The impact of ischemia on wound healing is increased in old age but can be countered by hyperbaric oxygen therapy

Hemodynamic response during hyperbaric treatment on skeletal muscle in a type 2 diabetes rat model

Mild hyperbaric treatment prevents type 2 diabetes progression due to increased oxygen concentration and blood flow in skeletal muscle. However, it remains unknown whether this treatment is effective during all stages of type 2 diabetes. This study aimed to investigate the influences of hyperbaric treatment at 1.3 atmospheres absolute (ATA) on hemodynamic response in various stages of type 2 diabetes. Otsuka Long-Evans Tokushima fatty (OLETF) and Long-Evans Tokushima Otsuka (LETO) rats were used as models of type 2 diabetes and healthy controls, respectively. Glucose levels were significantly higher in OLETF rats than in LETO rats at all ages. Glucose intolerance gradually increased with age in OLETF rats. Insulin levels in OLETF rats were significantly higher at 20-week-old, however, were significantly lower at 60-week-old than in LETO rats. Oxy-Hb, total Hb, and StO₂ in skeletal muscle were increased during hyperbaric treatment in both rats. The hemodynamic changes were significantly higher in OLETF rats than LETO rats, and those changes were also pronounced at 8-week-old compared with other age in OLETF rats. These results suggest that hyperbaric treatment at 1.3 ATA acts on pathophysiological factors and the efficacy could be found only in the early stage of type 2 diabetes.

Therapeutic Effects of Hyperbaric Oxygen in the Process of Wound Healing

Chronic and non-healing wounds, especially diabetic foot ulcers and radiation injuries, imply remarkable morbidity with a significant effect on the quality of life and a high sanitary cost. The management of these wounds requires complex actions such as surgical debris, antibiotic treatment, dressings and even revascularization. These wounds are characterized by poor oxygen supply resulting in inadequate oxygenation of the affected tissue. The adjuvant treatment with hyperbaric oxygen therapy (HBOT) may increase tissue oxygenation favoring the healing of wounds which do not respond to the usual clinical care. The increase in the partial pressure of oxygen contributes to cover the energy demands necessary for the healing process and reduces the incidence of infections. Moreover, the increase in oxygen leads to the production of reactive species with hormetic activity, acting on signaling pathways that modulate the synthesis of inflammation mediators, antioxidants and growth factors which can contribute to the healing process. Studies performed with cell cultures and in animal models seem to demonstrate the beneficial effects of HBOT. However, clinical trials do not show such conclusive results; thus, additional randomized placebo-controlled studies are necessary to determine the real efficacy of HBOT and the mechanism of action for various types of wounds.

Analysis of factors influencing drain amount, time to drain removal, and seroma formation in patients undergoing immediate expander-implant breast reconstruction

BACKGROUND

Placement of a closed suction drain is a common cause of patient complaints, such as postoperative pain or discomfort following immediate expander-implant breast reconstruction. This study aims to identify factors that affect drainage volume, time to drain removal, and seroma formation.

METHODS

A retrospective chart review of prospectively collected data was conducted on patients who underwent immediate expander-implant breast reconstructions following nipple-sparing or skin-sparing mastectomy without skin excision (nipple areolar complex excision only) between February 2010 and April 2015. Daily drainage volume was measured until the drain was removed. Eight independent variables, including acellular dermal matrix (ADM) usage and inflation ratio (the rate of initial inflation volume to mastectomy weight) were analysed by univariable and multivariable analyses.

RESULTS

A total of 162 breasts in 148 patients were included in this study. The inflation ratio did not influence the drain amount or days to drain removal. Although the use of ADM was significantly associated with increased drainage during the first 5 postoperative days (p = 0.015), it was not significant when adjusted for time. Old age, larger expander size, and larger drain amount on the first postoperative day were predictors for longer days to drain removal (p < 0.001). Old age had a trend toward higher risk of seroma formation that approached statistical significance (p = 0.057).

CONCLUSIONS

The use of ADM and initial inflation ratio do not influence days to drain removal or seroma formation. A longer period of drain placement is expected when a larger expander is used or in elderly patients.

Cutaneous wound healing in aging small mammals: a systematic review

As the elderly population grows, so do the clinical and socioeconomic burdens of nonhealing cutaneous wounds, the majority of which are seen among persons over 60 years of age. Human studies on how aging effects wound healing will always be the gold standard, but studies have ethical and practical hurdles. Choosing an animal model is dictated by costs and animal lifespan that preclude large animal use. Here, we review the current literature on how aging effects cutaneous wound healing in small animal models and, when possible, compare healing across studies. Using a literature search of MEDLINE/PubMed databases, studies were limited to those that utilized full-thickness wounds and compared the wound-healing parameters of wound closure, reepithelialization, granulation tissue fill, and tensile strength between young and aged cohorts. Overall, wound closure, reepithelialization, and granulation tissue fill were delayed or decreased with aging across different strains of mice and rats. Aging in mice was associated with lower tensile strength early in the wound healing process, but greater tensile strength later in the wound healing process. Similarly, aging in rats was associated with lower tensile strength early in the wound healing process, but no significant tensile strength difference between young and old rats later in healing wounds. From studies in New Zealand White rabbits, we found that reepithelialization and granulation tissue fill were delayed or decreased overall with aging. While similarities and differences in key wound healing parameters were noted between different strains and species, the comparability across the studies was highly questionable, highlighted by wide variability in experimental design and reporting. In future studies, standardized experimental design and reporting would help to establish comparable study groups, and advance the overall knowledge base, facilitating the translatability of animal data to the human clinical condition.

Anesthesia, microcirculation, and wound repair in aging

Age-related changes in skin contribute to impaired wound healing after surgical procedures. Changes in skin with age include decline in thickness and composition, a decrease in the number of most cell types, and diminished microcirculation. The microcirculation provides tissue perfusion, fluid homeostasis, and delivery of oxygen and other nutrients. It also controls temperature and the inflammatory response. Surgical incisions cause further disruption of the microvasculature of aged skin. Perioperative management can be modified to minimize insults to aged tissues. Judicious use of fluids, maintenance of normal body temperature, pain control, and increased tissue oxygen tension are examples of adjustable variables that support the microcirculation. Anesthetic agents influence the microcirculation of a combination of effects on cardiac output, arterial pressure, and local microvascular changes. The authors examined the role of anesthetic management in optimizing the microcirculation and potentially improving postoperative wound repair in older persons.

Age-dependent response of murine female bone marrow cells to hyperbaric oxygen

Consequences of age on the effects of hyperbaric oxygen (HBO) on bone marrow (BM) derived stem cells and progenitors (SCPs) are largely unknown. We treated 2- and 18-month old C57BL/6 female mice by HBO. Hematopoietic stem cells and progenitors, enumerated as colony-forming units in culture, were doubled only in peripheral leukocytes and BM cells of young mice receiving HBO. In old mice colony-forming unit fibroblast numbers, a measure of mesenchymal stromal cells (MSCs) from BM, were high but unaffected by HBO. To further explore this finding, in BM-MSCs we quantified the transcripts of adipocyte early-differentiation genes peroxisome proliferator-activated receptor-γ, CCAAT/enhancer binding protein-β and fatty-acid binding protein 4; these transcripts were not affected by age or HBO. However, osteoblast gene transcripts runt-related transcription factor 2, osterix (OSX) and alkaline phosphatase (AP) were twofold to 20-fold more abundant in MSCs from old control mice relative to those of young control mice. HBO affected expression of osteoblast markers only in old MSCs (OSX gene expression was reduced by twofold and AP expression was increased threefold). Our data demonstrate the impact of aging on the response of BM SCPs to HBO and indicate the potentially different age-related benefit of HBO in wound healing and tissue remodeling.

Topical oxygen therapy induces vascular endothelial growth factor expression and improves closure of clinically presented chronic wounds

1. Chronic wounds, especially in diabetics, represent a serious threat to human health. 2. Correcting a compromised state of tissue oxygenation by the administration of supplemental O(2) is known to benefit wound healing. Beyond its role as a nutrient and antibiotic, O(2) supports wound healing by driving redox signaling. 3. Hyperbaric oxygen (HBO) therapy is widely used and approved by Center for Medicare and Medicaid Services to treat specific ulcerations. The current literature supports the notion that approaches to topically oxygenate wounds may be productive. 4. Here, we present the results of two simultaneous studies testing the effects of HBO and portable topical oxygen (TO) therapies. These two therapeutic approaches have several contrasting features. 5. In total, 1854 patients were screened in outpatient wound clinics for non-randomized enrolments into the HBO (n = 32; 31% diabetic) and TO (n = 25; 52% diabetic) studies. 6. Under the conditions of the present study, HBO treatment seemed to benefit some wounds while not benefiting others. Overall, HBO did not result in statistically significant improvements in wound size in the given population over the time monitored in the present study. 7. However, TO significantly improved wound size. Among the three O(2)-sensitive genes (VEGF, TGFbeta1 and COL1A1) studied in wound edge tissue biopsies, TO treatment was associated with higher VEGF165 expression in healing wounds. Expression of the other genes mentioned was not affected by TO. There was no significant change in the expression levels of any of genes studied in patients in the HBO study. This establishes a link between VEGF gene expression and healing outcome for TO therapy. 8. Taken together, the present study provides evidence demonstrating that TO treatment benefits wound healing in patients suffering from chronic wounds. Treatment with TO is associated with an induction of VEGF expression in wound edge tissue and an improvement in wound size.

Effect of allopurinol, superoxide-dismutase, and hyperbaric oxygen on flap survival

The effect of allopurinol, superoxide-dismutase, and hyperbaric oxygen was compared on axial pattern skin flap survival. An abdominal flap based on the inferior epigastric pedicle was raised in rats for this purpose. Three experimental groups were studied. In the first group, adult male Wistar rats received 50 mg/kg I.P. of allopurinol. The second received 20,000 I.U./kg of superoxide-dismutase. The third group was submitted to hyperbaric oxygen therapy. The flaps were exposed to 8-h warm ischemia. Flap survival was evaluated on postoperative day 7. All flaps survived, and the mean survival areas were 63.53%, 83.03%, and 55.98%, respectively, in the allopurinol, superoxide-dismutase, and hyperbaric groups. The percentage of flap necrosis was significantly smaller in all experimental groups when compared to controls (P < 0.05). It was clear that the superoxide-dismutase group had better results on axial pattern ischemic skin flap survival, under the tested conditions. The tested methods improved flap survival to ischemic injury, and the flap designed is a reliable model for further investigations.

Cellular, biochemical, and clinical aspects of wound healing

BACKGROUND

The response to tissue injury requires the symphonious interaction of immune cells, keratinocytes, fibroblasts, and endothelial cells, which unite to regenerate the damaged epithelium. Recent insights have elucidated the cellular and molecular mechanisms required for wound healing and have raised the prospect of novel therapeutic targets.

METHODS

Review of the pertinent literature.

RESULTS

The initial inflammatory response leads to the influx of macrophages and neutrophils, which release cytokines, growth factors, and nitric oxide, and induce nearby keratinocytes to migrate across the wounded epithelium. This process, known as re-epithelialization, requires integrin-mediated activation of Rho-GTPases. The subsequent influx of fibroblasts and endothelial cells results in the production of tissue stroma and formation of new blood vessels, which lead to the generation of functional tissue. Importantly, disease states associated with impaired or excessive wound healing can be attributed to defects in these responses, providing a rationale for the use of evidence-based biological therapies.

CONCLUSION

The elucidation of the cellular and biochemical response to wound healing is essential for an understanding to the treatment of clinical conditions during which impaired healing is encountered.

Experimental gerontology in the Nordic countries

Research in geriatric medicine developed in the Nordic countries in the 1950s, following the tradition from the United Kingdom. Quite early, longitudinal epidemiological studies of 'normal' ageing emerged. Now there are chairs in geriatric medicine at many of the medical schools. Experimental gerontology came much later, typically scattered in a variety of medical school departments. There is only one chair in gerontology (in Tampere). Two major research undertakings have emerged in recent years, the Danish Centre for Molecular Gerontology, and a cluster of research groups at the Division of Geriatrics at the Karolinska Institutet. Other research groups are found in Denmark at the universities in Aarhus, Copenhagen and Odense; in Finland at the universities in Jyväskylä, Kuopio, Tampere and Turku; and in Norway at the university in Trondheim. These activities are reviewed country-wise.

The effect of stitch type on flap tip blood flow

BACKGROUND

The 3-point corner stitch is generally used for apposition of skin flap tips to recipient wound corners. This stitch theoretically provides better blood flow, leading to improved flap tip survival, than alternative suture techniques. However, this assumption is not based on human experimental data.

OBJECTIVE

We tested in patients whether certain stitch types influence flap tip blood flow and necrosis.

METHODS

Flap tips were closed with either a 3-point corner stitch, a vertical loop stitch at the tip, or two vertical loop stitches adjacent to the tip. Blood flow was indirectly measured by means of the laser Doppler imager, and flap tips were observed for subsequent necrosis.

RESULTS

The 3-point corner stitch resulted in a higher overall mean percent flux ratio implying greater blood flow than the other stitch types used. However, none of the stitch types resulted in a large number of necrotic flap tips.

CONCLUSION

The 3-point corner stitch provides increased blood flow to flap tips that may be critical when flap tip survival is problematic.

The effect of recombinant basic fibroblast growth factor (bFGF) in fibrin adhesive vehicle on the healing of ischaemic and normal incisional skin wounds

Normal and ischaemic incisional wounds in rats were treated with recombinant human basic fibroblast growth factor (rbFGF) in fibrin adhesive vehicle. After 10 days of healing the maximum load*S and stress*S (S denotes correction for shrinkage) of ischaemic wounds were increased by 45% and 39%, respectively, after treatment with 20 micrograms rbFGF and by 67% and 56% after treatment with 60 micrograms rbFGF. After 20 days only 20 micrograms rbFGF had any effect and increased maximum load*S by 31% and energy at maximum (load*S, stress*S) by 40%-48%. In normal wounds 0.6-20 micrograms and 60 micrograms rbFGF decreased the strength parameters by 19%-34% and 49%-52%, respectively, after 10 days. After 20 days there was no negative influence but 60 micrograms rbFGF increased the biomechanical properties by 15%-24%. Treatment with the fibrin adhesive vehicle alone decreased the biomechanical properties of ischaemic wounds after 20 days, and of normal wounds after both 10 and 20 days. In conclusion, rbFGF can improve the healing of ischaemic wounds and may be used in the treatment of ischaemic wounds in patients, but it can have negative effects on normal wound healing.