One systemic administration of transforming growth factor-beta 1 reverses age- or glucocorticoid-impaired wound healing

Ex vivo supplementation of TGF-beta1 enhances the fibrous tissue regeneration effect of synovium-derived fibroblast transplantation in a tendon defect: a biomechanical study

The present study was conducted to test a hypothesis that the ex vivo supplementation of TGF-beta1 into medium will significantly improve the mechanical properties of the fibrous tissue regenerated in the patellar tendon defect after transplantation of cultured autologous synovium-derived fibroblasts. Thirty rabbits were divided into the following three groups. In Group A, we applied phosphate buffered saline of 0.1 ml to the defect created in the patellar tendon. In Group B, we transplanted autologous fibroblasts, which had been cultured into the tendon defect. In Group C, we transplanted autologous fibroblasts, which had been cultured with supplementation of TGF-beta1, into the tendon defect. Animals were killed at 6 weeks, and the regenerated tissue was examined for biomechanics and histology. The tangent modulus and the tensile strength of Group C were significantly higher than that of Group B, while the tensile strength of Group C was significantly lower than that of Group A. Histologically, vascular formation was abundantly found in the regenerated tissue of Groups B and C as compared to the regenerated tissues in Group A. The present study showed that transplantation of cultured autologous synovium-derived fibroblasts enhanced vascular formation in the fibrous tissue regenerated in the patellar tendon defect, while cell transplantation deteriorated the mechanical properties of the regenerated fibrous tissue. However, the ex vivo supplementation of TGF-beta1 into the medium significantly decreased mechanical deterioration of the fibrous tissue regenerated in the tendon defect after transplantation of cultured autologous synovium-derived fibroblasts.

The hormonal regulation of cutaneous wound healing

Conditions of impaired wound healing in the elderly are associated with substantial morbidity and mortality and impose a significant financial burden upon the world's health services. The findings of a series of recent studies have served to highlight the contrasting contributions made by sex steroid hormones to the regulation of cutaneous repair processes. Although estrogens accelerate healing, the actions of the "male" sex hormones 5alpha-dihydrotestosterone and testosterone are primarily deleterious. The shift that occurs in the balance between serum estrogen and androgen levels as a normal feature of human aging may therefore have important consequences for fundamental tissue repair processes.

Tumor necrosis factor-alpha receptor p75 is required in ischemia-induced neovascularization

BACKGROUND

Aging is a risk factor for coronary and peripheral artery disease. Tumor necrosis factor-alpha (TNF-alpha), a proinflammatory cytokine, is expressed in ischemic tissue and is known to modulate angiogenesis. Little is known about the role of TNF-alpha receptors (TNFR1/p55 and TNFR2/p75) in angiogenic signaling.

METHODS AND RESULTS

We studied neovascularization in the hindlimb ischemia model in young and old TNFR2/p75 knockout (p75KO) and wild-type age-matched controls. Between days 7 to 10 after hindlimb surgery, 100% of old p75KOs experienced autoamputation of the operated limbs, whereas none of the age-matched wild-type mice exhibited hindlimb necrosis. Poor blood flow recovery in p75KO mice was associated with increased endothelial cell apoptosis, decreased capillary density, and significant reductions in the expression of vascular endothelial growth factor and basic fibroblast growth factor-2 mRNA transcripts in ischemic tissue and in circulating endothelial progenitor cells. The number of circulating bone marrow-derived endothelial progenitor cells was significantly reduced in p75KO mice. Transplantation of wild-type bone marrow mononuclear cells into irradiated old p75KO mice 1 month before hindlimb surgery prevented limb loss.

CONCLUSIONS

Our present study suggests that ischemia-induced endothelial progenitor cell-mediated neovascularization is dependent, at least in part, on p75 TNF receptor expressed in bone marrow-derived cells. Specifically, endothelial cell/endothelial progenitor cell survival, vascular endothelial growth factor expression, endothelial progenitor cell mobilization from bone marrow, endothelial progenitor cell differentiation, and ultimately ischemia-induced collateral vessel development are dependent on signaling through TNFR2/p75. Furthermore, because TNFR2/p75 becomes an age-related limiting factor in postischemic recovery, it may be a potential gene target for therapeutic interventions in adult vascular diseases.

Role of TGF beta-mediated inflammation in cutaneous wound healing

Among many molecules known to influence wound healing, transforming growth factor beta 1 (TGF beta 1) has the broadest spectrum of actions, affecting all cell types that are involved in all stages of wound healing. Both positive and negative effects of TGF beta 1 on wound healing have been reported. However, the underlying mechanisms are largely unknown. We observed that endogenous TGF beta 1 was elevated in a narrow window of time after injury, and transgenic mice constitutively overexpressing wild-type TGF beta 1 in keratinocytes (K5.TGF beta 1wt) exhibited a significant delay in full-thickness wound healing as compared to non-transgenic mice. Delayed wound healing was associated with profound inflammation throughout all stages of wound healing in K5.TGF beta 1wt mice. Our data suggest that excessive and prolonged TGF beta 1 at the wound site does not benefit wound healing, which is partially owing to its pro-inflammatory effect. Future studies need to be conducted to assess whether tightly regulated TGF beta 1 expression will benefit wound healing. To this end, we have developed a gene-switch TGF beta 1 transgenic system that allows TGF beta 1 induction in keratinocytes temporally with desired levels. These mice will provide a tool to study stage-specific effects of TGF beta 1 on cutaneous wound healing.

Gingival crevicular fluid transforming growth factor-β1 in several forms of periodontal disease

BACKGROUND

Transforming growth factor-beta(1) (TGF-beta(1)) has significant effects on periodontal host response regulation. Limited knowledge on the role of TGF-beta(1) in various periodontal disease types and particularly in advanced periodontitis forms warranted the present study. The aim of the present study was to evaluate the gingival crevicular fluid (GCF) TGF-beta(1) levels in patients with different forms of periodontal disease.

METHODS

GCF TGF-beta(1) levels were investigated in 32 chronic periodontitis (CP), 30 generalized aggressive periodontitis (G-AgP), 15 gingivitis patients and 16 periodontally healthy subjects. Periodontal status was evaluated by measuring probing depth, clinical attachment loss, plaque and bleeding on probing. TGF-beta(1) levels were analyzed by enzyme-linked immunosorbent assay. The results were expressed in terms of total amount (pg) and concentration (pg/microl).

RESULTS

G-AgP and CP groups had significantly elevated GCF TGF-beta(1) total amount compared to healthy group (p<0.008). Moreover, GCF TGF-beta(1) total amount of G-AgP group was significantly higher than that of gingivitis group (p<0.008). G-AgP and CP groups had similar GCF TGF-beta(1) total amount (p>0.008). Significant correlation was found between GCF TGF-beta(1) total amount and all clinical periodontal parameters (p<0.05).

CONCLUSIONS

The results of the present study suggest contribution of TGF-beta(1) to the pathogenesis of advanced chronic and aggressive periodontitis. TGF-beta(1) may thus be one of the components modulating exaggerated host response together with other major mediators of inflammation.

Age-related changes in focal adhesions lead to altered cell behavior in tendon fibroblasts

During aging the increase in collagen cross-linking and total amount of collagen in tendon leads to a decline in both its flexibility and its ability to heal after injury. Fibroblasts are responsible for the synthesis of the macromolecules that constitute tendonous tissue. The ability of fibroblasts to maintain tissue homeostasis is compromised with increasing age underlying many of the age-related pathologies of the musculoskeletal system. This leads to a slowdown in connective tissue healing. Whether these deficits are due to changes in connective tissue, structure or to changes in tendon fibroblast function is unknown. We show that tendon fibroblasts from old mice have an altered morphology, reduced level of function, and exhibit changes in protein transport, compared to fibroblasts from young mice. The fibroblasts from old mice are not senescent, they are distinct phenotypes. Achilles tendon fibroblasts from old mice have low motility and proliferation, a poorly organised actin cytoskeleton and a different localisation of key focal adhesion proteins compared to the same cells from young mice. Additionally we found more of the protein misfolding indicator protein, GADD 153, in fibroblasts from old tendon. These results indicate that changes in tendon fibroblast function may well explain the age-related decline in tendon healing.

A mathematical model for the regulation of tumor dormancy based on enzyme kinetics

In this paper we present a two-compartment model for tumor dormancy based on an idea of Zetter [1998, Ann. Rev. Med. 49, 407-422] to wit: The vascularization of a secondary (daughter) tumor can be suppressed by an inhibitor originating from a larger primary (mother) tumor. We apply this idea at the avascular level to develop a model for the remote suppression of secondary avascular tumors via the secretion of primary avascular tumor inhibitors. The model gives good agreement with the observations of [De Giorgi et al., 2003, Derm. Surgery 29, 664-667]. These authors reported on the emergence of a polypoid melanoma at a site remote from a primary polypoid melanoma after excision of the latter. The authors observed no recurrence of the melanoma at the primary site, but did observe secondary tumors at secondary sites 5-7 cm from the primary site within a period of 1 month after the excision of the primary site. We attempt to provide a reasonable biochemical/cell biological model for this phenomenon. We show that when the tumors are sufficiently remote, the primary tumor will not influence the secondary tumor while, if they are too close together, the primary tumor can effectively prevent the growth of the secondary tumor, even after it is removed. It should be possible to use the model as the basis for a testable hypothesis.

The αvβ6 integrin plays a role in compromised epidermal wound healing

The alphavbeta6 integrin is an exclusively epithelial integrin that is highly expressed during fetal development. In adult tissue, alphavbeta6 integrin is expressed during inflammation, carcinogenesis, and in wound healing. We previously reported that alphavbeta6 integrin is highly expressed in poorly healing human wounds and its over-expression is associated with chronic wounds in a mouse model. The objective of this study was to investigate the role of alphavbeta6 integrin in compromised wound healing induced by hydrocortisone treatment or aging by using young and old mice deficient in or overexpressing the beta6 integrin subunit in the epidermis. Untreated aged beta6 integrin-deficient (beta6-/-) animals showed a significant delay in wound healing when compared to their age-matched controls or younger beta6-/- mice. The most significant delay was observed at the stages where granulation tissue deposition was occurring. Hydrocortisone treatment significantly delayed wound healing in wild-type and beta6 integrin-deficient mice in comparison with the untreated controls. However, hydrocortisone treatment in beta6 integrin overexpressing animals did not cause a significant delay in wound healing. The results of this study suggest that alphavbeta6 integrin plays an important role in wound healing in animals compromised by either age or stress mimicked by hydrocortisone.

Platelet-rich plasma and platelet gel: a review

Strategies to reduce blood loss and transfusion of allogeneic blood products during surgical procedures are important in modern times. The most important and well-known autologous techniques are preoperative autologous predonation, hemodilution, perioperative red cell salvage, postoperative wound blood autotransfusion, and pharmacologic modulation of the hemostatic process. At present, new developments in the preparation of preoperative autologous blood component therapy by whole blood platelet-rich plasma (PRP) and platelet-poor plasma (PPP) sequestration have evolved. This technique has been proven to reduce the number of allogeneic blood transfusions during open heart surgery and orthopedic operations. Moreover, platelet gel and fibrin sealant derived from PRP and PPP mixed with thrombin, respectively, can be exogenously applied to tissues to promote wound healing, bone growth, and tissue sealing. However, to our disappointment, not many well-designed scientific studies are available, and many anecdotic stories exist, whereas questions remain to be answered. We therefore decided to study perioperative blood management in more detail with emphasis on the application and production of autologous platelet gel and the use of fibrin sealant. This review addresses a large variety of aspects relevant to platelets, platelet-rich plasma, and the application of platelet gel. In addition, an overview of recent animal and human studies is presented.

Enhanced bone formation by transforming growth factor-beta1-releasing collagen/chitosan microgranules

Collagen/chitosan composite microgranules were fabricated as bone substitutes for the purpose of obtaining high bone-forming efficacy. The microgranules have the flexibility to fill various types of defect sites with closer packing. The interconnected pores formed spaces between the microgranules, which allowed new bone ingrowth and vascularization. In addition, the transforming growth factor-beta 1 (TGF-beta1) was incorporated into the microgranules in order to improve bone-healing efficacy. The collagen/chitosan microgranules were fabricated by dropping a mixed solution into a NaOH/ethanol solution. TGF-beta1 was loaded into the collagen/chitosan microgranules by soaking the microgranules in a TGF-beta1 solution. Scanning electron microscopy (SEM) observations and experiments examining the release of TGF-beta1 from chitosan and the collagen/chitosan microgranules were performed. SEM was used to examine the cell morphologies on the microgranules and cell proliferation was evaluated using a dimethylthiazole tetrazolium bromide assay. The differentiated cell function was assessed by measuring the alkaline phosphatase (ALPase) activity as well as detecting an osteocalcin assay. The in vivo bone-regeneration experiments were performed using a rabbit calvarial defect model. TGF-beta1 was released from the collagen/chitosan microgranules at a therapeutic concentration for 4 weeks. SEM indicated that the seeded osteoblastic cells were firmly attached to the microgranules and proliferated in a multilayer manner. The proliferation of the osteoblasts on the TGF-beta1-loaded microgranules was the highest among the different types of microgranules tested. The ALPase activity and osteocalcin level of all the samples increased during the culture period, and the TGF-beta1-loaded microgranules had a significantly higher ALPase activity and osteocalcin content than the other microgranules. The TGF-beta1-loaded microgranules demonstrated a higher bone-regenerative capacity in the rabbit calvarial defects after 4 weeks than the TGF-beta1-unloaded microgranules.

Absence of IL-1 Receptor Antagonist Impaired Wound Healing along with Aberrant NF-κB Activation and a Reciprocal Suppression of TGF-β Signal Pathway

Although enhanced expression of IL-1 family proteins, including IL-1alpha, IL-1beta, and IL-1 receptor antagonist (IL-1ra) during wound healing has been observed, the pathophysiological roles of these factors, particularly IL-1ra, still remain elusive. We explored skin wound-healing processes in IL-1ra-deficient mice. Compared to wild-type (WT) mice, IL-1ra-deficient mice exhibited impaired wound healing, as evidenced by attenuated collagen deposition and delayed neovascularization. In contrast, neutrophil recruitment was significantly exaggerated, with the augmented expression of IL-1s, TNF-alpha, and CXC chemokines, MIP-2 and KC, in IL-1ra-deficient mice compared with WT mice. Because the transcription of these proinflammatory cytokines and CXC chemokines requires the activation of NF-kappaB, a major target of IL-1- and TNF-alpha-mediated signal pathway, we examined the activation states of NF-kappaB. Nuclear translocation of NF-kappaB p65 was significantly enhanced and prolonged in IL-1ra-deficient mice, compared to that in WT mice. The cross-talk between NF-kappaB and TGF-beta-mediated signals has been proposed based on in vitro observations. Indeed, compared to WT mice, the amounts of total and phosphorylated Smad2 and Smad3 were decreased with a reciprocal increase in the amount of Smad7 in skin wound sites of IL-1ra-deficient mice. Moreover, the gene expression of vascular endothelial growth factor, a target gene of TGF-beta1, was decreased in IL-1ra-deficient mice. Thus, the absence of IL-1ra may suppress TGF-beta-mediated signaling pathway, which is crucial for collagen deposition and vascular endothelial growth factor-mediated neovascularization in wound healing.

Decreased expression of inhibitory SMAD6 and SMAD7 in keloid scarring

Keloids are benign skin tumours occurring during wound healing in genetically predisposed patients. They are characterised by an abnormal deposition of extracellular matrix components, in particular collagen. There is evidence that transforming growth factor-beta (TGFbeta) is involved in keloid formation. SMAD proteins play a crucial role in TGFbeta signaling and in terminating the TGFbeta signal by a negative feedback loop through SMAD6 and 7. It is unclear how TGFbeta signaling is connected to the pathogenesis of keloids. Therefore, we investigated the expression of SMAD mRNA and proteins in keloids, in normal skin and in normal scars. Dermal fibroblasts were obtained from punch-biopsies of keloids, normal scars and normal skin. Cells were stimulated with TGFbeta1 and the expression of SMAD2, 3, 4, 6 and 7 mRNA was analysed by real time RT-PCR. Protein expression was determined by Western blot analysis. Our data demonstrate a decreased mRNA expression of the inhibitory SMAD6 and 7 in keloid fibroblasts as compared to normal scar (p<0.01) and normal skin fibroblasts (p<0.05). SMAD3 mRNA was found to be lower in keloids (p<0.01) and in normal scar fibroblasts (p<0.001) compared to normal skin fibroblasts. Our data showed for the first time a decreased expression of the inhibitory SMAD6 and SMAD7 in keloid fibroblasts. This could explain why TGFbeta signaling is not terminated in keloids leading to overexpression of extracellularmatrix in keloids. These data support a possible role of SMAD6 and 7 in the pathogenesis of keloids.

Local administration of TGF-β1 to reinforce the anterior abdominal wall in a rat model of incisional hernia

The purpose of this study was to investigate different forms of the local application of TGF-beta(1) for augmentation of the anterior abdominal wall in an appropriate model of an incisional hernia. Sixty male Sprague-Dawley rats were divided into six groups. Artificial defects of the anterior abdominal wall were closed with one of the following methods: running Prolene suture, Vicryl mesh, prolene suture followed by an intramuscular injection of 1 mug TGF-beta(1), Vicryl mesh coated with 1 mug TGF-beta(1), and prolene suture coated with 1 mug TGF-beta(1). A control group did not receive any defect and treatment. Six weeks after operation, tensile strength, collagen content, gene expression of collagen I and III, blood vessels, and thickness of collagen fibres were evaluated. Tensile strength was strongest in the controls (14.2 (10.5-18 N)). There was no increase in tensile strength due to the administration of TGF-beta(1). On the contrary, bolus injection of the growth factor resulted in a significantly decreased strength of the wound tissue when compared to the groups 1, 4, 5, and 6 (9.1 (4.2-9.1 N)). These results correlated with the gene expression of collagen I and III. Local application of TGF-beta(1) did not augment the strength of the abdominal wall after 6 weeks.

Gene therapy in the treatment of lower extremity wounds

This article presents a brief overview of the etiology of chronic wounds of the lower extremities and their current medical and surgical treatment. Gene therapy as a potential tool for treating therapeutically challenging wounds is described in terms of the vectors employed in gene transfer, as well as the strategies used to promote wound healing. Results from animal model studies, as well as clinical trials, are presented.

Single dose of inducible nitric oxide synthase inhibitor induces prolonged inflammatory cell accumulation and fibrosis around injured tendon and synovium

The aim of the current study was to investigate the effect of inhibition of nitric oxide (NO) production after injury on inflammatory cell accumulation and fibrosis around digital flexor tendon and synovium. A standard crush injury was applied to the flexor tendons of the middle digit of the hindpaw and the overlying muscle and synovium of female Wistar rats. Thirty animals received an intraperitoneal injection of either isotonic saline or N(G)-nitro-l-arginine methyl ester (L-NAME; 5 mg/kg) immediately following the crush injury, and five animals were then sacrificed at various intervals and the paws processed for histology. Another group of five animals was sacrificed after 3 days for nitrite determinations. The results showed that nitrite production and hence NO synthase activity is doubled at the acute phase of tendon wound healing, and we can prevent this by administering a single dose of L-NAME immediately after injury. The incidence and severity of fibrocellular adhesions between tendon and synovium was much more marked in animals treated with L-NAME. Treatment with L-NAME elicited a chronic inflammatory response characterised by a persistent and extraordinarily severe accumulation of large numbers of inflammatory cells in the subcutaneous tissues, in muscle and in tendon. These findings indicate that in the case of injured tendon and synovium, NO could act to protect the healing tissue from an uncontrolled inflammatory response.

The effect of cell-based therapy with autologous synovial fibroblasts activated by exogenous TGF-beta1 on the in situ frozen-thawed anterior cruciate ligament

The present study was conducted to clarify the effect of cell therapy with autologous synovial tissue-derived fibroblasts activated by transforming growth factor (TGF)-beta1 on the necrotized anterior cruciate ligament (ACL). Thirty-six mature female Japanese white rabbits were used in this study. In Group I, fibrin glue with autologous synovial tissue-derived fibroblasts after TGF-beta stimulation was wrapped around the necrotized ACL after freeze-thaw treatment. In Group II, the glue without TGF-beta stimulation was wrapped around the frozen-thawed ACL. In Group III, the fibrin glue without fibroblasts was applied in the same manner on the frozen-thawed ACL. Histological observation found that implantation of fibroblasts after TGF-beta stimulation accelerated cellular infiltration into the ACL following fibroblast necrosis. Biomechanically, the transplantation of synovial tissue-derived autologous fibroblasts activated by TGF-beta inhibited mechanical deterioration of the ACL after the freeze-thaw treatment. The present study has shown that cell-based therapy using synovial tissue-derived fibroblasts activated by TGF-beta1 is a possible solution to mechanical deterioration of the graft after ACL reconstruction.

Energy metabolism during cutaneous wound healing in immunocompromised and aged rats

Cutaneous cells primarily depend upon carbohydrate metabolism for their energy requirement during healing process. But, it may be greatly hampered during various pathological and altered physiological conditions. The present study was therefore undertaken to investigate the intermediate steps of energy metabolism by measuring enzyme activities in the granulation tissues of immunocompromised and aged rats following excision-type of cutaneous injury. The activities of key regulatory enzymes hexokinase (HK), phosphofructokinase (PFK), lactate dehydrogenase (LDH), citrate synthase (CS) and glucose-6 phosphate dehydrogenase (G6PD) have been monitored in the wound tissues of immunocompromised and aged rats at different time intervals (2, 7, 14 and 21 days) of postwounding. The activities of HK and CS were found significantly decreased both in immunocompromised and aged rats as compared to control subjects. However G6PD exhibited an elevated activity at early stage followed by a decreased activity at later phase of healing both in immunocompromised and aged rats. The PFK and LDH demonstrated an upward trend in immunocompromised rats but a decreasing trend in aged rats. Thus, the results suggest that significant alterations in the activities of energy metabolizing enzymes in the granulation tissues in both immunocompromised as well as in aged rats may overall affect the energy availability for cellular activity needed for repair process. Hence, this may perhaps be one of the factor responsible for impaired healing in these subjects.

Enhanced angiogenesis characteristic of SPARC-null mice disappears with age

The impairment of angiogenesis in aging has been attributed, in part, to alterations in proteins associated with the extracellular matrix (ECM). SPARC (secreted protein acidic and rich in cysteine/osteonectin/BM-40) is a matricellular protein that regulates endothelial cell function as well as cell-ECM interactions. We have previously shown that angiogenesis, as reflected by fibrovascular invasion into subcutaneously implanted polyvinyl alcohol (PVA) sponges, is increased in SPARC-null mice (6-9 months of age) relative to their wild-type (WT) counterparts. In this study, we define the influence of aging on (a) the expression of SPARC and (b) fibrovascular invasion into sponge implants in SPARC-null and WT mice. The expression of SPARC in fibroblasts and endothelial cells derived from young donors (humans mean age less than 30 years and mice 4-6 months of age) and old donors (humans mean age over 65 years and mice 22-27 months of age) decreased 1.6 to 2.3-fold with age. Analysis of fibrovascular invasion into sponges implanted into old (22-27 months) SPARC-null and WT mice showed no differences in percent area of invasion or collagenous ECM. Moreover, sponges from old SPARC-null and WT mice contained similar levels of VEGF that were significantly lower than those from young (4-6 months) mice. In contrast to fibroblasts from young SPARC-null mice, dermal fibroblasts from old SPARC-null mice did not migrate farther, proliferate faster, or produce greater amounts of VEGF relative to their old WT counterparts. However, when stimulated with TGF-beta1, primary cells isolated from the sponge implants, and dermal fibroblasts from both old SPARC-null and WT mice, showed marked increases in VEGF secretion. These data indicate that aging results in a loss of enhanced angiogenesis in SPARC-null mice, as a result of the detrimental impact of age on cellular functions, collagen deposition, and VEGF synthesis. However, the influence of aging on these processes may be reversed, in part, by growth factor stimulation.

Clinical implications of growth factors in flexor tendon wound healing

Recent research has focused on the role of growth factors in flexor tendon wound healing. These basic science reports have described the identification and quantification of various growth factors in in vitro and in vivo models. Although these reports have begun to piece together the cascade of events involved in flexor tendon wound healing, the clinical relevance for the practicing hand surgeon is unclear. Growth factors are cell-secreted proteins that regulate cellular functions. These growth factors are involved in cell differentiation and growth, including the normal processes of development and tissue repair. Several growth factors recently have been identified as playing roles in tendon healing including vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF), and transforming growth factor beta (TGF-beta). In addition, the transcription factor NF-kappaB has been implicated in the signaling pathways of these growth factors. The purpose of this article is to describe what is known about the molecular basis of flexor tendon wound healing, to review the most commonly studied growth factors, and to summarize likely clinical applications of these growth factors to flexor tendon repair.

Growth factors and chronic wound healing: past, present, and future

Growth substances (cytokines and growth factors) are soluble signaling proteins affecting the process of normal wound healing. Cytokines govern the inflammatory phase that clears cellular and extracellular matrix debris. Wound repair is controlled by growth factors (platelet-derived growth factor [PDGF], keratinocyte growth factor, and transforming growth factor beta). Endogenous growth factors communicate across the dermal-epidermal interface. PDGF is important for most phases of wound healing. Becaplermin (PDGF-BB), the only growth factor approved by the Food and Drug Administration, requires daily application for neuropathic wound healing. Gene therapy is under development for more efficient growth factor delivery; a single application will induce constitutive growth factor expression for weeks. Based on dramatic preclinical animal studies, a phase 1 clinical trial planned on a PDGF genetic construct appears promising.

Impaired Angiogenesis in the Aged

The process of angiogenesis, during which new blood vessels are formed, is impaired during aging. This Perspective describes many of the myriad components of the angiogenic response that are altered with age. In addition, the impact of impaired angiogenesis on wound healing, vascular disease, and cancer in the aged is discussed.

The Essential Involvement of Cross-Talk between IFN-γ and TGF-β in the Skin Wound-Healing Process

Several lines of in vitro evidence suggest the potential role of IFN-gamma in angiogenesis and collagen deposition, two crucial steps in the wound healing process. In this report, we examined the role of IFN-gamma in the skin wound healing process utilizing WT and IFN-gamma KO mice. In WT mice, excisional wounding induced IFN-gamma mRNA and protein expression by infiltrating macrophages and T cells, with a concomitant enhancement of IL-12 and IL-18 gene expression. Compared with WT mice, IFN-gamma KO mice exhibited an accelerated wound healing as evidenced by rapid wound closure and granulation tissue formation. Moreover, IFN-gamma KO mice exhibited enhanced angiogenesis with augmented vascular endothelial growth factor mRNA expression in wound sites, compared with WT mice, despite a reduction in the infiltrating neutrophils, macrophages, and T cells. IFN-gamma KO mice also exhibited accelerated collagen deposition with enhanced production of TGF-beta1 protein in wound sites, compared with WT mice. Furthermore, the absence of IFN-gamma augmented the TGF-beta1-mediated signaling pathway, as evidenced by increases in the levels of total and phosphorylated Smad2 and a reciprocal decrease in the levels of Smad7. These results demonstrate that there is crosstalk between the IFN-gamma/Stat1 and TGF-beta1/Smad signaling pathways in the wound healing process.

Interference with transforming growth factor-beta/ Smad3 signaling results in accelerated healing of wounds in previously irradiated skin

Transforming growth factor (TGF)-beta regulates many aspects of wound repair including inflammation, chemotaxis, and deposition of extracellular matrix. We previously showed that epithelialization of incisional wounds is accelerated in mice null for Smad3, a key cytoplasmic mediator of TGF-beta signaling. Here, we investigated the effects of loss of Smad3 on healing of wounds in skin previously exposed to ionizing radiation, in which scarring fibrosis complicates healing. Cutaneous wounds made in Smad3-null mice 6 weeks after irradiation showed decreased wound widths, enhanced epithelialization, and reduced numbers of neutrophils and myofibroblasts compared to wounds in irradiated wild-type littermates. Differences in breaking strength of wild-type and Smad3-null wounds were not significant. As shown previously for neutrophils, chemotaxis of primary dermal fibroblasts to TGF-beta required Smad3, but differentiation of fibroblasts to myofibroblasts by TGF-beta was independent of Smad3. Previous irradiation-enhanced induction of connective tissue growth factor mRNA in wild-type, but not Smad3-null fibroblasts, suggested that this may contribute to the heightened scarring in irradiated wild-type skin as demonstrated by Picrosirius red staining. Overall, the data suggest that attenuation of Smad3 signaling might improve the healing of wounds in previously irradiated skin commensurate with an inhibition of fibrosis.

Growth factors: the wound healing therapy of the future

'Growth factors' is an umbrella term used to describe a variety of chemical messengers found in a wide range of tissues, which have a number of functions including the regulation of cell and tissue growth and development. Several growth factors have been proposed as ideal agents to promote wound healing. This review discusses their functions and how they can be applied in the management of chronic wounds.

Expression of transforming growth factor beta isoform mRNA in injured peritoneum that healed with adhesions and without adhesions and in uninjured peritoneum

OBJECTIVE

To compare the mRNA levels of transforming growth factor beta (TGF-beta) isoforms 1, 2, and 3 among surgically injured peritoneum that healed with adhesions, surgically injured peritoneum that healed without adhesions, and uninjured peritoneum.

DESIGN

Prospective experimental study.

SETTING

University vivarium.

ANIMAL(S)

Fourteen sexually mature female Sprague-Dawley rats, 226-250 grams.

INTERVENTION(S)

Standardized cecal abrasion was performed on 120 Sprague-Dawley rats. The areas of abrasion and any resultant adhesions were harvested at necropsy 7 days later. Total RNA was then extracted from the serosal adhesions of four rats, from the serosa of five rats that healed without adhesion formation, and from analogous areas of cecum from five rats that did not undergo abrasion and served as controls.

MAIN OUTCOME MEASURE(S)

Quantification of the expression of the TGF-beta1, TGF-beta2, and TGF-beta3 mRNA transcripts in peritoneal adhesions, normally healed peritoneum, and fresh, uninjured peritoneal tissue through the use of multiplex reverse transcriptase-polymerase chain reaction analysis.

RESULT(S)

Peritoneal adhesion TGF-beta1 and TGF-beta3 mRNA expression was 3.7-fold and 8.6-fold higher, respectively, than in abraded tissues that healed normally; and 5.6-fold and 4.6-fold higher, respectively, than in nonabraded tissues. While TGF-beta2 mRNA levels were also higher in serosal adhesions compared with normally healed and uninjured peritoneum, this rise was not statically significant.

CONCLUSION(S)

Peritoneal adhesions resulting from surgical abrasion of a serosal surface have statistically significant increased levels of TGF-beta1 and -beta3 mRNA transcripts compared with both uninjured and normally healed peritoneum.

Pleural fluid transforming growth factor-beta1 correlates with pleural fibrosis in experimental empyema

Transforming growth factor-beta1 (TGF-beta1) is a growth factor that is implicated in fibrosis of many organs. The purpose of this study was to determine the sequential levels of TGF-beta1 in the pleural fluid of rabbits that had undergone empyema induction, as fibrosis of the pleural space develops. Thirty-seven rabbits underwent empyema induction. Rabbits were sacrificed on Days 1, 2, 3, 4, 5, 6, and 8. Pleural fluid and viscera pleura specimens were collected at autopsy. TGF-beta1 levels were measured in pleural fluid using a commercially available ELISA kit, and pathologic specimens were scored for evidence of fibrosis (pleural thickness and number of fibroblasts). The median levels of pleural fluid TGF-beta1 increased from 8,100 pg/ml (Days 1 and 2) to 39,600 pg/ml (Day 8). Pleural fluid TGF-beta1 levels closely correlated with microscopic pleural thickness (r = 0.7, p < 0.001) and number of fibroblasts present in the visceral pleura (r = 0.68, p < 0.001). The first increase in pleural fluid levels of TGF-beta1 (Day 3) occurred before the increase in pleural thickness (Day 4) and before the increase in number of fibroblasts (Day 4). In conclusion, pleural fluid levels of TGF-beta1 rise in experimental empyema as pleural fibrosis develops. The rise in empyemic pleural fluid TGF-beta1 levels correlates with markers of pleural space fibrosis.

Basic fibroblast growth factor and epidermal growth factor reverse impaired ulcer healing of the rabbit oral mucosa

BACKGROUND

The therapies for refractory ulcers on the oral mucosa are symptomatic and very unsatisfactory. We hypothesized that application of growth factors might be able to achieve successful remission of the lesion. We evaluated the effects of systemic administration and topical application of epidermal growth factor (EGF) and basic fibroblast growth factor (bFGF) on impaired wound healing of ulcers in the rabbit gingiva.

METHODS

Almost uniform round ulcers could be created on the gingiva of the rabbits by chemical injury with acetic acid. When the submandibular glands were removed or i.v. injection of cisplatin (CDDP) and peplomycin sulfate was performed before ulcer formation, healing of the ulcers took longer than in untreated rabbits. To ascertain whether or not human EGF and bFGF affect rabbit cells, we first examined the effects of EGF and bFGF on the proliferation of the cells derived from rabbit gingiva. We then applied EGF or bFGF in these impaired healing models.

RESULTS

EGF and bFGF promoted proliferation of the fibroblasts, and EGF also promoted proliferation of the keratinocytes isolated from gingival tissue of rabbits in vitro. Systemic injections of EGF and bFGF in rabbits, which had their submandibular glands removed, and topical application of bFGF accelerated healing of ulcers created in rabbits injected with CDDP and peplomycin sulfate. The ability of bFGF to promote the healing of ulcers was much greater than that of EGF.

CONCLUSION

Basic FGF may be effective for refractory oral mucosal lesions.

Essential involvement of IL-6 in the skin wound-healing process as evidenced by delayed wound healing in IL-6-deficient mice

To clarify interleukin (IL)-6 roles in wound healing, we prepared skin excisions in wild-type (WT) and IL-6-deficient BALB/c [knockout (KO)] mice. In WT mice, the wound area was reduced to 50% of original size at 6 days after injury. Microscopically, leukocyte infiltration was evident at wound sites. Furthermore, the re-epithelialization rate was approximately 80% at 6 days after injury with increases in angiogenesis and hydroxyproline contents. The gene expression of IL-1, chemokines, adhesion molecules, transforming growth factor-beta1, and vascular endothelial growth factor was enhanced at the wound sites. In contrast, the enhanced expression of these genes was significantly reduced in KO mice. Moreover, in KO mice, the reduction of wound area was delayed with attenuated leukocyte infiltration, re-epithelialization, angiogenesis, and collagen accumulation. Finally, the administration of a neutralizing anti-IL-6 monoclonal antibody significantly delayed wound closure in WT mice. These observations suggest that IL-6 has crucial roles in wound healing, probably by regulating leukocyte infiltration, angiogenesis, and collagen accumulation.

Effects of transforming growth factor-beta 1 (TGF-beta1) on in vitro mineralization of human osteoblasts on implant materials

An in vitro cell-implant mineralization model system was used to study the effect of transforming growth factor-beta 1(TGF-beta1) on mineralization in human osteoblast cultures. SaOs-2 and primary human osteoblast (HOB) cells were cultured on Tivanium (Ti-6Al-4V) disks. Administration of different concentrations of TGF-beta1 (0.02, 0.01, 0.2, 1.0, 2.0ng/ml) to these cultures demonstrated a biphasic dose response with 0.2ng/ml TGF-beta1 maximally increasing the calcium content compared to control culture. Results with SaOs-2 and HOB cultures were similar. An optimal dose of TGF-beta1 (0.2ng/ml) was provided to the cultures either in one single dose or multiple doses. Continuous administration of 0.2ng/ml TGF-beta1 caused 77% (SaOs-2) and 60% (HOB) increases in calcification compared to the control and 0.2ng/ml single dose groups. Single administration of the accumulative dose at 1.6ng/ml had no significant effect on the calcium content in either cell culture compared to control. Two weeks continuous administration of 0.2ng/ml TGF-beta1 in both cell cultures resulted in significant increases in the expression of bone specific extracellular matrix proteins which included alkaline phosphatase, Type I collagen, and osteocalcin as measured by Northern blot analysis and RT-PCR. At 4 weeks, the mRNA level of Type I collagen was still significantly higher in the TGF-beta1 treatment group compared to control. In conclusion, TGF-beta1 enhances mineralization of HOB on implant materials.

The biomechanical response to doses of TGF-beta 2 in the healing rabbit medial collateral ligament

Ligament injuries result in significant disability in over 100,000 patients each year. Despite current methods of treatment, 13% of patients with medial collateral ligament (MCL) injury develop early signs of arthritis, suggesting an incomplete return of knee stability. The principal hypothesis of this work was that the addition of TGF-beta 2 to the healing MCL would accelerate the development of scar strength and stiffness. Forty-four rabbits were divided evenly into four groups, with each group receiving either 0.1, 1 or 5 microg of TGF-beta 2 and the fourth group receiving 1 microg TGF-beta 2 and 1 microg of PDGF. Each rabbit underwent bilateral transection of the MCL, with one side having treatment with one of four doses of growth factor and the other side left untreated. All animals were sacrificed at 6 weeks and the structural properties of maximum load at failure, stiffness, and energy absorbed at failure measured. All treatment groups demonstrated an increase in scar mass, but no group had a significant increase in scar load at failure at 6 weeks. The addition of 0.1 microg TGF-beta 2 led to a significant increase in scar stiffness. The addition of PDGF had no significant effect on any of the parameters studied. This study suggests the mechanical stiffness, but not the load at failure, of ligament scar can be significantly altered by the administration of TGF-beta 2.

An extract of the root of Lithospermun erythrorhison accelerates wound healing in diabetic mice

Many people suffer from intractable bedsores, which sometimes develop because of chronic metabolic failure in patients. An extract of the root of Lithospermun erythrorhison (SK) has been reported to have an effect on wound healing. However, the effects of SK have not been studied in chronic wounds, such as bedsores. The healing-impaired diabetic (db/db) mouse is a good model for the investigation of clinical healing therapies. Therefore, we examined whether SK accelerates wound healing in db/db mice. Full-thickness round wounds of 6-mm diameter were created on the backs of mice. After applying SK, we covered the wound with a film dressing to keep it moist. At three weeks, wound closure was complete in SK-treated mice but not in controls. Capillary vessel number and collagen synthesis increased early in wound healing in SK-treated wounds. At this time, vascular endothelial growth factor (VEGF)-positive neutrophils had infiltrated the wound and the appearance of apoptotic fibroblasts and endothelial cells in the granulation tissue was more advanced than in the controls. Where the wound was covered with epithelium, there tended to be less infiltration of VEGF-positive cells and apoptotic cells. These results suggest that the inflammatory phase was shortened, and the proliferative and maturation phases were advanced by SK. It is known that SK also has antibacterial activity. Therefore, we conclude that SK is useful for wound healing in db/db mice, and could potentially help patients with intractable bedsores.

Accelerated wound healing in tumor necrosis factor receptor p55-deficient mice with reduced leukocyte infiltration

To clarify biological roles of tumor necrosis factor receptor p55 (TNF-Rp55) -mediated signals in wound healing, skin excisions were prepared in BALB/c (WT) and TNF-Rp55-deficient (KO) mice. In WT mice, the wound area was reduced to 50% of the original area 6 days after injury, with angiogenesis and collagen accumulation. Histopathologically, reepithelialization rate was approximately 80% 6 days. Myeloperoxidase activity and macrophage recruitment were the most evident 1 and 6 days after injury, respectively. Gene expression of adhesion molecules, interleukin 1alpha (IL-1alpha), IL-1beta, monocyte chemoattractant protein 1, macrophage inflammatory protein 1alpha (MIP-1alpha), MIP-2, transforming growth factor beta1 (TGF-beta1) connective tissue growth factor (CTGF), vascular endothelial growth factor (VEGF), Flt-1, and Flk-1 was enhanced at the wound site. In KO mice, an enhancement in angiogenesis, collagen content, and reepithelialization was accelerated with the increased gene expression of TGF-beta1, CTGF, VEGF, Flt-1, and Flk-1 at the wound sites, resulting in accelerated wound healing compared with WT mice. In contrast, leukocyte infiltration, mRNA expression of adhesion molecules, and cytokines were significantly reduced in KO mice. These observations suggest that TNF-Rp55-mediated signals have some role in promoting leukocyte infiltration at the wound site and negatively affect wound healing, probably by reducing angiogenesis and collagen accumulation.

Transforming growth factor-beta 1, 2, 3 and receptor type I and II in diabetic foot ulcers

AIMS

To study the distribution of transforming growth factor-beta (TGF-beta) 1, 2 and 3, and TGF-beta receptor types I and II in diabetic foot ulcers, diabetic skin and normal skin by immunohistochemistry, immunofluorescence and Western blotting. We also compared the TGF-betas with those of chronic venous ulcers.

METHODS

Skin biopsies were obtained from the leg or the foot of non-diabetic and diabetic subjects, and from the edge of diabetic foot ulcers and chronic venous ulcers. Distribution (by immunofluorescence and immunocytochemistry) of TGF-beta 1, 2 and 3 and TGF-beta receptors (RI and RII) was done by staining 8-microm skin sections using appropriate antibodies. Protein levels of TGF-beta were measured by Western blot analysis.

RESULTS

TGF-beta3 expression was increased in the epithelium at the edge of diabetic foot ulcers, being more intense than diabetic and normal skin (P = 0.03, 0.02, respectively), as was its expression in venous ulcers compared with normal skin. However, TGF-beta1 expression was not increased in diabetic foot ulcers and chronic venous ulcers, and was comparable to diabetic and normal skin. There was also no increase for the receptors in diabetic foot ulcers.

CONCLUSION

The lack of TGF-beta1 up-regulation in both diabetic foot ulcers and venous ulcers may explain the impaired healing in these chronic wounds, and could represent a general pattern for chronicity.

Endocrine expression of the active form of TGF-beta1 in the TGF-beta1 null mice fails to ameliorate lethal phenotype

TGF-beta1 null mice die by 3 to 4 weeks of age due to a severe autoimmune-mediated multifocal inflammation resulting in multi-organ failure. To assess the therapeutic potential of circulating levels of active TGF-beta1, we generated mice with endocrine expression of active TGF-beta1 on a TGF-beta1 null background (TGF-beta1 (-/-/TG)) by crossing TGF-beta1(+/-) mice with transgenic mice (TG) that express recombinant TGF-beta1 specifically in the liver and secrete it in the blood. The TGF-beta1 (-/-/TG) mice exhibit a survival profile similar to the TGF-beta1 (-/-) mice indicating a failure to rescue the lethal phenotype. However, serum TGF-beta1 levels in the TGF-beta1 (-/-/TG) mice were restored to near normal levels with expression in all the tissues, notably in the kidney and spleen. Histopathology showed reduced inflammation in the target tissues, especially in the heart. Interestingly, unlike TGF-beta1 (-/-) mice, the TGF-beta1 (-/-/TG) mice have glomerulonephritis in their kidneys similar to the TG mice. Thus, the phenotype of TGF-beta1 (-/-/TG) animal model indicates the potential role of circulating active-TGF-beta1 in reducing inflammation, but its failure to rescue lethality in TGF-beta1 null mice indicates a critical autocrine role of TGF-beta1.

Beyond Mitomycin: TGF-beta and wound healing

The introduction of the anti-cancer drugs Mitomycin and 5-fluorouracil as anti-scarring agents within the last decade, has greatly improved surgical results of glaucoma filtration surgery. However, a number of problems associated with their use have emerged. At the same time, the transforming growth factor-beta (TGF-beta) has been identified as an important component of wound healing, particularly in the conjunctival scarring response. Recent developments in molecular therapy offer exciting prospects for the modulation of wound healing, specifically those targeting TGF-beta. As TGF-beta is such a potent stimulant of scarring, this review examines its biology and role in ocular wound healing and repair, and discusses promising new approaches to modifying its activity.

Cross-talk between transforming growth factor-beta and estrogen receptor signaling through Smad3

Transforming growth factor-beta (TGF-beta) plays central roles in embryonic development, organogenesis, and physiologic connective tissue remodeling during wound healing and tissue repair as well as in carcinogenesis. Estrogens have key roles in a variety of biological events, such as the development and maintenance of female reproductive organs and bone and lipid metabolism. Previous studies demonstrated that estrogens suppress TGF-beta-induced gene expression, such as type IV collagen in kidney mesangial cells. However, the molecular mechanisms that mediate this antagonistic effect are unknown. To elucidate the mechanisms of cross-talk between TGF-beta and estrogen receptor (ER) signaling pathways, we reconstituted TGF-beta and ER signaling in human kidney carcinoma cells. Here we demonstrate that TGF-beta-induced activation of Sma and MAD-related protein 3 (Smad3) activity, one of the major intracellular transducers of TGF-beta signaling, was suppressed by ER, whereas ER-mediated transcriptional activation was enhanced by TGF-beta signaling. We provide evidence that this two-way cross-talk between the estrogen and TGF-beta signaling pathways was the result of direct physical interactions between Smad3 and ER. These findings have implications for a variety of disease states, such as the pathophysiology of kidney function, atherosclerosis, and breast cancer.

Differential expression of transforming growth factor-beta receptors in a rabbit zone II flexor tendon wound healing model

Flexor tendon repair in zone II is complicated by adhesions that impair normal postoperative gliding. Transforming growth factor-beta (TGF-beta) is a family of growth factors that has been implicated in scar formation. The TGF-beta family of proteins binds to three distinct classes of membrane receptors, termed RI, RII, and RIII. In this study, we analyzed the temporal and spatial distribution of TGF-beta receptor isoforms (RI, RII, and RIII) in a rabbit zone II flexor tendon wound healing model.Twenty-eight adult New Zealand White rabbit forepaws underwent isolation of the middle digit flexor digitorum profundus tendon in zone II. The tendons underwent transection in zone II and immediate repair. The tendons were harvested at increasing time points: 1, 3, 7, 14, 28, and 56 days postoperatively (n = 4 at each time point). The control flexor tendons were harvested without transection and repair (n = 4). Immunohistochemical analysis was used to detect the expression patterns for TGF-beta receptors RI, RII, and RIII. Immunohistochemical staining of the transected and repaired tendons demonstrated up-regulation of TGF-beta RI, RII, and RIII protein levels. TGF-beta receptor production in the experimental group (transection and repair) was concentrated in the epitenon and along the repair site. Furthermore, the TGF-beta receptor expression levels peaked at day 14 and decreased by day 56 postoperatively. In contrast, minimal receptor expression was observed in the untransected and unrepaired control tendons. These data provide evidence that (1) TGF-beta receptors are up-regulated after injury and repair; (2) peak levels of TGF-beta receptor expression occurred at day 14 and decreased by day 56 after wounding and repair; and (3) both the tendon sheath and epitenon have the highest receptor expression, and both may play critical roles in flexor tendon wound healing. Understanding the up-regulation of TGF-beta isoforms and the up-regulation of their corresponding receptors during flexor tendon wound healing provides new targets for biomolecular modulation of postoperative scar formation.

Age and growth factors in porcine full-thickness wound healing

It has been recognized that the rate of cutaneous wound healing declines with age, yet the molecular processes that affect this decline remain poorly understood. The purpose of this study was to compare reepithelialization and contraction rates, and growth factor profiles in full-thickness wounds in swine of various ages. Multiple full-thickness excisional wounds were created on the dorsum of 24-month-old (n=2), 4-month-old (n=2), and 2-month-old (n=2) Yucatan Minipigs. The extent of reepithelialization was shown to decrease with increasing age in a manner that was statistically significant among the 2-month-old (79%), 4-month-old (48%), and 24-month-old pigs (22%). Enzyme-linked immunosorbent assay results showed that endogenous vascular endothelial growth factor concentrations in the 2- and 4-month-old animals peaked on day 4, reaching levels of 482 pg/ml and 420 pg/ml, respectively. In the 24-month-old pigs the vascular endothelial growth factor concentration peaked later (day 6), and was present at a lower level (229 pg/ml). On day 4 the vascular endothelial growth factor levels in the older pigs reached only 120 pg/ml, representing a four-fold decrease in concentration compared to the younger pigs. A comparison of platelet-derived growth factor-BB concentrations across the age groups showed similar patterns in the 2- and 4-month-old pigs (peaks of 77 and 91 pg/ml on days 2 and 3, respectively), and levels in the 24-month-old were below the sensitivity level (31.5 pg/ml) of the assay. Transforming growth factor-beta1 levels across the age groups did not differ in a manner that was statistically significant, and all age groups peaked on day 9. Wound contraction showed no statistical differences among the age groups from days 3 to 9. On day 11, however, wound contraction in 2-month-old pigs was about 10% faster than in 24-month-old pigs (p < 0.05). These data suggest a possible new algorithm for treating wounds in aged skin, by which exogenous growth factors can be added to the wound microenvironment in doses and at times that match the growth factor profiles observed in wounds made in younger skin.

Transforming growth factor beta2 induced pleurodesis is not inhibited by corticosteroids

BACKGROUND

Talc and tetracyclines induce pleurodesis by directly injuring the pleura. The injury results in intense inflammation which subsequently leads to fibrosis. Corticosteroids can inhibit talc pleurodesis by reducing the inflammatory process. We hypothesised that transforming growth factor beta2 (TGFbeta2), a fibrogenic cytokine with immunomodulatory functions, could induce effective pleurodesis without generating significant pleural inflammation and therefore remain effective despite co-administration of corticosteroids.

METHODS

Thirty rabbits were divided into two groups. Rabbits in the steroid group received weekly intramuscular injections of triamcinolone diacetate (0.8 mg/kg). Ten rabbits in each group were given 5.0 microg TGFbeta2 intrapleurally via a chest tube while the remaining five received 1.7 microg TGFbeta2. Pleurodesis was graded macroscopically after 14 days from 1 (none) to 8 (>50% symphysis).

RESULTS

TGFbeta2 produced excellent pleurodesis at both 5.0 microg and 1.7 microg doses. The pleural effusions produced after the injection were low in all inflammatory markers. No significant differences were seen between the steroid group and controls in macroscopic pleurodesis scores (7.2 (1.3) v 7.1 (1.2)), levels of inflammatory markers in the pleural fluids (leucocyte 1107 (387)/mm(3) v 1376 (581)/mm(3); protein 3.1 (0.3) mg/dl v 2.9 (0.3) mg/dl, and LDH 478 (232) IU/l v 502 (123) IU/l), and the degree of microscopic pleural fibrosis and pleural inflammation.

CONCLUSIONS

TGFbeta2 can induce effective pleurodesis and remains effective in the presence of high dose parenteral corticosteroids.

Transforming growth factor β2 induced pleurodesis is not inhibited by corticosteroids

BACKGROUND

Talc and tetracyclines induce pleurodesis by directly injuring the pleura. The injury results in intense inflammation which subsequently leads to fibrosis. Corticosteroids can inhibit talc pleurodesis by reducing the inflammatory process. We hypothesised that transforming growth factor β2 (TGFβ2), a fibrogenic cytokine with immunomodulatory functions, could induce effective pleurodesis without generating significant pleural inflammation and therefore remain effective despite co-administration of corticosteroids.

METHODS

Thirty rabbits were divided into two groups. Rabbits in the steroid group received weekly intramuscular injections of triamcinolone diacetate (0.8 mg/kg). Ten rabbits in each group were given 5.0 μg TGFβ2 intrapleurally via a chest tube while the remaining five received 1.7 μg TGFβ2. Pleurodesis was graded macroscopically after 14 days from 1 (none) to 8 (>50% symphysis).

RESULTS

TGFβ2produced excellent pleurodesis at both 5.0 μg and 1.7 μg doses. The pleural effusions produced after the injection were low in all inflammatory markers. No significant differences were seen between the steroid group and controls in macroscopic pleurodesis scores (7.2 (1.3)v 7.1 (1.2)), levels of inflammatory markers in the pleural fluids (leucocyte 1107 (387)/mm3v 1376 (581)/mm3; protein 3.1 (0.3) mg/dl v 2.9 (0.3) mg/dl, and LDH 478 (232) IU/l v 502 (123) IU/l), and the degree of microscopic pleural fibrosis and pleural inflammation.

CONCLUSIONS

TGFβ2can induce effective pleurodesis and remains effective in the presence of high dose parenteral corticosteroids.

Impaired migration, integrin function, and actin cytoskeletal organization in dermal fibroblasts from a subset of aged human donors

Deficits in the motility of fibroblasts contribute to age-related impairment of wound healing. We analyzed 'young' fibroblasts from four healthy donors 22-30 years old and 'aged' fibroblasts from six healthy donors 81-92 years old for migratory ability on type I collagen, secretion of matrix metalloproteases (MMPs), attachment to matrices and, expression and function of integrin alpha2beta1. Cells from each donor were analyzed separately in each experiment. Whereas migration of young fibroblasts was uniformly robust, three aged lines migrated well and three migrated poorly. Synthesis of MMP1 and TIMP1, but not MMP2 or MMP9, was increased in the aged fibroblasts relative to the young fibroblast lines irrespective of their motility. All lines of young and aged fibroblasts attached to plastic or collagen with similar efficiency. Although young and aged fibroblasts expressed comparable levels of the alpha2 integrin; the lines of aged fibroblasts that were poor migrators exhibited a significant reduction in alpha2beta1 function relative to fibroblasts with normal migratory capacities. Moreover, the lines of aged fibroblasts that exhibited poor migration demonstrated a disordered actin cytoskeleton and a reduced ability to contract collagen gels. In conclusion, aged fibroblasts, unlike young fibroblasts, displayed variable migratory capacities. Deficient migration by specific lines of aged fibroblasts was not related to the capacity to attach, express alpha2 integrin, or secrete MMPs and TIMP1, but was characterized by disorganized cytoskeletal actin and reduced alpha2beta1 function.

Angiogenesis: is it the key to controlling the healing process?

Much research has been undertaken on the complex processes involved in angiogenesis. This may lead to the development of new treatments that help to improve patients' quality of life

Transforming growth factor-beta signal transduction in epithelial cells

Transforming growth factor (TGF)-beta is a natural and potent growth inhibitor of a variety of cell types, including epithelial, endothelial, and hematopoietic cells. The ability of TGF-beta to potently inhibit the growth of many solid tumors of epithelial origin, including breast and colon carcinomas, is of particular interest. However, many solid tumor cells become refractory to the growth inhibitory effects of TGF-beta due to defects in TGF-beta signaling pathways. In addition, TGF-beta may stimulate the invasiveness of tumor cells via the paracrine effects of TGF-beta. Accordingly, in order to develop more effective anticancer therapeutics, it is necessary to determine the TGF-beta signal transduction pathways underlying the growth inhibitory effects and other cellular effects of TGF-beta in normal epithelial cells. Thus far, two primary signaling cascades downstream of the TGF-beta receptors have been elucidated, the Sma and mothers against decapentaplegic homologues and the Ras/mitogen-activated protein kinase pathways. The major objective of this review is to summarize TGF-beta signaling in epithelial cells, focusing on recent advances involving the Sma and mothers against decapentaplegic homologues and Ras/mitogen-activated protein kinase pathways. This review is particularly timely in that it provides a comprehensive summary of both signal transduction mechanisms and the cell cycle effects of TGF-beta.

Specific growth factors and the healing of chronic wounds

Part II of this two-part review focuses on the function of specific growth factors in wound healing and considers the results of clinical trials of their use in chronic wounds.

Locally delivered rhTGF-beta2 enhances bone ingrowth and bone regeneration at local and remote sites of skeletal injury

The purposes of the present study were to determine if recombinant human transforming growth factor-beta-2 (rhTGF-beta2) enhances bone ingrowth into porous-coated implants and bone regeneration in gaps between the implant and surrounding host bone. The implants were placed bilaterally for four weeks in the proximal humeri of skeletally mature, adult male dogs in the presence of a 3-mm gap. In three treatment groups of animals, the test implant was treated with hydroxyapatite/tricalcium phosphate (HA/TCP) and rhTGF-beta2 in buffer at a dose per implant of 1.2 microg (n = 6), 12 microg (n = 7), or 120 microg (n = 7) and placed in the left humerus. In these same animals, an internal control implant treated only with HA/TCP and buffer was placed in the right humerus. In a non-TGF-beta treated external control group of animals (n = 7), one implant was treated with HA/TCP while the contralateral implant was not treated with the ceramic. In vitro analyses showed that approximately 15%, of the applied dose was released within 120 h with most of the release occurring in the first 24 h. The TGF-beta treated implants had significantly more bone ingrowth than the controls with the greatest effect in the 12 microg/implant group (a 2.2-fold increase over the paired internal control (P = 0.004) and a 4-fold increase over the external control (P < 0.001)). The TGF-beta treated implants had significantly more bone formation in the gap than the controls with the greatest effect in the 12 and 120 microg groups (1.8-fold increases over the paired internal controls (P = 0.003 and P = 0.012, respectively) and 2.8-fold increases over the external controls (P < 0.001 and P = 0.001, respectively)). Compared to the external controls, the internal control implants tended to have more bone ingrowth (1.9-fold increase, P = 0.066) and had significantly more bone formation in the gap (1.7-fold increase. P = 0.008). Thus, application of rhTGF-beta2 to a porous-coated implant-stimulated local bone ingrowth and gap healing in a weakly dose-dependent manner and stimulated bone regeneration in the 3-mm gap surrounding the contralateral control implant, a site remote from the local treatment with the growth factor.

Gene therapy in wound repair and regeneration

The potential use of gene therapy to treat human disease increases with the development of various physical, chemical, and biological methods to deliver genes to mammalian cells, and with our rapidly expanding knowledge of the human genome. One area of therapeutic interest for gene therapy is the treatment of wound healing disorders. Most recently, recombinant human growth factor therapy has been examined as a means to treat problem wounds. However, this approach suffers from the difficulty in providing an accurate dose of growth factor and the expense of the recombinant proteins. Delivery of a gene that could be expressed within the wound is an attractive alternative to application of the protein. This review discusses several methods that have been used to deliver genes encoding growth factor proteins into wounds and the advantages/disadvantages of each approach. Novel methods to regulate the expression of the transgene are also presented, highlighting the ability of these unique vector systems to adjust gene dose as the wound heals. We expect that gene therapy will become a significant treatment modality for those wound healing pathologies refractory to other wound management approaches in the years ahead.

Antioxidant status in delayed healing type of wounds

This investigation studied the contribution of antioxidants in delaying healing in excision cutaneous wounds (8 mm) in diabetic, aged and immunocompromised animals. Skin levels of catalase, glutathione (GSH), ascorbic acid (AA) and vitamin E in streptozotocin-induced diabetic rat were lower as compared to nondiabetics. The 7-d wound tissue of diabetic rats showed an increased vitamin E level along with depleted GSH content. In aged rats (18 months old), higher levels of skin superoxide dismutase (SOD), glutathione peroxidase (Gpx) and thiobarbituric acid reactive substances (TBARS) and lower levels of catalase and GSH were found as compared to their values in young rats (3-4 months old). The levels of SOD, GPx, catalase, AA, GSH and vitamin E in 7-d wound tissue of aged rats were significantly lower in comparison to those in young rats. However, TBARS were elevated in these wound tissues. The non-wounded skin of immunocompromised (athymic) mice showed lower levels of SOD, catalase, and TBARS and higher GSH and GPx levels in comparison to those present in normal mouse skin. Surprisingly, the analysis of 7-d wound tissue showed higher levels of SOD, catalase, GPx, and GSH and lower TBARS level in athymic mice compared to the wound tissue of normal mice. Thus low levels of antioxidants accompanied by raised levels of markers of free radical damage play a significant role in delaying wound healing in aged rats. In diabetic rats reduced glutathione levels may have a contributory role in delaying the healing process. However, in immunocompromised mice the antioxidant status following injury showed an adapted response.

Increase in wound breaking strength in rats in the presence of positively charged dextran beads correlates with an increase in endogenous transforming growth factor-beta1 and its receptor TGF-betaRI in close proximity to the wound

We have previously shown that positively charged beads (DEAE A25) increase wound breaking strength in linear incisions in rats and nonhuman primates at days 10-14 post-wounding. The increased wound strength may result in part from a stimulation of cells adjacent to the DEAE A25 beads to produce growth factors important for wound healing. In this report, we investigate this hypothesis by comparing the relative expression levels of transforming growth factor-beta1 and its receptor transforming growth factor-beta receptor type I in DEAE A25-treated and contralateral untreated rat linear incisions. DEAE A25-treated incisions were stronger than untreated control wounds at 3 days post-wounding, and the difference in breaking strength reached statistical significance at days 5, 7 and 10. Immunohistochemical analysis revealed a significant increase in transforming growth factor-beta1 and transforming growth factor-beta receptor type I expression in DEAE A25-treated incisions, up to 7 days post-wounding, as compared to untreated control wounds. FACS analysis revealed that macrophage cell lines exposed to DEAE A25 in vitro upregulate transforming growth factor-beta1 and transforming growth factor-beta receptor type I expression by 2-3 fold. Therefore, the increase in expression of transforming growth factor-beta1 and transforming growth factor-beta receptor type I in DEAE A25-treated incisions may be due to an increase in the concentration of macrophages adjacent to DEAE A25 beads, as well as the stimulation of individual macrophages to produce greater amounts of transforming growth factor-beta1 and transforming growth factor-beta receptor type I. This study also supports the significance of transforming growth factor-beta1 in wound healing.

The role of the immune system in conjunctival wound healing after glaucoma surgery

The immune system has a fundamental role in the development and regulation of ocular healing, which plays an important role in the pathogenesis of most blinding diseases. This review discusses the mechanisms of normal wound healing, describing the animal and fetal wound healing models used to provide further insight into normal wound repair. In particular, conjunctival wound repair after glaucoma filtration surgery will be used to illustrate the contributions that the different components of the immune system make to the healing process. The potential role of macrophages, the possible regulatory effect of lymphocytes, and the important role of growth factors and cytokines in the wound healing reaction are discussed. The significance of the immune system in the pathogenesis of aggressive conjunctival scarring is addressed, particularly assessing the predisposing factors, including drugs, age, and ethnicity. The rationale behind the pharmacological agents currently used to modulate the wound healing response and the effects these drugs have on the function of the immune system are described. Finally, potential new therapeutic approaches to regulating the wound healing response are reported.