Introduction to DIN-specification 91315 based on the characterization of the plasma jet kINPen® MED

In-vitro biofilm removal from TiUnite® implant surface with an air polishing and two different plasma devices

BACKGROUND

We investigated the efficacy of two different cold atmospheric pressure jet plasma devices (CAP09 and CAPmed) and an air polishing device with glycine powder (AP) either applied as monotherapies or combined therapies (AP + CAP09; AP + CAPmed), in microbial biofilm removal from discs with anodised titanium surface.

METHODS

Discs covered with 7-day-old microbial biofilm were treated either with CAP09, CAPmed, AP, AP + CAP09 or AP + CAPmed and compared with negative and positive controls. Biofilm removal was assessed with flourescence and electron microscopy immediately after treatment and after 5 days of reincubation of the treated discs.

RESULTS

Treatment with CAP09 or CAPmed did not lead to an effective biofilm removal, whereas treatment with AP detached the complete biofilm, which however regrew to baseline magnitude after 5 days of reincubation. Both combination therapies (AP + CAP09 and AP + CAPmed) achieved a complete biofilm removal immediately after cleaning. However, biofilm regrew after 5 days on 50% of the discs treated with the combination therapy.

CONCLUSION

AP treatment alone can remove gross biofilm immediately from anodised titanium surfaces. However, it did not impede regrowth after 5 days, because microorganisms were probably hidden in holes and troughs, from which they could regrow, and which were inaccessible to AP. The combination of AP and plasma treatment probably removed or inactivated microorganisms also from these hard to access spots. These results were independent of the choice of plasma device.

Cold Atmospheric Pressure Plasma-Activated Medium Modulates Cellular Functions of Human Mesenchymal Stem/Stromal Cells In Vitro

Cold atmospheric pressure plasma (CAP) offers a variety of therapeutic possibilities and induces the formation of reactive chemical species associated with oxidative stress. Mesenchymal stem/stromal cells (MSCs) play a central role in tissue regeneration, partly because of their antioxidant properties and ability to migrate into regenerating areas. During the therapeutic application, MSCs are directly exposed to the reactive species of CAP. Therefore, the investigation of CAP-induced effects on MSCs is essential. In this study, we quantified the amount of ROS due to the CAP activation of the culture medium. In addition, cell number, metabolic activity, stress signals, and migration were analyzed after the treatment of MSCs with a CAP-activated medium. CAP-activated media induced a significant increase in ROS but did not cause cytotoxic effects on MSCs when the treatment was singular and short-term (one day). This single treatment led to increased cell migration, an essential process in wound healing. In parallel, there was an increase in various cell stress proteins, indicating an adaptation to oxidative stress. Repeated treatments with the CAP-activated medium impaired the viability of the MSCs. The results shown here provide information on the influence of treatment frequency and intensity, which could be necessary for the therapeutic application of CAP.

Inhibitory effects of non-thermal atmospheric plasma on Yersinia enterocolitica and Staphylococcus aureus in the Korean traditional non-fermented kimchi "Geotjeori"

Food-borne bacteria have frequently been detected in kimchi, a representative and traditional fermented ethnic food of Korea. This study investigated the effect of atmospheric dielectric barrier discharge (DBD) plasma treatment (1.1 kV, 43 kHz, N2: 1.5 m/s, 5-60 min) on reduction of Yersinia enterocolitica and Staphylococcus aureus and on quality parameters in Geotjeroi, a non-fermented kimchi. A decrease of 0.12/0.09, 0.19/0.19, 0.34/0.45, 0.64/0.72, and 1.13/1.12 log10 CFU/g was observed by 5, 10, 20, 30, and 60 min of DBD plasma, respectively. D-value of 52.83 and 51.95 min was determined for Y. enterocolitica (R2 = 0.99) and S. aureus (R2 = 0.98) using the first order kinetics model. The quality parameters (pH, Brix, and hardness) were not significantly different (P > 0.05) between treated and untreated Geotjeori. Moreover, a decrease of >1 log10 CFU/g, for both bacteria was observed without any change in the quality of Geotjeori. These findings imply that DBD plasma treatment enhances Geotjeori safety and protects product from microbial risk.

Development of a Mobile Sensory Device to Trace Treatment Conditions for Various Medical Plasma Source Devices

The emerging use of low-temperature plasma in medicine, especially in wound treatment, calls for a better way of documenting the treatment parameters. This paper describes the development of a mobile sensory device (referred to as MSD) that can be used during the treatment to ease the documentation of important parameters in a streamlined process. These parameters include the patient's general information, plasma source device used in the treatment, plasma treatment time, ambient humidity and temperature. MSD was developed as a standalone Raspberry Pi-based version and attachable module version for laptops and tablets. Both versions feature a user-friendly GUI, temperature-humidity sensor, microphone, treatment report generation and export. For the logging of plasma treatment time, a sound-based plasma detection system was developed, initially for three medically certified plasma source devices: kINPen^® MED, plasma care^®, and PlasmaDerm^® Flex. Experimental validation of the developed detection system shows accurate and reliable detection is achievable at 5 cm measurement distance in quiet and noisy environments for all devices. All in all, the developed tool is a first step to a more automated, integrated, and streamlined approach of plasma treatment documentation that can help prevent user variability.

Emerging innovations in cold plasma therapy against cancer: A paradigm shift

Cancer is one of the major causes of mortality, accounting for ∼ 9.5 million deaths globally in 2018. The spectrum of conventional treatment for cancer includes surgery, chemotherapy and radiotherapy. Recently, cold plasma therapy surfaced as a novel technique in the treatment of cancer. The FDA approval of the first trial for the use of cold atmospheric plasma (CAP) in cancer therapy in 2019 is evidence of this. This review highlights the mechanisms of action of CAP. Additionally, its applications in anticancer therapy have been reviewed. In summary, this article will introduce the readers to the exciting field of plasma oncology and help them understand the current status and prospects of plasma oncology.

Enhancement of Nitric Oxide Bioavailability by Modulation of Cutaneous Nitric Oxide Stores

The generation of nitric oxide (NO) in the skin plays a critical role in wound healing and the response to several stimuli, such as UV exposure, heat, infection, and inflammation. Furthermore, in the human body, NO is involved in vascular homeostasis and the regulation of blood pressure. Physiologically, a family of enzymes termed nitric oxide synthases (NOS) generates NO. In addition, there are many methods of non-enzymatic/NOS-independent NO generation, e.g., the reduction of NO derivates (NODs) such as nitrite, nitrate, and nitrosylated proteins under certain conditions. The skin is the largest and heaviest human organ and contains a comparatively high concentration of these NODs; therefore, it represents a promising target for many therapeutic strategies for NO-dependent pathological conditions. In this review, we give an overview of how the cutaneous NOD stores can be targeted and modulated, leading to a further accumulation of NO-related compounds and/or the local and systemic release of bioactive NO, and eventually, NO-related physiological effects with a potential therapeutical use for diseases such as hypertension, disturbed microcirculation, impaired wound healing, and skin infections.

Insight into the Impact of Oxidative Stress on the Barrier Properties of Lipid Bilayer Models

As a new field of oxidative stress-based therapy, cold physical plasma is a promising tool for several biomedical applications due to its potential to create a broad diversity of reactive oxygen and nitrogen species (RONS). Although proposed, the impact of plasma-derived RONS on the cell membrane lipids and properties is not fully understood. For this purpose, the changes in the lipid bilayer functionality under oxidative stress generated by an argon plasma jet (kINPen) were investigated by electrochemical techniques. In addition, liquid chromatography-tandem mass spectrometry was employed to analyze the plasma-induced modifications on the model lipids. Various asymmetric bilayers mimicking the structure and properties of the erythrocyte cell membrane were transferred onto a gold electrode surface by Langmuir-Blodgett/Langmuir-Schaefer deposition techniques. A strong impact of cholesterol on membrane permeabilization by plasma-derived species was revealed. Moreover, the maintenance of the barrier properties is influenced by the chemical composition of the head group. Mainly the head group size and its hydrogen bonding capacities are relevant, and phosphatidylcholines are significantly more susceptible than phosphatidylserines and other lipid classes, underlining the high relevance of this lipid class in membrane dynamics and cell physiology.

Efficiency of biofilm removal by combination of water jet and cold plasma: an in-vitro study

Background

Peri-implantitis therapy is a major problem in implantology. Because of challenging rough implant surface and implant geometry, microorganisms can hide and survive in implant microstructures and impede debridement. We developed a new water jet (WJ) device and a new cold atmospheric pressure plasma (CAP) device to overcome these problems and investigated aspects of efficacy in vitro and safety with the aim to create the prerequisites for a clinical pilot study with these medical devices.

Methods

We compared the efficiency of a single treatment with a WJ or curette and cotton swab (CC) without or with adjunctive use of CAP (WJ + CAP, CC + CAP) to remove biofilm in vitro from rough titanium discs. Treatment efficacy was evaluated by measuring turbidity up to 72 h for bacterial re-growth or spreading of osteoblast-like cells (MG-63) after 5 days with scanning electron microscopy. With respect to application safety, the WJ and CAP instruments were examined according to basic regulations for medical devices.

Results

After 96 h of incubation all WJ and CC treated disks were turbid but 67% of WJ + CAP and 46% CC + CAP treated specimens were still clear. The increase in turbidity after WJ treatment was delayed by about 20 h compared to CC treatment. In combination with CAP the cell coverage significantly increased to 82% (WJ + CAP) or 72% (CC + CAP), compared to single treatment 11% (WJ) or 10% (CC).

Conclusion

The newly developed water jet device effectively removes biofilm from rough titanium surfaces in vitro and, in combination with the new CAP device, biologically acceptable surfaces allow osteoblasts to grow. WJ in combination with CAP leads to cleaner surfaces than the usage of curette and cotton swabs with or without subsequent plasma treatment. Our next step will be a clinical pilot study with these new devices to assess the clinical healing process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02195-1.

Application of scanning electrochemical microscopy for topography imaging of supported lipid bilayers

Oxidative stress in cellular environments may cause lipid oxidation and membrane degradation. Therefore, studying the degree of lipid membrane morphological changes by reactive oxygen and nitrogen species will be informative in oxidative stress-based therapies. This study introduces the possibility of using scanning electrochemical microscopy as a powerful imaging technique to follow the topographical changes of a solid-supported lipid bilayer model induced by reactive species produced from gas plasma. The introduced strategy is not limited to investigating the effect of reactive species on the lipid bilayer but could be extended to understand the morphological changes of the lipid bilayer due to the action of membrane proteins or antimicrobial peptides.

Plasma bioscience for medicine, agriculture and hygiene applications

Nonthermal biocompatible plasma (NBP) sources operating in atmospheric pressure environments and their characteristics can be used for plasma bioscience, medicine, and hygiene applications, especially for COVID-19 and citizen. This review surveyed the various NBP sources, including a plasma jet, micro-DBD (dielectric barrier discharge) and nanosecond discharged plasma. The electron temperatures and the plasma densities, which are produced using dielectric barrier discharged electrode systems, can be characterized as 0.7 ~ 1.8 eV and (3-5) × 1014-15 cm-3, respectively. Herein, we introduce a general schematic view of the plasma ultraviolet photolysis of water molecules for reactive oxygen and nitrogen species (RONS) generation inside biological cells or living tissues, which would be synergistically important with RONS diffusive propagation into cells or tissues. Of the RONS, the hydroxyl radical [OH] and hydrogen peroxide H2O2 species would mainly result in apoptotic cell death with other RONS in plasma bioscience and medicines. The diseased biological protein, cancer, and mutated cells could be treated by using a NBP or plasma activated water (PAW) resulting in their apoptosis for a new paradigm of plasma medicine.

Conductivity augments ROS and RNS delivery and tumor toxicity of an argon plasma jet

Gas plasma jet technology was recently identified as a potential adjuvant in the palliation of cancer patients. However, a practical point raised is if higher therapeutic efficacy is achieved with the gas plasma applied in direct contact to the tumor tissue (conducting) or during treatment with the remote cloud of reactive oxygen and nitrogen species (ROS/RNS) being expelled. In a bedside-to-bench study, this clinical question was translated into studying these two distinct treatment modalities using a three-dimensional tumor cell-matrix-hydrogel assay with subsequent quantitative confocal imaging. Z-resolved fluorescence analysis of two cancer cell lines revealed greater toxicity of the conducting mode. This result was re-iterated in the growth analysis of vascularized tumor tissue cultured on chicken embryos' CAM using in ovo bioluminescence imaging. Furthermore, for conducting compared to free mode, optical emission spectroscopy revealed stronger RNS signal lines in the gas phase, while both ROS/RNS deposition in the liquid was drastically exacerbated in the conducting mode. Altogether, our results are vital in understanding the importance of standardized treatment distances on the therapeutic efficacy of gas plasma exposure in clinical oncology and will help to give critical implications for clinicians involved in plasma onco-therapy in the future.

Inhibitory effects of atmospheric dielectric barrier discharge plasma against Bacillus cereus and Staphylococcus aureus on Gwamegi (Semi-dried Cololabis saira)

AIMS

The current study was conducted to investigate the effects of atmospheric dielectric barrier discharge (DBD) plasma on the reduction of B. cereus and S. aureus, both potential hazardous bacteria on Gwamegi.

METHODS AND RESULTS

DBD plasma devices (1.1 kV, 43 kHz, 5-60 min, N₂ : 1.5 lpm for 5, 10, 20, 30 and 60 min) were used to investigate the reduction effect. In the B. cereus by DBD plasma treatment, the 5-60 min indicated a reduction of 0.2-1.2 log CFU/g. The reductions of S. aureus at the same duration time of DBD plasma were 0.1-1.1 log CFU/g. The D-values for B. cereus and S. aureus were 49.0 (R² =0.98) and 61.0 (R² =0.94) min respectively. The pH values for 0-30 min (6.00-6.01) were not significantly different, but significant differences at 60 min (6.09). There were no significant sensorial differences in color (6.4-5.2) and flavor (6.2-5.3), but showing significant differences in appearance (6.6-5.2), texture (6.3-5.1), and overall acceptability (6.5-5.5).

CONCLUSIONS

This study indicates that the 60 min of DBD plasma treatment resulted in > 1 log CFU/g of B. cereus and S. aureus without concomitant adverse changes of pH and most sensory properties in semi-dried Gwamegi.

SIGNIFICANCE AND IMPACT OF THE STUDY

This novel DBD plasma technology can be applied in semi-dried food production and distribution processes to enhance dried fishery food hygiene and safety.

Cold Atmospheric Pressure Plasma Jet Operated in Ar and He: From Basic Plasma Properties to Vacuum Ultraviolet, Electric Field and Safety Thresholds Measurements in Plasma Medicine

Application desired functionality as well as operation expenses of cold atmospheric pressure plasma (CAP) devices scale with properties like gas selection. The present contribution provides a comparative investigation for a CAP system operated in argon or helium at different operation voltages and distance to the surface. Comparison of power dissipation, electrical field strength and optical emission spectroscopy from vacuum ultraviolet over visible up to near infrared ((V)UV-VIS-NIR) spectral range is carried out. This study is extended to safety relevant investigation of patient leakage current, induced surface temperature and species density for ozone (O3) and nitrogen oxides (NOx). It is found that in identical operation conditions (applied voltage, distance to surface and gas flow rate) the dissipated plasma power is about equal (up to 10 W), but the electrical field strength differs, having peak values of 320 kV/m for Ar and up to 300 kV/m for He. However, only for Ar CAP could we measure O3 up to 2 ppm and NOx up to 7 ppm. The surface temperature and leakage values of both systems showed different slopes, with the biggest surprise being a constant leakage current over distance for argon. These findings may open a new direction in the plasma source development for Plasma Medicine.

Cold Physical Plasma in Cancer Therapy: Mechanisms, Signaling, and Immunity

Despite recent advances in therapy, cancer still is a devastating and life-threatening disease, motivating novel research lines in oncology. Cold physical plasma, a partially ionized gas, is a new modality in cancer research. Physical plasma produces various physicochemical factors, primarily reactive oxygen and nitrogen species (ROS/RNS), causing cancer cell death when supplied at supraphysiological concentrations. This review outlines the biomedical consequences of plasma treatment in experimental cancer therapy, including cell death modalities. It also summarizes current knowledge on intracellular signaling pathways triggered by plasma treatment to induce cancer cell death. Besides the inactivation of tumor cells, an equally important aspect is the inflammatory context in which cell death occurs to suppress or promote the responses of immune cells. This is mainly governed by the release of damage-associated molecular patterns (DAMPs) to provoke immunogenic cancer cell death (ICD) that, in turn, activates cells of the innate immune system to promote adaptive antitumor immunity. The pivotal role of the immune system in cancer treatment, in general, is highlighted by many clinical trials and success stories on using checkpoint immunotherapy. Hence, the potential of plasma treatment to induce ICD in tumor cells to promote immunity targeting cancer lesions systemically is also discussed.

Singlet-Oxygen-Induced Phospholipase A2 Inhibition: A Major Role for Interfacial Tryptophan Dioxidation

Several studies have revealed that various diseases such as cancer have been associated with elevated phospholipase A2 (PLA2 ) activity. Therefore, the regulation of PLA2 catalytic activity is undoubtedly vital. In this study, effective inactivation of PLA2 due to reactive species produced from cold physical plasma as a source to model oxidative stress is reported. We found singlet oxygen to be the most relevant active agent in PLA2 inhibition. A more detailed analysis of the plasma-treated PLA2 identified tryptophan 128 as a hot spot, rich in double oxidation. The significant dioxidation of this interfacial tryptophan resulted in an N-formylkynurenine product via the oxidative opening of the tryptophan indole ring. Molecular dynamics simulation indicated that the efficient interactions between the tryptophan residue and phospholipids are eliminated following tryptophan dioxidation. As interfacial tryptophan residues are predominantly involved in the attaching of membrane enzymes to the bilayers, tryptophan dioxidation and indole ring opening leads to the loss of essential interactions for enzyme binding and, consequently, enzyme inactivation.

Medical gas plasma-stimulated wound healing: Evidence and mechanisms

Defective wound healing poses a significant burden on patients and healthcare systems. In recent years, a novel reactive oxygen and nitrogen species (ROS/RNS) based therapy has received considerable attention among dermatologists for targeting chronic wounds. The multifaceted ROS/RNS are generated using gas plasma technology, a partially ionized gas operated at body temperature. This review integrates preclinical and clinical evidence into a set of working hypotheses mainly based on redox processes aiding in elucidating the mechanisms of action and optimizing gas plasmas for therapeutic purposes. These hypotheses include increased wound tissue oxygenation and vascularization, amplified apoptosis of senescent cells, redox signaling, and augmented microbial inactivation. Instead of a dominant role of a single effector, it is proposed that all mechanisms act in concert in gas plasma-stimulated healing, rationalizing the use of this technology in therapy-resistant wounds. Finally, addressable current challenges and future concepts are outlined, which may further promote the clinical utilization, efficacy, and safety of gas plasma technology in wound care in the future.

Assessment of potential infectivity of human norovirus in the traditional Korean salted clam product "Jogaejeotgal" by floating electrode-dielectric barrier discharge plasma

This study investigated the antiviral effects of floating electrode-dielectric barrier discharge (FE-DBD) plasma treatment (1.1 kV, 43 kHz, N₂ 1.5 m/s, 5-30 min) against human norovirus (HuNoV) GII.4 in Jogaejeotgal Infectivity was assessed using real-time quantitative-PCR (RT-qPCR) following treatment of samples with propidium monoazide (PMA) and sodium lauroyl sarcosinate (Sarkosyl). This study also investigated the effects of FE-DBD plasma treatment on Jogaejeotgal quality (assessed using pH value and Hunter colors). Following inoculation, the average titers of HuNoV GII.4 in Jogaejeotgal significantly (P < 0.05) decreased with increases in the FE-DBD plasma treatment time in both the non-PMA-treated and PMA + Sarkosyl-treated samples; in the non-PMA and PMA + Sarkosyl treated Jogaejeotgal, HuNoV GII.4 titers (log₁₀ copy number/µL) were to: 3.16 and 2.95 (5 min), 2.90 and 2.48 (10 min), 2.82 and 2.40 (15 min), 2.58 and 2.26 (20 min), 2.48 and 2.06 (25 min), and 2.23 and 1.91 (30 min), respectively. The average titers of HuNoV demonstrated significant (P < 0.05) reductions of 0.35 log₁₀ (55.3%) in PMA + Sarkosyl-treated samples compared with the non-PMA treated samples following exposure to 5-30 min of FE-DBD plasma. Reductions of >1-log for HuNoV in PMA + Sarkosyl- treated Jogaejeotgal required treatments of FE-DBD of 5-30 min. Using the first order kinetic model (R² = 0.95), GII.4 decimal reduction time (D-value) resulting from FE-DBD plasma was 23.75 min. The pH and Hunter colors ("L", "a", and "b") were not significantly different (P > 0.05) between the untreated and FE-DBD plasma-treated Jogaejeotgal. Based on these results, the PMA + Sarkosyl/RT-qPCR method could be assessing HuNoV viability following 5-30 min treatment of FE-DBD plasma. Furthermore, may be an optimal treatment for Jogaejeotgal without altering the food quality (color and pH).

Tumor cytotoxicity and immunogenicity of a novel V-jet neon plasma source compared to the kINPen

Recent research indicated the potential of cold physical plasma in cancer therapy. The plethora of plasma-derived reactive oxygen and nitrogen species (ROS/RNS) mediate diverse antitumor effects after eliciting oxidative stress in cancer cells. We aimed at exploiting this principle using a newly designed dual-jet neon plasma source (^Vjet) to treat colorectal cancer cells. A treatment time-dependent ROS/RNS generation induced oxidation, growth retardation, and cell death within 3D tumor spheroids were found. In TUM-CAM, a semi in vivo model, the ^Vjet markedly reduced vascularized tumors' growth, but an increase of tumor cell immunogenicity or uptake by dendritic cells was not observed. By comparison, the argon-driven single jet kINPen, known to mediate anticancer effects in vitro, in vivo, and in patients, generated less ROS/RNS and terminal cell death in spheroids. In the TUM-CAM model, however, the kINPen was equivalently effective and induced a stronger expression of immunogenic cancer cell death (ICD) markers, leading to increased phagocytosis of kINPen but not ^Vjet plasma-treated tumor cells by dendritic cells. Moreover, the ^Vjet was characterized according to the requirements of the DIN-SPEC 91315. Our results highlight the plasma device-specific action on cancer cells for evaluating optimal discharges for plasma cancer treatment.

Concept for Improved Handling Ensures Effective Contactless Plasma Treatment of Patients with kINPen® MED

The nursing of patients with wounds is an essential part of medical healthcare. In this context, cold atmospheric-pressure plasma sources can be applied for skin decontamination and stimulation of wound healing. One of these plasma devices is the commercially available kINPen® MED (neoplas tools GmbH), a cold atmospheric-pressure plasma jet which is approved as a medical device, class-IIa. For the plasma treatment, a sterile disposable spacer is recommended to ensure a constant and effective distance between plasma and skin. The disadvantage of this spacer is its form and size which means that the effective axis/area is not visible for the attending doctor or qualified personnel and consequently it is a more or less intuitive treatment. In addition, the suggested perpendicular treatment is not applicable for the attending specialist due to lack of space or patient/wound positioning. A concept of a sensory unit was developed to measure the treatment distance and to visualize the effective treatment area for different angles. To determine the effective area for the plasma treatment, some exemplary methods were performed. Thus, the antimicrobial (Staphylococcus aureus DSM799/ATCC6538) efficacy, reactive oxygen species (ROS) distribution and (vacuum) ultraviolet ((V)UV) irradiation were determined depending on the treatment angle. Finally, a simplified first approach to visualize the effective treatment area at an optimal distance was designed and constructed to train attending specialists for optimal wound area coverage.

Long-Term Risk Assessment for Medical Application of Cold Atmospheric Pressure Plasma

Despite increasing knowledge gained based on multidisciplinary research, plasma medicine still raises various questions regarding specific effects as well as potential risks. With regard to significant statements about in vivo applicability that cannot be prognosticated exclusively based on in vitro data, there is still a deficit of clinical data. This study included a clinical follow-up of five probands who had participated five years previously in a study on the influence of cold atmospheric pressure plasma (CAP) on the wound healing of CO2 laser-induced skin lesions. The follow-up included a complex imaging diagnostic involving dermatoscopy, confocal laser scanning microscopy (CLSM) and hyperspectral imaging (HSI). Hyperspectral analysis showed no relevant microcirculatory differences between plasma-treated and non-plasma-treated areas. In summary of all the findings, no malignant changes, inflammatory reactions or pathological changes in cell architecture could be detected in the plasma-treated areas. These unique in vivo long-term data contribute to a further increase in knowledge about important safety aspects in regenerative plasma medicine. However, to confirm these findings and secure indication-specific dose recommendations, further clinical studies are required.

Long-term Risk Assessment for Medical Application of Cold Atmospheric Pressure Plasma

Despite increasing knowledge gained based on multidisciplinary research, plasma medicine still raises various questions regarding specific effects as well as potential risks. With regard to significant statements about in vivo applicability that cannot be prognosticated exclusively based on in vitro data, there is still a deficit of clinical data. This study included a clinical follow-up of five probands who had participated five years previously in a study on the influence of cold atmospheric pressure plasma (CAP) on the wound healing of CO₂ laser-induced skin lesions. The follow-up included a complex imaging diagnostic involving dermatoscopy, confocal laser scanning microscopy (CLSM) and hyperspectral imaging (HSI). Hyperspectral analysis showed no relevant microcirculatory differences between plasma-treated and non-plasma-treated areas. In summary of all the findings, no malignant changes, inflammatory reactions or pathological changes in cell architecture could be detected in the plasma-treated areas. These unique in vivo long-term data contribute to a further increase in knowledge about important safety aspects in regenerative plasma medicine. However, to confirm these findings and secure indication-specific dose recommendations, further clinical studies are required.

The Role of Thermal Effects in Plasma Medical Applications: Biological and Calorimetric Analysis

Plasma Medicine tools exploit the therapeutic effects of the exposure of living matter to plasma produced at atmospheric pressure. Since these plasmas are usually characterized by a non-thermal equilibrium (highly energetic electrons, low temperature ions), thermal effects on the substrate are usually considered negligible. Conversely, reactive oxygen and nitrogen species (RONS), UV radiation and metastables are thought to play a major role. In this contribution, we compare the presence of thermal effects in different operational regimes (corresponding to different power levels) of the Plasma Coagulation Controller (PCC), a plasma source specifically designed for accelerating blood coagulation. In particular, we analyze the application of PCC on human blood samples (in vitro) and male Wistar rats tissues (in vivo). Histological analysis points out, for the highest applied power regime, the onset of detrimental thermal effects such as red cell lysis in blood samples and tissues damages in in-vivo experiments. Calorimetric bench tests performed on metallic targets show that the current coupled by the plasma on the substrate induces most of measured thermal loads through a resistive coupling. Furthermore, the distance between the PCC nozzle and the target is found to strongly affect the total power.

Plasma Medicine: Applications of Cold Atmospheric Pressure Plasma in Dermatology

The ability to produce cold plasma at atmospheric pressure conditions was the basis for the rapid growth of plasma-related application areas in biomedicine. Plasma comprises a multitude of active components such as charged particles, electric current, UV radiation, and reactive gas species which can act synergistically. Anti-itch, antimicrobial, anti-inflammatory, tissue-stimulating, blood flow-enhancing, and proapoptotic effects were demonstrated in in vivo and in vitro experiments, and until now, no resistance of pathogens against plasma treatment was observed. The combination of the different active agents and their broad range of positive effects on various diseases, especially easily accessible skin diseases, renders plasma quite attractive for applications in medicine. For medical applications, two different types of cold plasma appear suitable: indirect (plasma jet) and direct (dielectric barrier discharge-DBD) plasma sources. The DBD device PlasmaDerm® VU-2010 (CINOGY Technologies GmbH), the atmospheric pressure plasma jet (APPJ) kINPen® MED (INP Greifswald/neoplas tools GmbH), and the SteriPlas (Adtec Ltd., London, United Kingdom) are CE-certified as a medical product to treat chronic wounds in humans and showed efficacy and a good tolerability. Recently, the use of plasma in cancer research and oncology is of particular interest. Plasma has been shown to induce proapoptotic effects more efficiently in tumor cells compared with the benign counterparts, leads to cellular senescence, and-as shown in vivo-reduces skin tumors. To this end, a world-wide first Leibniz professorship for plasmabiotechnology in dermatology has been introduced to establish a scientific network for the investigation of the efficacy and safety of cold atmospheric plasma in dermatooncology. Hence, plasma medicine especially in dermatology holds great promise.

Chemistry and biochemistry of cold physical plasma derived reactive species in liquids

Reactive oxygen and nitrogen species deposited by cold physical plasma are proposed as predominant effectors in the interaction between discharge and biomedical application. Most reactive species found in plasma sources are known in biology for inter- and intracellular communication (redox signaling) and mammalian cells are equipped to interpret the plasma derived redox signal. As such, considerable effort has been put into the investigation of potential clinical applications and the underlying mechanism, with a special emphasis on conditions orchestrated significantly via redox signaling. Among these, immune system control in wound healing and cancer control stands out with promising in vitro and in vivo effects. From the fundamental point of view, further insight in the interaction of the plasma-derived species with biological systems is desired to (a) optimize treatment conditions, (b) identify new fields of application, (c) to improve plasma source design, and (d) to identify the trajectories of reactive species. Knowledge on the biochemical reactivity of non-thermal plasmas is compiled and discussed. While there is considerable knowledge on proteins, lipids and carbohydrates have not received the attention deserved. Nucleic acids have been profoundly investigated yet focusing on molecule functionality rather than chemistry. The data collected underline the efforts taken to understand the fundamentals of plasma medicine but also indicate 'no man's lands' waiting to be discovered.

Biological and medical applications of plasma-activated media, water and solutions

Non-thermal atmospheric pressure plasma has been proposed as a new tool for various biological and medical applications. Plasma in close proximity to cell culture media or water creates reactive oxygen and nitrogen species containing solutions known as plasma-activated media (PAM) or plasma-activated water (PAW) - the latter even displays acidification. These plasma-treated solutions remain stable for several days with respect to the storage temperature. Recently, PAM and PAW have been widely studied for many biomedical applications. Here, we reviewed promising reports demonstrating plasma-liquid interaction chemistry and the application of PAM or PAW as an anti-cancer, anti-metastatic, antimicrobial, regenerative medicine for blood coagulation and even as a dental treatment agent. We also discuss the role of PAM on cancer initiation cells (spheroids or cancer stem cells), on the epithelial mesenchymal transition (EMT), and when used for metastasis inhibition considering its anticancer effects. The roles of PAW in controlling plant disease, seed decontamination, seed germination and plant growth are also considered in this review. Finally, we emphasize the future prospects of PAM, PAW or plasma-activated solutions in biomedical applications with a discussion of the mechanisms and the stability and safety issues in relation to humans.

Safety implications of plasma-induced effects in living cells - a review of in vitro and in vivo findings

Cold atmospheric plasma is a versatile new tool in the biomedical field with applications ranging from disinfection, wound healing and tissue regeneration to blood coagulation, and cancer treatment. Along with improved insights into the underlying physical, chemical and biological principles, plasma medicine has also made important advances in the introduction into the clinic. However, in the absence of a standard plasma 'dose' definition, the diversity of the field poses certain difficulties in terms of comparability of plasma devices, treatment parameters and resulting biological effects, particularly with regards to the question of what constitutes a safe plasma application. Data from various in vitro cytotoxic and genotoxic studies along with in vivo findings from animal and human trials are reviewed to provide an overview of the current state of knowledge on the safety of plasma for biological applications. Treatment parameters employed in clinical studies were well tolerated but intense treatment conditions can also induce tissue damage or genotoxicity. There is a need identified to establish both guidelines and safety limits that ensure an absence of (long-term) side effects and to define treatments as safe for applications, where cell stimulation is desired, e.g. in wound healing, or those aimed at inducing cell death in the treatment of cancer.

Investigation of Power Transmission of a Helium Plasma Jet to Different Dielectric Targets Considering Operating Modes

The interaction of an atmospheric pressure plasma jet with different dielectric surfaces is investigated using a setup of two ring electrodes around a ceramic capillary. In this study, in addition to electrical measurement methods such as the determination of voltage and current, special emphasis was placed on the power measurements at the electrodes and the effluent. The power dissipation is correlated with Fourier-transform infrared (FTIR) absorption spectroscopy measurements of O3 and NO2 densities. The results show the correlation between the dielectric constant and the dissipated power at the target. The ratio between power dissipation at the grounded ring electrode and the grounded surface shows an increase with increasing dielectric constant of the target. A correlation of the results with bacteria, tissue and water as envisaged dielectric targets shows four times the power dissipation at the treatment spot between bacteria and tissue.

Dose-Dependent Tissue-Level Characterization of a Medical Atmospheric Pressure Argon Plasma Jet

Nonthermal treatment with cold atmospheric plasma (CAP) is a promising option for local treatment of chronic-inflammatory and precancerous lesions as well as various mucosal cancer diseases, besides its primary indication for wound healing and antiseptics. Atmospheric pressure plasma jets (APPJs) are versatile plasma sources, some of which are well-characterized and medically approved. The characterization of APPJs, however, is often based on the treatment of simple solutions or even studies on the plasma effluent itself. To better assess the in vivo effects of CAP treatment, this study aims to recapitulate and study the physicochemical tissue-level effects of APPJ treatment on human primary mucosal tissue and tissue models. High resolution on-tissue infrared (IR) thermography and a first-time-performed spatially resolved optical emission spectroscopy (OES) of the APPJ emissions did not identify potentially tissue-harming effects. In this study, electron-spin-resonance (ESR) spectroscopy on human tissue samples, treated with different CAP doses, enabled the measurement and the distribution of CAP-derived radicals in the tissues. The results correlate plasma dosage and the generation of radical species with cell viability and cell proliferation of primary human fibroblasts while demonstrating apoptosis-independent antiproliferative cell effects. Moreover, a dose-dependent increase of cells in the G1 phase of the cell cycle was observed, stressing the likely important role of cell cycle regulation for antiproliferative CAP mechanisms. This study introduces suitable methods for CAP monitoring on tissues and contributes to a better understanding of tissue-derived plasma effects of APPJs.

Redox for Repair: Cold Physical Plasmas and Nrf2 Signaling Promoting Wound Healing

Chronic wounds and ulcers are major public health threats. Being a substantial burden for patients and health care systems alike, better understanding of wound pathophysiology and new avenues in the therapy of chronic wounds are urgently needed. Cold physical plasmas are particularly effective in promoting wound closure, irrespective of its etiology. These partially ionized gases deliver a therapeutic cocktail of reactive oxygen and nitrogen species safely at body temperature and without genotoxic side effects. This field of plasma medicine reanimates the idea of redox repair in physiological healing. This review compiles previous findings of plasma effects in wound healing. It discusses new links between plasma treatment of cells and tissues, and the perception and intracellular translation of plasma-derived reactive species via redox signaling pathways. Specifically, (i) molecular switches governing redox-mediated tissue response; (ii) the activation of the nuclear E2-related factor (Nrf2) signaling, together with antioxidative and immunomodulatory responses; and (iii) the stabilization of the scaffolding function and actin network in dermal fibroblasts are emphasized in the light of wound healing.

Chemical fingerprints of cold physical plasmas - an experimental and computational study using cysteine as tracer compound

Reactive oxygen and nitrogen species released by cold physical plasma are being proposed as effectors in various clinical conditions connected to inflammatory processes. As these plasmas can be tailored in a wide range, models to compare and control their biochemical footprint are desired to infer on the molecular mechanisms underlying the observed effects and to enable the discrimination between different plasma sources. Here, an improved model to trace short-lived reactive species is presented. Using FTIR, high-resolution mass spectrometry, and molecular dynamics computational simulation, covalent modifications of cysteine treated with different plasmas were deciphered and the respective product pattern used to generate a fingerprint of each plasma source. Such, our experimental model allows a fast and reliable grading of the chemical potential of plasmas used for medical purposes. Major reaction products were identified to be cysteine sulfonic acid, cystine, and cysteine fragments. Less-abundant products, such as oxidized cystine derivatives or S-nitrosylated cysteines, were unique to different plasma sources or operating conditions. The data collected point at hydroxyl radicals, atomic O, and singlet oxygen as major contributing species that enable an impact on cellular thiol groups when applying cold plasma in vitro or in vivo.

Transport and accumulation of plasma generated species in aqueous solution

The interaction between cold atmospheric pressure plasma and liquids is receiving increasing attention for various applications. In particular, the use of plasma-treated liquids (PTL) for biomedical applications is of growing importance, in particular for sterilization and cancer treatment. However, insight into the underlying mechanisms of plasma-liquid interactions is still scarce. Here, we present a 2D fluid dynamics model for the interaction between a plasma jet and liquid water. Our results indicate that the formed reactive species originate from either the gas phase (with further solvation) or are formed at the liquid interface. A clear increase in the aqueous density of H₂O₂, HNO₂/NO₂^- and NO₃^- is observed as a function of time, while the densities of O₃, HO₂/O₂^- and ONOOH/ONOO^- are found to quickly reach a maximum due to chemical reactions in solution. The trends observed in our model correlate well with experimental observations from the literature.

Effects of plasma jet, dielectric barrier discharge, photodynamic therapy and sodium hypochlorite on infected curved root canals

The aim of this investigation was to evaluate the effects of 2 different cold atmospheric plasma (CAP) sources, photodynamic therapy and sodium hypochlorite (NaOCl), on infected root canals. Therefore, 50 standardized curved human root canals were infected with Enterococcus faecalis and assigned to 5 groups-negative control (NC), plasma jet (CAP I), dielectric barrier discharge (CAP II), photodynamic therapy (PDT) and NaOCl + passive ultrasonic irrigation-for 30 s. Colony forming units (CFUs) were determined. NaOCl was significantly more effective at reducing CFUs than all test groups (P < .0001 [Mann-Whitney U test]) in both parts of the root canal. CFUs in PDT were significantly lower than those in CAP II (P = .015), and those in CAP I were lower than those in CAP II (P = .05). Among all other groups and in the apical parts, no significant differences were found (P > .05).

Medical applications of nonthermal atmospheric pressure plasma in dermatology

Plasma is an ionized gas that consists of positively and negatively charged particles, neutral atoms, and photons. Recent developments in plasma sources have made it possible to generate room-temperature plasma in the "open air", thus enabling the application of plasma in vivo. Using nonthermal plasma, active agents can be efficiently delivered to target cells without creating thermal damage. Also known as cold atmospheric pressure plasma (CAP), nonthermal atmospheric pressure plasma offers innovative medical applications. In this context, it has also gained wide attention in the field of dermatology. The complex and variable mixture of active agents in plasma - predominantly reactive oxygen and nitrogen species (ROS, RNS) - can control or trigger complex biochemical reactions, achieving the desired effects in a dose-dependent manner. The objective of the present review is to present potential applications of plasma in dermatology and analyze its potential mechanisms of action.

Anti-cancer capacity of plasma-treated PBS: effect of chemical composition on cancer cell cytotoxicity

We evaluate the anti-cancer capacity of plasma-treated PBS (pPBS), by measuring the concentrations of NO₂⁻ and H₂O₂ in pPBS, treated with a plasma jet, for different values of gas flow rate, gap and plasma treatment time, as well as the effect of pPBS on cancer cell cytotoxicity, for three different glioblastoma cancer cell lines, at exactly the same plasma treatment conditions. Our experiments reveal that pPBS is cytotoxic for all conditions investigated. A small variation in gap between plasma jet and liquid surface (10 mm vs 15 mm) significantly affects the chemical composition of pPBS and its anti-cancer capacity, attributed to the occurrence of discharges onto the liquid. By correlating the effect of gap, gas flow rate and plasma treatment time on the chemical composition and anti-cancer capacity of pPBS, we may conclude that H₂O₂ is a more important species for the anti-cancer capacity of pPBS than NO₂⁻. We also used a 0D model, developed for plasma-liquid interactions, to elucidate the most important mechanisms for the generation of H₂O₂ and NO₂⁻. Finally, we found that pPBS might be more suitable for practical applications in a clinical setting than (commonly used) plasma-activated media (PAM), because of its higher stability.