Autologous platelet-rich plasma for treating chronic wounds

Slow-sculpting graphene oxide/alginate gel loaded with platelet-rich plasma to promote wound healing in rats

Wounds, especially chronic wounds, have become an important problem that endangers human health. At present, there are many repair methods, and among them combines materials science and biology is one of the important repair methods. This study explored the preparation method, physicochemical properties, biological activity and safety of Platelet-Rich plasma (PRP)-loaded slow-sculpting graphene oxide (GO)/alginate gel, and applied it to acute full-thickness skin defect wounds in rats to observe its role in wound healing. The results show that the slow-sculpting GO/alginate gel has excellent plasticity and is suitable for a variety of irregularly shaped wounds. At the same time, its porous structure and water content can maintain the activity of platelets and their released growth factors in PRP, thereby promoting wound collagen synthesis and angiogenesis to accelerate wound healing. This indicates that the slow-sculpting GO/alginate gel is an excellent loading material for PRP, and the combination of the two may become one of the methods to promote wound repair.

Efficacy and safety of platelet-rich plasma in the treatment of venous ulcers: A systematic review and meta-analysis of randomized controlled trials

Considering the substantial impact of venous ulcers on quality of life and healthcare systems, this study evaluated the efficacy and safety of platelet-rich plasma (PRP) in comparison to conventional therapy. A systematic review of four databases identified 16 randomized clinical trials, including 20 study groups. PRP significantly enhanced complete ulcer healing, exhibiting an odds ratio (OR) of 5.06 (95% confidence interval [CI]: 2.35-10.89), and increased the percentage of healed ulcer area by a mean difference of 47% (95% CI: 32%-62%). Additionally, PRP shortened the time required for complete healing by an average of 3.25 months (95% CI: -4.06 to -2.43). Although pain reduction was similar in both groups, PRP considerably decreased ulcer recurrence rates (OR = 0.16, 95% CI: 0.05-0.50) without increasing the risks of infection or irritative dermatitis. These results suggest PRP as a viable, safe alternative for venous ulcer treatment, providing significant improvements in healing outcomes.

Comparative study on the efficacy of PRP gel and UC-MSCs gel as adjuvant therapies in the treatment of DFU wounds

BACKGROUND

Diabetic foot ulcer (DFU) is a common and serious complication of diabetes, and its treatment is challenging. Platelet-rich plasma (PRP) gel and umbilical cord mesenchymal stem cells (UC-MSCs) gel have been concerned as new therapies for DFU in recent years, and comparative studies on the efficacy and mechanisms of these methods, however, are rarely reported.

METHODS

Thirty patients with DFU were selected and divided into the PRP group and the UC-MSCs group, and wound healing, foot blood vessels (ABI index), infection index (CRP), neuropathy symptoms (TCSS score), and foot skin temperature before and after treatment were compared between the two groups. SPSS 21.0 was used for statistical analysis.

RESULTS

The results showed that the efficacy of the UC-MSCs gel group was significantly better than that of the PRP group in terms of wound healing rate, time to complete wound closure, ABI index, CRP level and TCSS score. No statistically significant difference in foot skin temperature was observed between the two groups.

CONCLUSION

The efficacy of UC-MSCs gel is significantly superior to that of PRP gel in the treatment of DFU, with shortened time to complete wound closure, increased wound healing rate, better pain and infection control, and improved vascular and neurological symptoms.

The use of platelet-rich plasma in wound healing and vitiligo: A systematic review and meta-analysis

OBJECTIVE

To critically assess the effect and safety of platelet-rich plasma (PRP) in chronic wounds and vitiligo.

METHODS

A systematic literature searching was performed. Results were expressed as weight mean difference (WMD) or risk ratio (RR) with 95% confidence intervals (CIs). Pooled estimates were performed using a fixed-effects model or random-effects model, depending on the heterogeneity among studies.

RESULTS

A total of 27 studies were included in this meta-analysis. In patients with chronic diabetic ulcers, PRP significantly increased proportion of complete wound healing, percentage of wound area healed, and shortened the complete wound healing. In venous ulcers, PRP improved the epithelialized area and percentage of wound area healed. In vitiligo, PRP had better results in degree of improvement and mean repigmentation than controls. Regarding the safety profile, PRP did not increase the risk of infection in patients with chronic diabetic ulcers. Meta-regression revealed that source of PRP and preparation method of PRP significantly affected the proportion of complete wound healing, whereas age, gender, country, duration of wound, and wound size had no impact on this outcome.

CONCLUSION

PRP is effective and safe, and can be used as a potential therapeutic adjunct or alternative treatment in chronic wounds of multiple etiologies and vitiligo.

Clinical Research on the Safety Evaluation of Platelet-rich Plasma Treatment in Oral Diseases: A Study Protocol

Background

Platelet-rich plasma (PRP) is a biological product obtained from autologous blood that contains growth factors, promoting the healing and regeneration of human tissues. Several oral diseases require surgical intervention, producing residual wounds that undergo a healing process, accompanied by pain, swelling, superinfections, and bone remodeling. This protocol study aims to evaluate the safety of PRP use for the following dental procedures: post-extraction socket healing, periodontal tissue regeneration, maxillary sinus floor elevation, tooth transplantation, and intentional tooth replantation.

Methods

Ten patients will be enrolled and subjected to the required treatment with the addition of PRP, after appropriate hematological and biochemical evaluations. The participants will then be subjected to an observation period of 4 weeks to monitor adverse events through clinical observation. Secondary outcomes will regard pain, and clinical evolution of the treated site. Among these, presence of infection, swelling, wound healing, stability of the transplanted tooth.

Discussion

Safety of medical procedures represents the first requirement for their introduction in routine practice. A careful evaluation of clinical response during follow-up period and registration of adverse effects is fundamental for safety confirmation and subsequent use of PRP for the proposed dental procedures.

Trial registration

Japan Registry of Clinical Trials (https://jrct.niph.go.jp/, registry number: jRCTc030190273, jRCTc030190274, jRCTc030190275, jRCTc030190276, jRCTc030190277; Date of registration: 31 March 2020).

Platelet Derivatives and the Immunomodulation of Wound Healing

Besides their primary role in hemostasis, platelets contain a plethora of immunomodulatory molecules that profoundly affect the entire process of wound repair. Therefore, platelet derivatives, such as platelet-rich plasma or platelet lysate, have been widely employed with promising results in the treatment of chronic wounds. Platelet derivatives provide growth factors, cytokines, and chemokines targeting resident and immigrated cells belonging to the innate and adaptive immune system. The recruitment and activation of neutrophils and macrophages is critical for pathogen clearance in the early phase of wound repair. The inflammatory response begins with the release of cytokines, such as TGF-β, aimed at damping excessive inflammation and promoting the regenerative phase of wound healing. Dysregulation of the immune system during the wound healing process leads to persistent inflammation and delayed healing, which ultimately result in chronic wound. In this review, we summarize the role of the different immune cells involved in wound healing, particularly emphasizing the function of platelet and platelet derivatives in orchestrating the immunological response.

Cost-Effectiveness Analysis for the Treatment of Diabetic Foot Ulcer in France: Platelet-Rich Plasma vs Standard of Care

Introduction

Diabetic chronic foot ulcers (DFU) lead to pain, reduced quality of life and represent a severe economic burden for patients and health systems. The clinical results of PRP effectiveness in the treatment of DFU are promising; on the other hand, the costs associated with treating DFUs with PRP are higher than those using standard therapy. Therefore, this study aims to determine the cost-effectiveness of platelet-rich plasma (PRP) therapy compared to standard therapy from the French healthcare system perspective.

Methods

A cost-effectiveness analysis (CEA) was performed using a decision Markov model with a cohort of patients with chronic DFU (duration of >3 weeks) with high orthopaedic risk and with ulcers graded 3A according to University of Texas classification. The effectiveness outcomes are reported in terms of quality adjusted life year (QALY). The costs are reported in euro (€) currency evaluated in 2019. A micro-costing approach alongside a clinical study was used to assess resource use. Deterministic sensibility analyses are reported to evaluate the robustness of the results. The analyses were carried out in the French setting.

Results

The incremental cost-effectiveness ratio (ICER) of PRP treatment is –€613/ QALY, which, being lower than zero, indicates the dominance of the PRP therapy. Deterministic and probabilistic sensitivity analysis underlines the main parameter affecting CE results. Lowest number of standard of care weekly medications (from 5 to 3) leads to a €622/QALY while increasing PRP weekly medication (from 1 to 4) has an ICER of €732/QALY.

Discussion

PRP is a cost-effective or even a cost-saving alternative in the French setting. PRP has higher cost for the complete medication, but, in the absence of wound complications, has the potential to involve lower consumption of resources in the form of routine medication over a 1-year time horizon.

Closure of a Difficult-to-Manage Chronic Pressure Injury with the Use of Autologous Platelet-Rich Plasma (APRP)

Pressure injury (PI) corresponds to a skin damage of ischemic aetiology that affects the integrity of the skin and is produced by prolonged pressure or friction between a hard internal and external surface. Treatment can be challenging when there is no resolution with usual care. The use of autologous platelet-rich plasma (APRP) gel arises as a therapeutic possibility in the presence of chronic pressure injuries. The case of a patient with chronic PI who has been treated with APRP is presented, achieving resolution of the lesion.

Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain

BACKGROUND

Autologous whole blood or platelet-rich plasma (PRP) injections are commonly used to treat lateral elbow pain (also known as tennis elbow or lateral epicondylitis or epicondylalgia). Based on animal models and observational studies, these injections may modulate tendon injury healing, but randomised controlled trials have reported inconsistent results regarding benefit for people with lateral elbow pain.

OBJECTIVES

To review current evidence on the benefit and safety of autologous whole blood or platelet-rich plasma (PRP) injection for treatment of people with lateral elbow pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase for published trials, and Clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal for ongoing trials, on 18 September 2020.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs comparing autologous whole blood or PRP injection therapy to another therapy (placebo or active treatment, including non-pharmacological therapies, and comparison between PRP and autologous blood) for lateral elbow pain. The primary comparison was PRP versus placebo. Major outcomes were pain relief (≥ 30% or ≥ 50%), mean pain, mean function, treatment success, quality of life, withdrawal due to adverse events, and adverse events; the primary time point was three months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 32 studies with 2337 participants; 56% of participants were female, mean age varied between 36 and 53 years, and mean duration of symptoms ranged from 1 to 22 months. Seven trials had three intervention arms. Ten trials compared autologous blood or PRP injection to placebo injection (primary comparison). Fifteen trials compared autologous blood or PRP injection to glucocorticoid injection. Four studies compared autologous blood to PRP. Two trials compared autologous blood or PRP injection plus tennis elbow strap and exercise versus tennis elbow strap and exercise alone. Two trials compared PRP injection to surgery, and one trial compared PRP injection and dry needling to dry needling alone. Other comparisons include autologous blood versus extracorporeal shock wave therapy; PRP versus arthroscopic surgery; PRP versus laser; and autologous blood versus polidocanol. Most studies were at risk of selection, performance, and detection biases, mainly due to inadequate allocation concealment and lack of participant blinding. We found moderate-certainty evidence (downgraded for bias) to show that autologous blood or PRP injection probably does not provide clinically significant improvement in pain or function compared with placebo injection at three months. Further, low-certainty evidence (downgraded for bias and imprecision) suggests that PRP may not increase risk for adverse events. We are uncertain whether autologous blood or PRP injection improves treatment success (downgraded for bias, imprecision, and indirectness) or withdrawals due to adverse events (downgraded for bias and twice for imprecision). No studies measured health-related quality of life, and no studies reported pain relief (> 30% or 50%) at three months. At three months, mean pain was 3.7 points (0 to 10; 0 is best) with placebo and 0.16 points better (95% confidence interval (CI) 0.60 better to 0.29 worse; 8 studies, 523 participants) with autologous blood or PRP injection, for absolute improvement of 1.6% better (6% better to 3% worse). At three months, mean function was 27.5 points (0 to 100; 0 is best) with placebo and 1.86 points better (95% CI 4.9 better to 1.25 worse; 8 studies, 502 participants) with autologous blood or PRP injection, for absolute benefit of 1.9% (5% better to 1% worse), and treatment success was 121 out of 185 (65%) with placebo versus 125 out of 187 (67%) with autologous blood or PRP injection (risk ratio (RR) 1.00; 95% CI 0.83 to 1.19; 4 studies, 372 participants), for absolute improvement of 0% (11.1% lower to 12.4% higher). Regarding harm, we found very low-certainty evidence to suggest that we are uncertain whether withdrawal rates due to adverse events differed. Low-certainty evidence suggests that autologous blood or PRP injection may not increase adverse events compared with placebo injection. Withdrawal due to adverse events occurred in 3 out of 39 (8%) participants treated with placebo versus 1 out of 41 (2%) treated with autologous blood or PRP injection (RR 0.32, 95% CI 0.03 to 2.92; 1 study), for an absolute difference of 5.2% fewer (7.5% fewer to 14.8% more). Adverse event rates were 35 out of 208 (17%) with placebo versus 41 out of 217 (19%) with autologous blood or PRP injection (RR 1.14, 95% CI 0.76 to 1.72; 5 studies; 425 participants), for an absolute difference of 2.4% more (4% fewer to 12% more). At six and twelve months, no clinically important benefit for mean pain or function was observed with autologous blood or PRP injection compared with placebo injection.

AUTHORS' CONCLUSIONS

Data in this review do not support the use of autologous blood or PRP injection for treatment of lateral elbow pain. These injections probably provide little or no clinically important benefit for pain or function (moderate-certainty evidence), and it is uncertain (very low-certainty evidence) whether they improve treatment success and pain relief > 50%, or increase withdrawal due to adverse events. Although risk for harm may not be increased compared with placebo injection (low-certainty evidence), injection therapies cause pain and carry a small risk of infection. With no evidence of benefit, the costs and risks are not justified.

Rapid Wound Healing and Acne Scar Improvement After Ablative Fractional Carbon Dioxide Laser Treatment Combined with the Application of Platelet-Lyophilized Treatment (PLT)

Objective

There are several clinical cases on the application of PRP (platelet-rich plasma) therapies. To improve disadvantages such as the inability to be standardized and stored long term, we proposed a novel platelet-lyophilized treatment (PLT) to enhance the wound healing rate and improve acne scarring.

Study Design

A single-blinded study at a single health care center was performed. All subjects were treated with a fractional carbon dioxide laser. On the right side of the face, 2 mL PLT solution (dissolved in normal saline) was applied, while on the left side of the face (control group), 2 mL normal saline was applied. The treatment described above was repeated every 3 to 4 weeks, and 4 treatments were performed in total. Assessments were performed prior to each treatment and at the one-month follow-up after the fourth treatment. Subjective assessments included questionnaires administered by the principal investigator and a self-assessment questionnaire completed by the subjects. Moreover, VISIA complexion analysis was used for objective data collection, and spots, wrinkles, texture, pores, UV spots, brown spots, red areas, and porphyrins were objectively analyzed.

Results

Our data indicated that the PLT side showed a more rapid recovery than the saline side; on average, the sloughing off of the crusts was noted on day 5 and day 6. The improvement rate for skin spots, texture, and pores was significantly increased on the PLT side, with the pigment and pore size both having a statistically significant improvement of p<0.001, while the texture had a significant improvement of p<0.01.

Conclusion

The results suggested that the application of PLT could be a novel method to enhance wound healing and improve acne scarring after laser skin rejuvenation.

Allogeneic Platelet-Rich Plasma: Is It Safe and Effective for Wound Repair?

BACKGROUND

Platelet-rich plasma (PRP) and its derivatives are an emerging biotechnology whereby concentrated platelets provide damaged tissue with growth factors, cytokines, and other mediators to improve healing outcomes. Although there is strong evidence in the benefits of autologous PRP for both acute and chronic wounds, allogeneic PRP has been studied far less in comparison.

SUMMARY

In this mini-review, we discuss critical steps of allogenic PRP (and its derivatives) preparation. We performed a non-systematic review of the literature to identify animal and human subject studies testing allogenic PRP for wound treatment. We searched OVID Medline and PubMed for articles using the keywords "wound, ulcer, lesion, skin, and cutaneous" and "PRP, or platelet-rich plasma, or platelet-rich fibrin, or PRF, or platelet releasate" and "homologous, allogeneic or allogenic," which were limited to non-review articles and English language. Two studies in animal models and 8 studies in patients were reviewed. There were inconsistencies in preparation methods, treatment regimens, and some lacked a control group in their studies. Despite these variations, none of the studies identified any major side effects or adverse events. The treatment resulted in a reduced time to heal and/or reduced wound size in most cases. Key Messages: In situations where autologous PRP is not available or suitable, allogeneic PRP appears to provide a safe alternative. Its efficacy, however, requires larger-scale studies with appropriate controls. Standardization in PRP preparation and treatment regime are also needed to be able to interpret allogenic PRP efficacy.

Platelet Lysate Induces in Human Osteoblasts Resumption of Cell Proliferation and Activation of Pathways Relevant for Revascularization and Regeneration of Damaged Bone

To understand the regenerative effect of platelet-released molecules in bone repair one should investigate the cascade of events involving the resident osteoblast population during the reconstructive process. Here the in vitro response of human osteoblasts to a platelet lysate (PL) stimulus is reported. Quiescent or very slow dividing osteoblasts showed a burst of proliferation after PL stimulation and returned to a none or very slow dividing condition when the PL was removed. PL stimulated osteoblasts maintained a differentiation capability in vitro and in vivo when tested in absence of PL. Since angiogenesis plays a crucial role in the bone healing process, we investigated in PL stimulated osteoblasts the activation of hypoxia-inducible factor 1-alpha (HIF-1α) and signal transducer and activator of transcription 3 (STAT3) pathways, involved in both angiogenesis and bone regeneration. We observed phosphorylation of STAT3 and a strong induction, nuclear translocation and DNA binding of HIF-1α. In agreement with the induction of HIF-1α an enhanced secretion of vascular endothelial growth factor (VEGF) occurred. The double effect of the PL on quiescent osteoblasts, i.e., resumption of proliferation and activation of pathways promoting both angiogenesis and bone formation, provides a rationale to the application of PL as therapeutic agent in post-traumatic bone repair.

Effectiveness of autologous PRP therapy in chronic nonhealing ulcer: A 2-year retrospective descriptive study

CONTEXT

Chronic nonhealing ulcer is a troublesome condition in patients especially with diabetes. Autologous PRP therapy can safely and effectively heal a chronic nonhealing ulcer in such patients.

AIMS

To study the effectiveness of autologous PRP therapy in a chronic nonhealing ulcer.

SETTINGS AND DESIGN

A retrospective descriptive study from previous case records of chronic nonhealing ulcer patients who were treated with autologous PRP therapy at a specialty orthopedic hospital from September 2017 to August 2019.

METHODS AND MATERIALS

Data on patients who presented with chronic nonhealing ulcers of >4 weeks duration who were treated with autologous PRP therapy and followed up for 20 weeks.

STATISTICAL ANALYSIS USED

Statistical Package for the Social Sciences (SPSS) version 20 was used to calculate mean. Microsoft Excel was used for preparing the chart.

RESULTS

The mean age of patients treated with autologous PRP therapy was 61.24 years, and the follow-up period was 20 weeks. The mean duration of ulcer healing following PRP therapy was 11.25 weeks, 80% of the patient showed ulcer size reduction of >75% following therapy.

CONCLUSIONS

In this retrospective descriptive study, it has demonstrated the effectiveness and safety of autologous PRP therapy in the healing of chronic nonhealing ulcers.

Functionalising Collagen-Based Scaffolds With Platelet-Rich Plasma for Enhanced Skin Wound Healing Potential

Porous collagen-glycosaminoglycan (collagen-GAG) scaffolds have shown promising clinical results for wound healing; however, these scaffolds do not replace the dermal and epidermal layer simultaneously and rely on local endogenous signaling to direct healing. Functionalizing collagen-GAG scaffolds with signaling factors, and/or additional matrix molecules, could help overcome these challenges. An ideal candidate for this is platelet-rich plasma (PRP) as it is a natural reservoir of growth factors, can be activated to form a fibrin gel, and is available intraoperatively. We tested the factors released from PRP (PRPr) and found that at specific concentrations, PRPr enhanced cell proliferation and migration and induced angiogenesis to a greater extent than fetal bovine serum (FBS) controls. This motivated us to develop a strategy to successfully incorporate PRP homogeneously within the pores of the collagen-GAG scaffolds. The composite scaffold released key growth factors for wound healing (FGF, TGFβ) and vascularization (VEGF, PDGF) for up to 14 days. In addition, the composite scaffold had enhanced mechanical properties (when compared to PRP gel alone), while providing a continuous upper surface of extracellular matrix (ECM) for keratinocyte seeding. The levels of the factors released from the composite scaffold were sufficient to sustain proliferation of key cells involved in wound healing, including human endothelial cells, mesenchymal stromal cells, fibroblasts, and keratinocytes; even in the absence of FBS supplementation. In functional in vitro and in vivo vascularization assays, our composite scaffold demonstrated increased angiogenic and vascularization potential, which is known to lead to enhanced wound healing. Upon pro-inflammatory induction, macrophages released lower levels of the pro-inflammatory marker MIP-1α when treated with PRPr; and released higher levels of the anti-inflammatory marker IL1-ra upon both pro- and anti-inflammatory induction when treated with the composite scaffold. Finally, our composite scaffold supported a co-culture system of human fibroblasts and keratinocytes that resulted in an epidermal-like layer, with keratinocytes constrained to the surface of the scaffold; by contrast, keratinocytes were observed infiltrating the PRP-free scaffold. This novel composite scaffold has the potential for rapid translation to the clinic by isolating PRP from a patient intraoperatively and combining it with regulatory approved scaffolds to enhance wound repair.

A Critical Update of the Assessment and Acute Management of Patients with Severe Burns

Significance: Burns are debilitating, life threatening, and difficult to assess and manage. Recent advances in assessment and management have occurred since a comprehensive review of the care of patients with severe burns was last published, which may influence research and clinical practice. Recent Advances: Recent advances have occurred in the understanding of burn pathophysiology, which has led to the identification of potential biomarkers of burn severity, such as protein C. There is new evidence about the potential superiority of natural colloids over crystalloids during fluid resuscitation, and new evidence about components of initial and perioperative management, including an improved understanding of pain following burns. Critical Issues: The limitations of the clinical examination highlight the need for imaging and biomarkers to assist in estimations of burn severity. Fluid resuscitation reduces mortality, although there is conjecture over the ideal method. The subsequent perioperative period is associated with significant morbidity and the evidence for preventing and treating pain, infection, and fluid overload while maximizing wound healing potential is described. Future Directions: Promising developments are ongoing in imaging technology, histopathology, biomarkers, and wound healing adjuncts such as hyperbaric oxygen therapy, topical negative pressure therapy, stem cell treatments, and skin substitutes. The greatest benefit from further research on management of patients with burns would most likely be derived from the elucidation of optimal fluid resuscitation protocols, pain management protocols, and surgical techniques from randomized controlled trials.

Synergistic Effects of Human Platelet-Rich Plasma Combined with Adipose-Derived Stem Cells on Healing in a Mouse Pressure Injury Model

Pressure injury (PI) affects quality of life and results in economic and social burdens. Local transplantation of human adipose-derived stem cells (ASCs) is considered an effective treatment. However, ASC suspension alone is vulnerable to the immune system and results in a shortened cell survival. There is increasing evidence of a synergistic effect of platelet-rich plasma (PRP) combined with ASCs on wound healing. This study investigated the effectiveness, synergy, and mechanism of wound healing following local injection of PRP combined with ASCs in a rodent PI model. PRP or ASCs alone were the control intervention. Wound healing, inflammatory infiltration, collagen deposition, angiogenesis, neurogenesis, and cell homing were investigated. PI healing was promoted by the synergistic effects of PRP combined with ASCs. The combination was more effective than ASCs alone for modulating inflammation, increasing collagen deposition, angiogenesis, neurogenesis, and the persistence of the injected ASCs. These data provide a theoretical foundation for the clinical administration of ASCs combined with PRP in PI healing and skin regeneration.

Efficacy and Safety of Platelet-Rich Plasma for Patients with Diabetic Ulcers: A Systematic Review and Meta-analysis

Significance: Autologous platelet-rich plasma (PRP) has been suggested to be effective for wound healing. However, clinical evidence for its use in patients with diabetic ulcer remains inconsistent. The aim of this systematic review and meta-analysis was to evaluate the efficacy and safety of PRP in patients with diabetic ulcer. Recent Advances: Relevant randomized controlled trials (RCTs) were identified via systematic search of PubMed, MEDLINE, EMBASE, the Cochrane Library, and Web of Knowledge databases. Results were pooled using a random-effects model. The primary outcome of the study was the healing rate of ulcers in patients with PRP, when compared with controls. Secondary outcomes included the percentage of ulcer area reduction, recurrence rate, and amputation rate. Critical Issues: Eight RCTs that involved 431 participants were included. Compared with controls, PRP was associated with a significantly increased ratio of complete ulcer healing (odds ratio [OR] = 3.77, 95% confidence interval [CI] = 1.91-7.45, I^2 =  42.2%) and reduced areas of ulcers (standard mean difference = 0.86, 95% CI = 0.27-1.45, I^2 =  0.0%). No differences were observed between patients allocated to PRP or controls, in terms of the outcomes of recurrence rate (OR = 3.32, 95% CI = 0.41-27.18, I^2 =  66.3%) or amputation rate (OR = 0.15, 95% CI = 0.15-1.28). The results of the trial sequence analyses revealed that the cumulative Z-curve crossed both the traditional boundary (p = 0.05) and trial sequential monitoring boundary. Future Directions: Our findings suggest that PRP may improve ulcer healing without significant adverse effects for patients with diabetic ulcers.

Efficacy of a Ceratothoa oestroides Olive Oil Extract in Patients With Chronic Ulcers: A Pilot Study

Chronic wounds unresponsive to existing treatments constitute a serious disease burden. Factors that contribute to the pathogenesis of chronic ulcers include oxidative stress, comorbid microbial infections, and the type of immune system response. Preclinically, and in a case study, a formulation containing a Ceratothoa oestroides olive oil extract promoted wound healing. Patients with chronic venous and pressure ulcers, clinically assessed as being unresponsive to healing agents, were treated for 3 months with an ointment containing the C oestroides extract combined with antibiotic and/or antiseptic agents chosen according to the type of bacterial infection. Treatment evaluation was performed using the Bates-Jensen criteria with +WoundDesk and MOWA cell phone applications. After 3 months of treatment, C oestroides resulted in an average decrease of 36% in the Bates-Jensen score of ulcers ( P < .000), with the decrease being significant from the first month ( P < .007). The combined use of topically applied antibiotics and antiseptics efficiently controlled microbial ulcer infection and facilitated wound healing. In relation to other factors such as initial wound size, chronicity appeared to be an important prognostic factor regarding the extent of wound healing. Future clinical investigations assessing the wound healing efficacy of the C oestroides olive oil extract are warranted.

Autistic-Undisciplined Thinking in the Practice of Medical Trichology

Medical trichology is the branch of dermatology that deals with the scientific study of the hair and scalp in health and disease. As any discipline, the practice of medical trichology is not immune to malpractice, either deliberately or carelessly. In his publication "Autistic Undisciplined Thinking in Medicine and How to Overcome It," Swiss psychiatrist Eugen Bleuler describes yet another form of malpractice in medicine reflecting autistic-undisciplined thinking. Autism is not limited to psychopathology, but inherent to the thinking of man throughout history in his drive for knowledge, with thousands of theories lacking any basis in reality. Bleuler recognized the drive character of autistic thinking and how it leads to conclusions that are unshakable because they are determined by, and fulfill, emotional needs, rather than rational argumentation. Even with correct questions, the complexity and incalculability of some problems are often so great that it cannot do justice to realistic thinking and the boundaries between inadequately substantiated hypothesis and autistic sham explanation disappear. Statistics, careful research design, and the attempt to impose stringent methods on our thinking are to be commended. The habituation of the public to useless medicine, to misconceptions, is not hygiene, but negligent endangerment. It has created an industry that largely lives on the autistic thinking of patients and doctors and because it is prosperous, makes propaganda among lay people as well as among doctors that necessarily leads to abuses. This article aims at exposing the most prevalent among abuses in trichological practice due to autistic-undisciplined thinking, specifically: iron supplementation, antiandrogenic treatment, and individualized cell-based therapy in female androgenetic alopecia, treatment of folliculitis decalvans with retinoids, and the value of nutritional therapies.

Platelet Lysate Activates Human Subcutaneous Adipose Tissue Cells by Promoting Cell Proliferation and Their Paracrine Activity Toward Epidermal Keratinocytes

Skin chronic wounds are non-healing ulcerative defects, which arise in association with a morbidity state, such as diabetes and vascular insufficiency or as the consequence of systemic factors including advanced age. Platelet Rich Plasma, a platelet-rich blood fraction, can significantly improve the healing of human skin chronic ulcers. Given that the subcutaneous adipose tissue is located beneath the skin and plays a role in the skin homeostasis, in this study, we investigated the in vitro response of human subcutaneous adipose tissue cells to platelet content in a model mimicking in vitro the in situ milieu of a deep skin injury. Considering that, at the wound site, plasma turn to serum, platelets are activated and inflammation occurs, human adipose-derived stromal cells (hASC) were cultured with Human Serum (HS) supplemented or not with Platelet Lysate (PL) and/or IL-1α. We observed that HS sustained hASC proliferation more efficiently than FBS and induced a spontaneous adipogenic differentiation in the cells. PL added to HS enhanced hASC proliferation, regardless the presence of IL-1α. In the presence of PL, hASC progressively lessened the adipogenic phenotype, possibly because the proliferation of less committed cells was induced. However, these cells resumed adipogenesis in permissive conditions. Accordingly, PL induced in quiescent cells activation of the proliferation-related pathways ERK, Akt, and STAT-3 and expression of Cyclin D1. Moreover, PL induced an early and transient increase of the pro-inflammatory response triggered by IL-1α, by inducing COX-2 expression and secretion of a large amount of PGE₂, IL-6, and IL-8. Media conditioned by PL-stimulated hASC exerted a chemotactic activity on human keratinocytes and favored the healing of an in vitro scratch wound. In order to bridge the gap between in vitro results and possible in vivo events, the stimuli were also tested in ex vivo cultures of in toto human adipose tissue biopsies (hAT). PL induced cell proliferation in hAT and outgrowth of committed progenitor cells able to differentiate in permissive conditions. In conclusion, we report that the adipose tissue responds to the wound microenvironment by activating the proliferation of adipose tissue progenitor cells and promoting the release of factors favoring wound healing.

Biologics in Microangiopathic Wounds

In the last decades the possibility to diagnose a skin ulcer has greatly improved. We learnt that a consistent percentage of nonhealing ulcers may be caused by a microangiopathic disorder that has not been properly investigated and cured. Pathogenetically, we can distinguish 2 main groups: (1) ulcers due to inflammatory microangiopathy, mainly including cutaneous small and medium vessel vasculitis, pyoderma gangrenosum, and connective tissue diseases, and (2) ulcers due to occlusive microangiopathy. The group of microangiopathic occlusive ulcers is more heterogeneous and includes different disorders ranging from livedo vasculopathy to calciphylaxis, hydroxyurea-induced ulcers, antiphospholipid antibodies ulcers, and various other types. These conditions can induce thromboses or anatomo-functional occlusion of cutaneous microvessels. Despite different physiopathologic mechanisms, the ulcer resulting from a primitive microangiopathy may receive basic treatments that are in the complex similar to other pathogenetically different wounds, including MOIST-based local therapy and elastic compression when it is not contraindicated. Persistent inflammatory processes are increasingly demonstrated as responsible for the chronicity of many skin ulcers. New data concerning the biological phases of wound healing and the molecules that play crucial roles in this process suggested the use of new specific therapies. Some of them such as growth factors and platelet-rich plasma are prevalently used as topical biologic agents with variable benefits. In recent years, a new class of systemic anti-inflammatory molecules, better known as biologic drugs, have been introduced in the cure of chronic inflammatory diseases that can induce microangiopathic injuries and ulcerative complication. They enlarged the therapeutic options in case of nonresponder microangiopathic ulcers and could represent a future model of “pathogenetically based” therapy of skin ulcers.

Immune Regulation of Skin Wound Healing: Mechanisms and Novel Therapeutic Targets

Significance: The immune system plays a central role in orchestrating the tissue healing process. Hence, controlling the immune system to promote tissue repair and regeneration is an attractive approach when designing regenerative strategies. This review discusses the pathophysiology of both acute and chronic wounds and possible strategies to control the immune system to accelerate chronic wound closure and promote skin regeneration (scar-less healing) of acute wounds. Recent Advances: Recent studies have revealed the key roles of various immune cells and immune mediators in skin repair. Thus, immune components have been targeted to promote chronic wound repair or skin regeneration and several growth factors, cytokines, and biomaterials have shown promising results in animal models. However, these novel strategies are often struggling to meet efficacy standards in clinical trials, partly due to inadequate drug delivery systems and safety concerns. Critical Issues: Excess inflammation is a major culprit in the dysregulation of normal wound healing, and further limiting inflammation effectively reduces scarring. However, current knowledge is insufficient to efficiently control inflammation and specific immune cells. This is further complicated by inadequate drug delivery methods. Future Directions: Improving our understanding of the molecular pathways through which the immune system controls the wound healing process could facilitate the design of novel regenerative therapies. Additionally, better delivery systems may make current and future therapies more effective. To promote the entry of current regenerative strategies into clinical trials, more evidence on their safety, efficacy, and cost-effectiveness is also needed.

The Effect of Local Platelet Rich Plasma Therapy on the Composition of Bacterial Flora in Chronic Venous Leg Ulcer

Microbial colonisation of chronic venous ulcers and synergism between bacterial species slow down the healing process. The study aimed at performing qualitative analysis of microbial flora in venous leg ulcers treated with platelet rich plasma (PRP). Twenty two women and twelve men aged 47-90 years were treated with PRP at our department between 2012 and 2015. Ulcer cultures collected before and after PRP therapy yielded 83 and 110 microbial isolates, respectively, of Gram positive, Gram negative bacteria and candida. Pseudomonas aueruginosa and Staphylococcus aureus were the most common pre- and post-treatment isolates. PRP therapy and increased the variety of microbial flora.

Systematic review of the efficacy of fat grafting and platelet-rich plasma for wound healing

Adipose-derived stem cells found in fat grafts may have significant healing properties. When fat is combined with autologous platelet-rich plasma (PRP), there may be enhanced healing effects due to the pro-angiogenic and anti-inflammatory effects of PRP. This study aimed to evaluate the current evidence on fat grafting in combination with PRP for wound healing to establish the efficacy of this technique. A comprehensive search in the MEDLINE, EMBASE, CENTRAL, Science Citation Index, and Google Scholar databases (to March 2017) was conducted to identify studies on fat grafting and PRP for wound healing. Case series of less than 3 cases and studies only describing harvest technique were excluded. The database identified 571 articles, of which 3 articles that used a combination of fat and PRP for wound healing (1 RCT and 2 case series) were included in this review. A total of 69 wounds in 64 patients were treated with an average wound size of 36.32cm² . Of these, 67% of wounds achieved complete healing. When reported, the mean time to healing was 7.5 weeks for those who underwent a single treatment. There were no significant complications in any patients. The combination of fat grafting and PRP may achieve adequate wound healing with relatively quick wound healing time compared with standard wound management options. However, evidence is extremely limited, and further studies are required to evaluate its efficacy for wound healing.

Leukocyte-reduced platelet-rich plasma increases proliferation of tenocytes treated with prednisolone: a cell cycle analysis

INTRODUCTION

The purpose of this study was to evaluate the effect of allogenic leukocyte-reduced platelet-rich plasma on human tenocytes after treatment with prednisolone and to develop a standardization of its application for clinical practice.

METHODS

A leukocyte-reduced PRP was produced using the Arthrex Double Syringe (Arthrex, Inc., Naples, FL, USA), in a modified single-spin separation method. Human tenocytes were isolated from discarded rotator cuff segments. Tenocytes were cultured in the presence of PRP and prednisolone, both alone and in combination. Control samples were treated in media containing 2% FCS for 72 h. After 72 h of incubation, cell cycle kinetics of tenocytes were analyzed to assess proliferation.

RESULTS

Incubation of the tenocytes with PRP alone for 48 h led to high proliferation rate (10% PRP, 28.0 ± 10.5%; 20% PRP, 40.9 ± 3.3%). Incubation in the presence of prednisolone led to a significant decrease of the proliferation rate (5.2 ± 3.1%; p < 0.05). Treatment with PRP for 48 h significantly increased the proliferation of tenocytes in a dose-dependent manner (10% PRP, 28.0 ± 10.5%; 20% PRP, 40.9 ± 3.3%; p < 0.05). The presence of prednisolone resulted in a decreased tenocyte proliferation (5.2 ± 3.1%; p < 0.05), whereas addition of PRP for 24 and 48 h after prednisolone exposure did not show any compensating effect independent of PRPs concentration (10% PRP, 3.7 ± 3.0%; 20% PRP, 2.5 ± 2.5%). However, a significantly increased cell proliferation of tenocytes was evident when PRP was applied 24 h after prednisolone incubation for 48 h (31.0 ± 3.4 and 34.3 ± 4.7%).

CONCLUSION

The use of leukocyte-reduced PRP stimulates the proliferation of tenocytes and antagonizes the negative effect of prednisolone 24 h after treatment. Addition of PRP 48 h after treatment with prednisolone has no positive effect on the proliferation rate of tenocytes.

Protocol for a systematic review of the efficacy of fat grafting and platelet-rich plasma for wound healing

BACKGROUND

The use of fat grafting as a reconstructive surgical option is becoming much more common. Adipose-derived stem cells found in fat grafts are believed to facilitate wound healing via differentiation into fibroblasts and keratinocytes and the release of pro-healing growth factors. Several small studies have shown a positive effect of fat grafting in healing of wounds of a variety of aetiologies. When fat is combined with autologous platelet-rich plasma (PRP), there may be enhanced healing effects. This may be due to the pro-angiogenic and anti-inflammatory effects of PRP. We aim to synthesise the current evidence on combination fat grafting and PRP for wound healing to establish the efficacy of this technique.

METHODS/DESIGN

We will conduct a comprehensive literature search in the MEDLINE, EMBASE, CENTRAL, Science Citation Index, and Google Scholar databases (up to July 2017) to identify studies on fat grafting and PRP for wound healing. All primary studies and systematic reviews of these studies will be included, except case reports and case series with fewer than three patients, to evaluate the outcome of fat grafting and PRP on wound healing either on its own or when compared to other studies. Primary outcome measures are expected to be the proportion of total wounds healed at 12 weeks and the average wound healing time (time for 100% re-epithelialisation). Expected secondary outcome measures are the proportion of wounds achieving 50% wound healing, the type of wound benefitting most from fat grafting, economic evaluation, health-related quality of life, and adverse events. Subgroup analysis will be performed for the proportions of wounds healed based on wound aetiology.

DISCUSSION

This review will provide robust evidence of the efficacy of fat grafting and PRP for wound healing. This is an emerging technique, and this review is expected to guide clinical practice and ongoing research aimed at improving wound care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016049881.

Hydrogel and Platelet-Rich Plasma Combined Treatment to Accelerate Wound Healing in a Nude Mouse Model

Background

Platelet-rich plasma (PRP) contains high concentrations of growth factors involved in wound healing. Hydrogel is a 3-dimensional, hydrophilic, high-molecular, reticular substance generally used as a dressing formulation to accelerate wound healing, and also used as a bio-applicable scaffold or vehicle. This study aimed to investigate the effects of PRP and hydrogel on wound healing, in combination and separately, in an animal wound model.

Methods

A total of 64 wounds, with 2 wounds on the back of each nude mouse, were classified into 4 groups: a control group, a hydrogel-only group, a PRP-only group, and a combined-treatment group. All mice were assessed for changes in wound size and photographed on scheduled dates. The number of blood vessels was measured in all specimens. Immunohistochemical staining was used for the analysis of vascular endothelial growth factor (VEGF) expression.

Results

Differences in the decrease and change in wound size in the combined-treatment group were more significant than those in the single-treatment groups on days 3, 5, 7, and 10. Analysis of the number of blood vessels through histological examination showed a pattern of increase over time that occurred in all groups, but the combined-treatment group exhibited the greatest increase on days 7 and 14. Immunohistochemical staining showed that VEGF expression in the combined-treatment group exhibited its highest value on day 7.

Conclusions

This experiment demonstrated improved wound healing using a PRP–hydrogel combined treatment compared to either treatment individually, resulting in a decrease in wound size and a shortening of the healing period.

Controlled delivery of platelet-derived proteins enhances porcine wound healing

Platelet-rich plasma (PRP) is widely used for many clinical indications including wound healing due to the high concentrations of growth factors. However, the short half-life of these therapeutic proteins requires multiple large doses, and their efficacy is highly debated among clinicians. Here we report a method of protecting these proteins and releasing them in a controlled manner via a heparin-based coacervate delivery vehicle to improve wound healing in a porcine model. Platelet-derived proteins incorporated into the coacervate were protected and slowly released over 3weeks in vitro. In a porcine model, PRP coacervate significantly accelerated the healing response over 10days, in part by increasing the rate of wound reepithelialization by 35% compared to control. Additionally, PRP coacervate doubled the rate of wound contraction compared to all other treatments, including that of free PRP proteins. Wounds treated with PRP coacervate exhibited increased collagen alignment and an advanced state of vascularity compared to control treatments. These results suggest that this preparation of PRP accelerates healing of cutaneous wounds only as a controlled release formulation. The coacervate delivery vehicle is a simple and effective tool to improve the therapeutic efficacy of platelet-derived proteins for wound healing.

Treatment of chronic non-healing ulcers using autologous platelet rich plasma: a case series

Background

Non-healing ulcers are a major health problem worldwide and have great impact at personal, professional and social levels, with high cost in terms of human and material resources. Recalcitrant non-healing ulcers are inevitable and detrimental to the lower limb and are a major cause of non-traumatic lower limb amputations. Application of autologous Platelet Rich Plasma (PRP) has been a major breakthrough for the treatment of non-healing and diabetic foot ulcers, as it is an easy and cost-effective method, and provides the necessary growth factors that enhance tissue healing. PRP is a conglomeration of thrombocytes, cytokines and various growth factors which are secreted by α-granules of platelets that augment the rate of natural healing process with decrease in time. The purpose of this case series was to evaluate the safety and efficacy of autologous platelet rich plasma for the treatment of chronic non-healing ulcers on the lower extremity.

Methods

Autologous PRP was prepared from whole blood utilizing a rapid, intraoperative point-of-care system that works on the principle of density gradient centrifugation. Twenty Four (24) patients with non-healing ulcers of different etiologies, who met the inclusion criteria, were treated with single dose of subcutaneous PRP injections along with topical application of PRP gel under compassionate use.

Results

The mean age of the treated patients was 62.5 ± 13.53 years and they were followed-up for a period of 24 weeks. All the patients showed signs of wound healing with reduction in wound size, and the mean time duration to ulcer healing was 8.2 weeks. Also, an average five fold increase in the platelet concentrate was observed in the final PRP product obtained using the rapid point-of-care device, and the average platelet dose administered to the patients was 70.10 × 10⁸.

Conclusion

This case series has demonstrated the potential safety and efficacy of autologous platelet rich plasma for the treatment of chronic non-healing ulcers.

Trial registration

NCT03026855, Registered 4 January 2017 ‘Retrospectively’

A Method for Reconstruction of Severely Damaged Spinal Cord using Autologous Hematopoietic Stem Cells and Platelet-rich Protein as a Biological Scaffold

Introduction:

There have been attempts to alter the prognosis of severe spinal cord injury in different centers, but none of which have reliably altered the outcome. Some trials use stem cells (SCs) that produced widely differing results. We hereby add our experience in our center of a surgical reconstruction of the damaged spinal cord using a mixture of SCs and Platelet-Rich Protein (PRP) with fibrin coated as a biological scaffold.

Materials and Methods:

Four cases of severely damaged spinal cord have been operated for neurolysis and reconstruction of the spinal cord using SCs and platelet-rich protein (PRP) with fibrin coated harvested from the peripheral circulation of the patient. PRP serves to maintain the position of the SCs. One milliliter suspension contains an average of 2.8 × 10⁶ of autologous hematopoietic SCs. Patients were intraoperatively monitored by somatosensory evoked potential, motor evoked potentials, and delta wave. They are clinically followed postoperatively and electromyogram was repeated every 2 weeks. Magnetic resonance imaging (MRI) was repeated regularly. The patients are followed up for a period between 2 and 3 years.

Results:

One patient demonstrated motor and objective sensory improvement (P = 0.05), two other patients reported subjective sensory improvement, and the fourth one remained without any improvement (P = 0.1). None of these patients demonstrated any sign of deterioration or complication either on the surgery or on implanting of the SCs. MRI clearly proved that the inserted biological scaffold remained in place of reconstruction.

Conclusion:

SCs may play a role in restoring spinal cord functions. However, the unsolved problems of the use of SCs and related ethical issues should be addressed.

Autologous platelet-rich plasma for treating chronic wounds

BACKGROUND

Autologous platelet-rich plasma (PRP) is a treatment that contains fibrin and high concentrations of growth factors with the potential to improve the healing of chronic wounds. This is the first update of a review first published in 2012.

OBJECTIVES

To determine whether autologous PRP promotes the healing of chronic wounds.

SEARCH METHODS

In June 2015, for this first update, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library): Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also searched for ongoing and unpublished clinical trials in the WHO International Clinical Trials Registry Platform (ICTRP) (searched January 2015). We did not impose any restrictions with respect to language, date of publication, or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared autologous PRP with placebo or alternative treatments for any type of chronic wound in adults. We did not apply any date or language restrictions.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology, including two reviewers independently selecting studies for inclusion, extracting data, and assessing risk of bias.

MAIN RESULTS

The search identified one new RCT, making a total of 10 included RCTs (442 participants, 42% women). The median number of participants per RCT was 29 (range 10 to 117). Four RCTs recruited people with a range of chronic wounds; three RCTs recruited people with venous leg ulcers, and three RCTs considered foot ulcers in people with diabetes. The median length of treatment was 12 weeks (range 8 to 40 weeks).It is unclear whether autologous PRP improves the healing of chronic wounds generally compared with standard treatment (with or without placebo) (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.95 to 1.50; I(2) = 27%, low quality evidence, 8 RCTs, 391 participants). Autologous PRP may increase the healing of foot ulcers in people with diabetes compared with standard care (with or without placebo) (RR 1.22, 95% CI 1.01 to 1.49; I(2) = 0%, low quality evidence, 2 RCTs, 189 participants). It is unclear if autologous PRP affects the healing of venous leg ulcers (RR 1.02, 95% CI 0.81 to 1.27; I(2) = 0% ). It is unclear if there is a difference in the risk of adverse events in people treated with PRP or standard care (RR 1.05, 95% CI 0.29 to 3.88; I(2) = 0%, low quality evidence from 3 trials, 102 participants).

AUTHORS' CONCLUSIONS

PRP may improve the healing of foot ulcers associated with diabetes, but this conclusion is based on low quality evidence from two small RCTs. It is unclear whether PRP influences the healing of other chronic wounds. The overall quality of evidence of autologous PRP for treating chronic wounds is low. There are very few RCTs evaluating PRP, they are underpowered to detect treatment effects, if they exist, and are generally at high or unclear risk of bias. Well designed and adequately powered clinical trials are needed.

Use of Platelet Preparations in Facial Rejuvenation and Wound Healing Remains Unproven

There is growing interest in the use of platelet derivatives in facial aesthetic surgery and wound healing. Sclafani et al. have concluded from their review of the literature that the vast majority of studies show a significant and measurable effect on facial aesthetic outcomes with the use of these platelet preparations. We suggest that an alternative review of the same literature may well have produced a different set of conclusions.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Mesenchymal Stem Cells in Chronic Wounds: The Spectrum from Basic to Advanced Therapy

Significance: Almost 7 million Americans have chronic cutaneous wounds and billions of dollars are spent on their treatment. The number of patients with nonhealing wounds keeps increasing worldwide due to an ever-aging population, increasing number of obese and diabetic patients, and cardiovascular disease. Recent Advances: Advanced treatments for difficult wounds are needed. Therapy with mesenchymal stem cells (MSCs) is attractive due to their differentiating potential, their immunomodulating properties, and their paracrine effects. Critical Issues: New technologies (including growth factors and skin substitutes) are now widely used for stimulating wound healing. However, in spite of these advances, the percentage of complete wound closure in most clinical situations is around 50-60%. Moreover, there is a high rate of wound recurrence. Future Directions: Recently, it has been demonstrated that MSCs speed up wound healing by decreasing inflammation, by promoting angiogenesis, and by decreasing scarring. However, there are some potential limitations to successful MSC therapy. These limitations include the need to improve cell delivery methods, cell viability, heterogeneity in MSC preparations, and suboptimal wound bed preparation. Further large, controlled clinical trials are needed to establish the safety of MSCs before widespread clinical application.

Efficacy of autologous platelet-rich plasma for the treatment of muscle rupture with haematoma: a multicentre, randomised, double-blind, placebo-controlled clinical trial

BACKGROUND

The goals of the treatment of muscle injuries are to shorten the time of healing and to avoid relapses. The aim of this study was to assess the efficacy of autologous platelet-rich plasma (PRP) in the healing of muscle injuries.

MATERIALS AND METHODS

A multicentre, randomised, double-blind, parallel, controlled clinical trial was conducted in 71 patients (81.8% males) aged 45.6 (SD=10.0) years with muscle tears in the legs and haematoma. The haematoma was evacuated in all patients. Thirty-three patients were randomised to a single dose of autologous PRP and 38 patients to simulation of PRP administration. The primary end-point was time to complete recovery of muscle injury. Secondary end-points were pain, relapses, ultrasound parameters, and adverse events. The total follow-up per patient was 12 months.

RESULTS

Time to complete recovery after the treatment was 31.63 days (SD=15.38) in the PRP group, and 38.43 days (SD=18.58) in the control group (p=0.261). Pain decreased over time in both groups without statistical differences between them. Eight patients relapsed (seven in the control group, and one in the PRP group). There were no adverse effects related to the interventions.

DISCUSSION

Autologous PRP did not significantly improve the time to healing compared to that in the control group.

What's new in the literature: an update of new research since the original WHS diabetic foot ulcer guidelines in 2006

The objective of the paper was to update the diabetic foot ulcer guidelines that were previously published in 2006. We performed a key word search using MEDLINE and Cochrane reviews for publication between January 2006 and January 2012. Articles that fit the inclusion criteria were reviewed and the previous guidelines were updated.

Infected Nonhealing Wound in a Kidney Transplant Recipient: Successful Treatment With Topical Homologous Platelet-Rich Gel

Impaired would healing is a known adverse effect of chronic immunosuppression. Solid-organ transplant recipients undergoing major abdominal surgery have an increased risk of wound-related complications compared with the general population. In this subset of patients, surgical site infections and wound dehiscence must be aggressively treated to avoid sepsis, graft loss, and death. Recently, topical application of platelet-rich plasma has been proposed as an alternative therapeutic option to enhance wound healing in difficult cases. Unfortunately, randomized controlled trials evaluating the efficacy of platelet-rich plasma compared with standard or advanced wound management are lacking, and the literature mostly refers to anecdotal reports in patients with no evidence of wound infection. This report documents a kidney transplant recipient who experienced spontaneous bladder rupture because of gangrenous cystitis. After an exploratory laparotomy and bladder repair, the patient developed a deep surgical site infection by multidrug resistant Acinetobacter baumannii and extensive wound dehiscence. Advanced wound management and vacuum-assisted closure therapy were ineffective. Topical homologous platelet-rich gel was used resulting in significant wound healing, without infections or immunologic complications.

Exploratory clinical trial of combination wound therapy with a gelatin sheet and platelet-rich plasma in patients with chronic skin ulcers: study protocol

INTRODUCTION

Chronic skin ulcers, such as diabetic ulcers, venous leg ulcers and pressure ulcers, are intractable and increasing in prevalence, representing a costly problem in healthcare. We developed a combination therapy with a gelatin sheet, capable of providing sustained release of platelet-rich plasma (PRP). The objective of this study is to investigate the safety and efficacy of autologous PRP covered with a hydrocolloid dressing and PRP covered with a gelatin sheet in the treatment of chronic skin ulcers.

METHODS AND ANALYSIS

Thirty patients with chronic skin ulcers who have not healed with conventional therapy for at least 1 month are being recruited. The patients will receive PRP after debridement, and the wounds will be covered with a hydrocolloid dressing or gelatin sheet. The efficacy will be evaluated according to the time from the beginning of PRP application to secondary healing or the day on which wound closure is achieved with a relatively simple surgical procedure, such as skin grafting or suturing. All patients will be followed up until 6 weeks after application to observe adverse events related to the application of PRP and the dressings. This study was designed to address and compare the safety and efficacy of PRP covered with a hydrocolloid dressing versus a gelatin sheet. If successful, this combination therapy may be an alternative to bioengineered skin substitutes containing living cells and lead to substantial progress in the management of chronic skin ulcers.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board of Kansai Medical University (KMU Number 0649-1, 4 August 2014: V.1.0). The findings of this trial will be disseminated through peer-reviewed journals, and national and international scientific meetings as well as to the patients.

TRIAL REGISTRATION NUMBER

UMIN000015689.

Preparation and application of an innovative thrombocyte/leukocyte-enriched plasma to promote tissue repair in chelonians

Platelet concentrates are widely used in mammalian regenerative medicine to improve tissue healing. Chelonians (Testudines) would benefit from the application of thrombocyte preparations to regenerate damaged tissues, since traumatic injuries are leading causes of morbidity and mortality for both wild-living and domesticated animals. The aim of this study was to establish a protocol that optimized the recovery of the thrombocytes from blood samples and to show the efficacy of thrombocyte-enriched plasma in chelonians. Peripheral blood samples were obtained from Testudo spp. (n = 12) and Trachemys scripta elegans (n = 10). Blood cells were fractionated by sodium diatrizoate-sodium polysucrose density gradient using a two-step centrifugation protocol. Thrombocytes and leukocytes were isolated and resuspended to obtain thrombocyte-leucocyte rich plasma (TLRP). The mean recovery of leukocytes and thrombocytes was 48.9% (±4.0 SEM, n = 22) of the whole blood cell content. No statistically significant difference was observed between blood samples collected from different turtle species. The ability of TLRP to form a gel was evaluated by adding variable concentrations of calcium gluconate at room temperature and at 37°C. A reliable and consistent clotting of the TLRP was obtained in glass tubes and dishes by adding 5-20% v/v of a 100 mg/ml solution of calcium gluconate. Furthermore, in order to test the clinical efficacy of TLRP, a preliminary evaluation was performed on four turtles (Testudo spp.) with traumatic injuries. In all the four animals, a successful clinical outcome was observed. The results demonstrated that a thrombocyte-enriched plasma, comparable to mammalian platelet rich plasma, can be prepared from chelonian blood samples. Furthermore, although the low number of cases presented does not allow definitive conclusions from a clinical point of view, their outcome suggests that TLRP application could be further investigated to improve the healing process of both soft and hard tissue injuries in chelonians.

Seeking effective interventions to treat complex wounds: an overview of systematic reviews

BACKGROUND

Numerous, often multi-faceted regimens are available for treating complex wounds, yet the evidence of these interventions is recondite across the literature. We aimed to identify effective interventions to treat complex wounds through an overview of systematic reviews.

METHODS

MEDLINE (OVID interface, 1946 until October 26, 2012), EMBASE (OVID interface, 1947 until October 26, 2012), and the Cochrane Database of Systematic Reviews (Issue 10 of 12, 2012) were searched on October 26, 2012. Systematic reviews that examined adults receiving care for their complex wounds were included. Two reviewers independently screened the literature, abstracted data, and assessed study quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool.

RESULTS

Overall, 99 systematic reviews were included after screening 6,200 titles and abstracts and 422 full-texts; 54 were systematic reviews with a meta-analysis (including data on over 54,000 patients) and 45 were systematic reviews without a meta-analysis. Overall, 44% of included reviews were rated as being of high quality (AMSTAR score ≥ 8). Based on data from systematic reviews including a meta-analysis with an AMSTAR score ≥ 8, promising interventions for complex wounds were identified. These included bandages or stockings (multi-layer, high compression) and wound cleansing for venous leg ulcers; four-layer bandages for mixed arterial/venous leg ulcers; biologics, ultrasound, and hydrogel dressings for diabetic leg/foot ulcers; hydrocolloid dressings, electrotherapy, air-fluidized beds, and alternate foam mattresses for pressure ulcers; and silver dressings and ultrasound for unspecified mixed complex wounds. For surgical wound infections, topical negative pressure and vacuum-assisted closure were promising interventions, but this was based on evidence from moderate to low quality systematic reviews.

CONCLUSIONS

Numerous interventions can be utilized for patients with varying types of complex wounds, yet few treatments were consistently effective across all outcomes throughout the literature. Clinicians and patients can use our results to tailor effective treatment according to type of complex wound. Network meta-analysis will be of benefit to decision-makers, as it will permit multiple treatment comparisons and ranking of the effectiveness of all interventions. Please see related article: http://dx.doi.org/10.1186/s12916-015-0326-3.

Efficacy and safety of autologous platelet rich plasma for the treatment of vascular ulcers in primary care: Phase III study

Background

Vascular ulcers are commonly seen in daily practice at all levels of care and have great impact at personal, professional and social levels with a high cost in terms of human and material resources. Given that the application of autologous platelet rich plasma has been shown to decrease healing times in various different studies in the hospital setting, we considered that it would be interesting to assess the efficacy and feasibility of this treatment in primary care. The objectives of this study are to assess the potential efficacy and safety of autologous platelet rich plasma for the treatment of venous ulcers compared to the conventional treatment (moist wound care) in primary care patients with chronic venous insufficiency (C, clinical class, E, aetiology, A, anatomy and P, pathophysiology classification C6).

Design

We will conduct a phase III, open-label, parallel-group, multicentre, randomized study. The subjects will be 150 patients aged between 40 and 100 years of age with an at least 2-month history of a vascular venous ulcer assigned to ten primary care centres. For the treatment with autologous platelet rich plasma, all the following tasks will be performed in the primary care setting: blood collection, centrifugation, separation of platelet rich plasma, activation of coagulation adding calcium chloride and application of the PRP topically after gelification. The control group will receive standard moist wound care. The outcome variables to be measured at baseline, and at weeks 5 and 9 later include: reduction in the ulcer area, Chronic Venous Insufficiency Quality of Life Questionnaire score, and percentage of patients who require wound care only once a week.

Discussion

The results of this study will be useful to improve the protocol for using platelet rich plasma in chronic vascular ulcers and to favour wider use of this treatment in primary care.

Trial registration

Current Controlled Trials NCT02213952

Wound repair and regeneration: mechanisms, signaling, and translation

The cellular and molecular mechanisms underpinning tissue repair and its failure to heal are still poorly understood, and current therapies are limited. Poor wound healing after trauma, surgery, acute illness, or chronic disease conditions affects millions of people worldwide each year and is the consequence of poorly regulated elements of the healthy tissue repair response, including inflammation, angiogenesis, matrix deposition, and cell recruitment. Failure of one or several of these cellular processes is generally linked to an underlying clinical condition, such as vascular disease, diabetes, or aging, which are all frequently associated with healing pathologies. The search for clinical strategies that might improve the body's natural repair mechanisms will need to be based on a thorough understanding of the basic biology of repair and regeneration. In this review, we highlight emerging concepts in tissue regeneration and repair, and provide some perspectives on how to translate current knowledge into viable clinical approaches for treating patients with wound-healing pathologies.