problem that faint handwriting, which might not have looked faint originally. But however, it came through the fax didn't come through well. And like you said, if it, if that's not a standardized form in some way, I would make the case, you weren't set up for success there.Theresa Brown (9m 22s):Yes. And, and that gets me to another thought I often had as a nurse, that healthcare is still such an oral culture. And it's as if we haven't adapted to the complexity of so many more drugs than they had 50 years ago, you know, so many more technologies. And as a patient, I really felt that I, I didn't understand why can't they just give me a piece of paper that says here's an algorithm of what might happen. Here's the order. We would like things to go in for you. And then on the other side could be a list of physicians, right?Theresa Brown (10m 6s):I mean, they gave me the names of some surgeons. And again, I asked my friend for a recommendation, very, you know, it's the rare person, right? Who has a breast surgeon, who's a good friend, but the lack of anything in writing, like we know that people go into appointments and they don't hear what is said well, and my husband would come with me. So between the two of us, you know, it was like, we would have one brain. Cause he, he had his own feelings about his wife having breast cancer. And I felt like every time I should leave with a piece of paper that tells me something,Mark Graban (10m 48s):I, I mean, I've heard patients who want to record those visits and sometimes doctors don't want them doing that. It's for their own reference. So I could go back when I'm maybe in a different state of mind or clear-headed to go back and make sure I heard it correctly. Cause even notes could be incomplete or inaccurate.Theresa Brown (11m 8s):Right. And yeah, it's, that is really, really a puzzle to me for why there isn't, I mean, every hospital could do it or we could have a national database, but of course, then everybody would argue about what goes in it, but sort of, you know, here's the, here's the 10-minute video you can watch about having breast cancer. And there was a video they made about exercises to do after lumpectomy, which, which I did, but you know that there's, there's at like where's the breast cancer app, you know?Mark Graban (11m 48s):I mean, I think there are online communities. I have friends who have been cancer patients where they really rely on kind of a peer group network of other patients. There's a society for empowered patients. I forget the, I, I think I have the name slightly wrong, but people are trying to fill in those gaps in different ways.Theresa Brown (12m 11s):Yeah. And I, and that's where I found help with Tamoxifen. I, I, as I talk about in the book, I made a decision to try and not spend a lot of time online because I'd seen so many patients and family members look online and end up being terrified by what they saw there. But I did find some chat groups talking about Tamoxifen and how hard it was to be on it. And that made me feel a lot less alone. That was very helpful.Mark Graban (12m 45s):One of the things I wanted to ask you about, and this is something you wrote about in "The Shift" and you did use the phrase too proud. You wrote about being too proud to speak up, to share a concern with a manager that a shift's assignment was as you called it potentially overwhelming. I'm curious to hear, you know, your, your thoughts on that. And then there's kind of a follow-up question when it comes to nurses being overburdened and nurse/patient ratios, your, your thoughts about d


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