First, the doctor emphasized that every one should stick to his/her computer in the exam, and that

if anyone change his/her computer will be considered as a cheating attempt. Last time, we were discussing the process of repair by regeneration, in which the tissue is repaired by the mitotic activity of its component so there will be regeneration of the tissue.

REPAIR BY CONNECTIVE TISSUE

Now, we will discuss the other type of repair which is repair by connective tissue. This process occurs in several situations: In severe injury with massive damage to the paranchymal and stromal cells and ECM, so this massive damage will result in inability of the tissue to regenerate.
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2If the damage or injury occurred to a prominent cells (myocardium, nervous tissue), which do not have the ability to divide and regenerate. In these two situations and due to the inability of the remaining tissue to regenerate, repair process will take place by connective tissue and fibrosis. The component of repair by connective tissue: Neovascularization(Angiogenesis): formation of new blood vessels. 2Proliferation and migration of fibroblasts: Those are needed for the build up of the fibrous tissue. 3Deposition of ECM. 4Remodeling and organization of the ECM.
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Granulation Tissue: is the tissue that is laid down in any sort of injury and is composed of: 1- Newly formed blood vessels. 2- Fibroblasts.
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3- Inflammatory cells: macrophages, neutrophiles and others.

One example of this tissue is found in coetaneous wounds just below the gap, which looks pink friable edematous tissue and it usually indicates a site of repair. - Angiogenesis: > It's the formation of new blood vessels, and can be formed: 1- From endothelial precursors cell (EPCs): which are present in the bone marrow, and migrate to the site of injury, then they start proliferate. 2-From pre-existing vessels: in a process called blood vessel sprouting. Now, this process of angiogenesis is under tight regulation by many growth factors, the most important of them in this process is VEGF (vascular endothelial growth factor), which is involved in: 1- Migration of Endothelial cells to the site of injury. 2- Stimulation of endothelial cells to start proliferating. 3- Differentiation of endothelial cells. 4- And also it's a mediator of inflammation that leads to increase of vascular permeability.

>Other growth factors involved in this process: Angioipoietins 1 and 2, PDGF (platelet derived growth factor), and TGF-b (transforming growth factor) stabilize the newly formed vessels, and act synergistically with VEGF.

- Angiogenesis by mobilization of EPCs:

We can see in the figure above, the bone marrow containing EPCs and by the affect of homing these EPCs will go to the circulation, and will migrate to the site of injury, and will start the formation of new blood vessels. Note: This mechanism is the main one responsible for embryonic angiogenesis. Hemangioblast Hematopoietic stem cells and angioblasts (EPCs) EPCs are stored in bone marrow EPCs express markers of hematopoietic stem cells and of endothelial cells EPCs play a role in neovascularization, replacement of endothelial cells, re-endothelialization of vascular implants.

- Angiogenesis by sprouting of preexisting vessels:

A parent vessel sends out capillary sprouts to produce new vessels Steps involved: Degradation of the parent vessel BM. Migration of endothelial cells (EC). Proliferation of endothelial cells. Maturation of EC and organization into capillary tubes. Blood vessels is composed of Endothelial cells, pericytes and smooth muscles, these pericytes and periendothelial tissue will be laid down by the extracellular matrix, so there will be a sort of interaction between endothelial cells and the ECM to form these periendothelial tissue (pericytes and smooth muscles). Growth factors involved: Basic fibroblast growth factor (bFGF). Vascular endothelial growth factor (VEGF).

- Fibrosis: is the formation of excess fibrous connective tissue in an organ or tissue in a reparative or reactive process, and this occurring after the emigration and proliferation of fibroblast in the site of injury. >Growth factors that are involved in regulation of the process of emigration and proliferation of fibroblast: - PDGF (platelet derived growth factor) - FGF (Fibroblast growth factor). - EGF (Epithelial growth factors). - TGF-B (Transforming growth factor). >Growth factors involved in the process of deposition of ECM: - PDGF. - FGF. - TGF-B. - Cytokines (IL-1 & TNF). One of the components of this ECM is collagen, which is very important to fill the gap to retain the strength of the wound especially the coetaneous wound, and to replace the lost tissue. Now this process if continued unchecked will result in extensive fibrous tissue deposition and overloading of the scar and this is pathological. So, we need some sort of balance or control between the synthesis and degradation of the collagen and the fibrous tissue (ECM), and this is called scar remodeling. - Scar Remodeling: Shift and change of the composition of the ECM of the scar as a result of synthesis and degradation. Metalloproteinases: Enzymes produced by many cells and capable of degrading different ECM constituents Interstitial collagenases Gelatinases: degrades the amorphous tissue. Stromelysins: more specific effect on subtypes of ECM component.

They are called metalloproteinases because they require metal, which is zinc, so they are zinc-dependent. Metalloproteinases (Zn dependent) activated by HOCl or proteases (plasmin). Inactivated by tissue inhibitors of metalloproteinases (TIMP) and steroids. So the use of steroids will impair to some extent- the proper healing. You can use steroids when there excessive degradation of fibrous tissue.

The figure shows the regulation of metalloproteinases. We see that first fibroblast is under stimulation by some growth factors while also may be under inhibition of others, now the fibroblast secrete some enzymes- metallproteinases- in their inactive form, then these enzymes will be activated by other enzymes, leading to the degradation of the ECM, but this does not go unbalanced, there inhibitor of these enzymes. Now, inhibition of metalloproteinases can occur by either medication (like steroids) or by endogenous inhibitors such as TGF-B, and also there

can be inhibition itself by what is called TIMPs (tissue inhibitors metalloproteinases).

Coetaneous wound healing:

Steps of wound healing in general: Fibrin clot formation and that will fill the gap. 2Induction of acute inflammatory response by an initial injury. 3If the injury is mild and the tissue is capable of regeneration healing will occur by regeneration. 4In more severe injury, or in injury to prominent tissue, migration and proliferation of paranchymal and connective tissue cells, and granulation tissue will be formed. 5Synthesis of ECM proteins. 6Remodeling of paranchymal tissue to restore function. 7Remodeling of connective tissue to achieve wound strength.
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Scar formation in the myocardium for example will lead to: 1Prevent proper function. 2Destroy significant amount of the myocardium. 3Damage to the conduction system. 4Increase the possibility for thrombosis to occur, and this thrombus may detach forming embolism, which may furthermore increase the problem. Now, remodeling is important to try restoring tissue function, so it's the process of modifying the content of the scar in a way that makes it more suitable for the tissue function.

REMEMBER: neutrophil predominate in the first 24 hrs of acute inflammation, while about 2-3 days later monocytes predominate. Remodeling of the connective tissue mainly in the coetaneous injury is important for strength; the most important thing I want to achieve from surgical incision is to restore the strength, in abdominal incisions if there were no strength, hernia (some abdominal organs go through this wound) may develop. We have two types of coetaneous wound healing:

1Healing by first intention: the approximation of the cup edges by sutures. Now, after we approximate them together there will be formation of a scab and fibrin clot, and that will be followed by neutrophils infiltrate within the first 24 hrs, in 3 7 days there will be basal epithelial or epidermal cells will start to proliferating by mitosis (some of them have stem cell-like activity) so they will start proliferating and maturation to form re-epithelium to the surface epithelium, at the same time there will be another process which is granulation tissue formation, after weeks we will have what is called fibrous union. 2Healing by second intention: when there is a large damage and gap, which will be filled by granulation tissue (huge one), and of coarse this will undergo more ECM deposition and fibroblastic proliferation, because there is no approximation, and this takes longer time more fibrous tissue formation and more scarring. In this mechanism of healing there will be wound contraction, and this mainly due to the presence of large number of myofibroblast. Myofibroblast are modified fibroblast that has some characteristics of smooth muscles so they have the potential to contract, and this contraction is for the strength of the tissue. In the figure in the next page is the process of healing by first intention (left) and second intention (right).

Wound strength:

Sutured wounds have 70% of the strength of unwounded skin (after 6 weeks) After sutures are removed at one week, wound strength is only 10% of unwounded skin By 3-4 months, wound strength is about 80% of unwounded skin Wounds never get back the strength of the tissue fully after wound healing. There is many factors that affect healing, there is systemic and local factors. SYSTEMIC Nutritional Protein deficiency Vitamin C deficiency (involved in the synthesis of collagen) Zinc deficiency (Metalloproteinases) Systemic diseases Diabetes mellitus
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Arteriosclerosis Renal failure Infections (systemic) Corticosteroid treatment Age Immune status

LOCAL Infection Poor blood supply Type of tissue (differences in ability to divide for example) Presence of foreign body material Ionizing irradiation ( that's why in cancer they don't start radiation after the operation immediately they wait about 6 weeks) Mechanical factors Excessive movement Hematoma Apposition Pathological Aspects of repair: Aberrations of growth may occur Exuberant granulation: Excessive amount of granulation tissue during wound healing Keloid: Excessive collagen accumulation during wound healing resulting in raised tumorous scar Excessive fibrosis: Cirrhosis, pulmonary fibrosis, rheumatoid arthritis (RA) Tissue damage Collagen destruction by collagenases in RA

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This is an example of keloid, there was a wound in this ear which has repaired, but the repair here is deficient and this has led to keloid formation.

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This is the histology of the keloid, and we can see excessive amounts of collagen. THE END I am sorry for any mistake in this lecture. I want to thank all the students that sacrifice a time of their own to help do the lectures. , , , .

DONE BY: EMAD ABABNEH

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