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Flis Z, Szatkowski P, Pielichowska K, Molik E. The Potential of Sheep or Camel Milk Constituents to Contribute to Novel Dressings for Diabetic Wounds. Int J Mol Sci 2023; 24:17551. [PMID: 38139380 PMCID: PMC10744295 DOI: 10.3390/ijms242417551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023] Open
Abstract
Impaired wound healing is a complication of diabetes, which constitutes a serious problem in clinical practice. Currently, there is a high demand on the market for local treatment options for difficult-to-heal wounds caused by diabetes. The development of dressings that accelerate wound healing has recently been the subject of much research. Sheep and camel milk is gaining importance due to the content of many bioactive substances with health-promoting effects, such as insulin, LF, proline, or CLA. Sheep and camel milk proteins are a promising source of insulin, antidiabetic, and antihypertensive peptides. Numerous studies show that local administration of insulin has a significant impact on the healing of diabetic wounds. Sheep and camel milk, due to the highest LF content among ruminants, reduces autoimmune inflammatory processes and protects against bacterial and viral infections in the wound environment. Sheep's milk has the highest content of proline and CLA, and their addition to a hydrogel dressing can help in the development of an effective dressing material. The production of hydrogel dressings containing sheep and camel milk, which are naturally rich in the bioactive substances presented in this review, may be a promising step in the market of specialized dressings for difficult-to-heal diabetic wounds.
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Affiliation(s)
- Zuzanna Flis
- Department of Animal Nutrition and Biotechnology, and Fisheries, Faculty of Animal Science, University of Agriculture in Krakow, Al. Mickiewicza 24/28, 31-059 Krakow, Poland
| | - Piotr Szatkowski
- Department of Biomaterials and Composites, Faculty of Materials Science and Ceramics, University of Science and Technology in Krakow, Al. Mickiewicza 30, 30-059 Krakow, Poland (K.P.)
| | - Kinga Pielichowska
- Department of Biomaterials and Composites, Faculty of Materials Science and Ceramics, University of Science and Technology in Krakow, Al. Mickiewicza 30, 30-059 Krakow, Poland (K.P.)
| | - Edyta Molik
- Department of Animal Nutrition and Biotechnology, and Fisheries, Faculty of Animal Science, University of Agriculture in Krakow, Al. Mickiewicza 24/28, 31-059 Krakow, Poland
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Leon-Villapalos J, Barret JP. Surgical Repair of the Acute Burn Wound: Who, When, What Techniques? What Is the Future? J Burn Care Res 2023; 44:S5-S12. [PMID: 36567475 DOI: 10.1093/jbcr/irac145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Modern burns surgery is multidisciplinary, multimodal and includes a dermal preservation approach. The management of the surgical wound starts in the pre-hospital environment with stabilization and assessment of the burn injured patient according to protocols of trauma resuscitation with special emphasis in the assessment of the burn depth and surface area. A large burn requires fluid resuscitation and physiological support, including counterbalancing hyper metabolism, fighting infection and starting a long burns intensive care journey. A deep burn may impose the need for surgical debridement and cover through a staged approach of excision of devitalized tissue depending on its extension and patient circumstances. These methodologies warrant patients survivability and require professionals integrated in a multidisciplinary team sharing decisions and directing management. Burns Multimodality involves multiple techniques used according to patient's needs, wound environment, operators experience and available resources. Traditional practices used together with new techniques may reduce morbidity and operative time but also challenge stablished practice. The concept of using the best teams with the best techniques combines with the need for selective and judicious surgery that preserves tissue architecture and spares as much as possible dermal component, therefore reducing the possibility of functional impairment and cosmetic embarrassment caused by pathological scars. Who is best placed to perform these tasks, the appropriate or best timing of surgery and the different practices used to achieve best results will be discussed, together with a reflection on what the future holds for these fundamental steps in the management of the burn injured patient turning into a functional burn survivor.
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Affiliation(s)
- Jorge Leon-Villapalos
- Consultant Plastic, Reconstructive, Laser and Burns Surgeon, Plastic Surgery and Burns Department, Chelsea and Westminster Hospital, London, UK.,BAPRAS Burns Special Interest and Advisory Group, London, UK.,Senior Honorary Clinical Lecturer, Imperial College School of Medicine, London, UK
| | - Juan P Barret
- Department of Plastic Surgery and Burns, Vall d'Hebron Barcelona Hospital Campus, Universidad Autònoma de Barcelona, Barcelona, Spain
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3
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Günter CI, Ilg FP, Hapfelmeier A, Egert-Schwender S, Jelkmann W, Giri S, Bader A, Machens HG. Relation Between Gender and Concomitant Medications With Erythropoietin-Treatment on Wound Healing in Burn Patients. Post Hoc Subgroup-Analysis of the Randomized, Placebo-Controlled Clinical Trial “EPO in Burns”. Front Pharmacol 2022; 13:812888. [PMID: 35847006 PMCID: PMC9284535 DOI: 10.3389/fphar.2022.812888] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/25/2022] [Indexed: 11/21/2022] Open
Abstract
Burns are leading causes of mortality and morbidity, including prolonged hospitalization, disfigurement, and disability. Erythropoietin (EPO) is a well-known hormone causing erythropoiesis. However, EPO may play a role in healing acute and chronic wounds due to its anti-inflammatory and pro-regenerative effects. Therefore, the large, prospective, placebo-controlled, randomized, double-blind, multi-center clinical trial “EPO in Burns” was initiated to investigate the effects of EPO versus placebo treatment in severely burned patients. The primary endpoint of “EPO in Burns” was defined as the time elapsed until complete re-epithelialization of a defined split skin graft donor site. Additional analyses of post hoc defined subgroups were performed in view of the primary endpoint. The verum (n 45) and control (n 39) groups were compared with regard to the time it took for study wounds (a predefined split skin graft donor site) to reach the three stages of wound healing (re-epithelialization levels). In addition, the effects of gender (females n 18) and concomitant medications insulin (n 36), non-steroidal anti-inflammatory drugs (NSAIDs) (n 41), and vasopressor agents (n 43) were tested. Life tables were used to compare study groups (EPO vs. placebo) within subgroups. The Cox regression model was applied to evaluate interactions between the study drug (EPO) and concomitant medications for each re-epithelialization level. Using our post hoc defined subgroups, we observed a lower chance of wound healing for women compared to men (in terms of hazard ratio: hr100%: 5.984 [95%-CI: (0.805–44.490), p = 0.080]) in our study population, regardless of the study medication. In addition, results indicated an earlier onset of re-epithelialization in the first days of EPO treatment (EPO: 10% vs. Placebo: 3%). Moreover, the interpretation of the hazard ratio suggested EPO might have a positive, synergistic effect on early stages of re-epithelialization when combined with insulin [hr50%: 1.307 (p = 0.568); hr75%: 1,199 (p = 0.715)], as well as a stabilizing effect on critically ill patients [reduced need for vasopressors in the EPO group (EPO: 44% vs. Placebo 59%)]. However, additional high-quality data from clinical trials designed to address these endpoints are required to gain further insight into these effects.
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Affiliation(s)
- Christina Irene Günter
- Clinic for Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
- *Correspondence: Christina Irene Günter,
| | - Felicitas Paula Ilg
- Clinic for Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Silvia Egert-Schwender
- Müncher Studienzentrum, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | | | - Shibashish Giri
- Institute for Cell Techniques and Applied Stem Cell Biology, University of Leipzig, Leipzig, Germany
| | - Augustinus Bader
- Institute for Cell Techniques and Applied Stem Cell Biology, University of Leipzig, Leipzig, Germany
| | - Hans-Günter Machens
- Clinic for Plastic and Hand Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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Nanocarrier-Mediated Topical Insulin Delivery for Wound Healing. MATERIALS 2021; 14:ma14154257. [PMID: 34361451 PMCID: PMC8348788 DOI: 10.3390/ma14154257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/23/2021] [Accepted: 07/25/2021] [Indexed: 12/12/2022]
Abstract
Wound care has been clinically demanding due to inefficacious treatment that represents an economic burden for healthcare systems. In Europe, approximately 7 million people are diagnosed with untreated wounds, leading to a cost between 6.000€ and 10.000€ per patient/year. In the United States of America, 1.5 million people over 65 years old suffer from chronic wounds. A promising therapeutic strategy is the use of exogenous growth factors because they are decreased at the wound site, limiting the recovery of the skin. Insulin is one of the cheapest growth factors in the market able to accelerate the re-epithelialization and stimulate angiogenesis and cell migration. However, the effectiveness of topical insulin in wound healing is hampered by the proteases in the wound bed. The encapsulation into nanoparticles improves its stability in the wound, providing adhesion to the mucosal surface and allowing its sustained release. The aim of this review is to perform a standing point about a promising strategy to treat different types of wounds by the topical delivery of insulin-loaded nanocarriers.
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Abianeh SH, Bajestani SM, Rahmati J, Shahrbaf MA, Shirzad N. The effect of local insulin injection on the healing process of split thickness skin graft donor site: a randomized, double-blind, placebo control clinical trial. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01683-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gus EI, Shahrokhi S, Jeschke MG. Anabolic and anticatabolic agents used in burn care: What is known and what is yet to be learned. Burns 2019; 46:19-32. [PMID: 31852612 DOI: 10.1016/j.burns.2018.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/17/2018] [Accepted: 03/18/2018] [Indexed: 12/15/2022]
Abstract
Major thermal injury induces profound metabolic derangements secondary to an inflammatory "stress-induced" hormonal environment. Several pharmacological interventions have been tested in an effort to halt the hypermetabolic response to severe burns. Insulin, insulin growth factor 1, insulin growth factor binding protein 3, metformin, human growth hormone, thyroid hormones, testosterone, oxandrolone, and propranolol, among others, have been proposed to have anabolic or anticatabolic effects. The aim of this broad analysis of pharmacological interventions was to raise awareness of treatment options and to help establishing directions for future clinical research efforts. A PubMed search was conducted on the anabolic and anticatabolic agents used in burn care. One hundred and thirty-five human studies published between 1999 and 2017 were included in this review. The pharmacological properties, rationale for the treatments, efficacy considerations and side effect profiles are summarized in the article. Many of the drugs tested for investigational purposes in the severely thermally injured are not yet gold-standard therapies in spite of their potential benefit. Propranolol and oxandrolone have shown great promise but further evidence is still needed to clarify their potential use for anabolic and anticatabolic purposes.
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Affiliation(s)
- Eduardo I Gus
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, D704, Toronto, ON M4N 3M5, Canada
| | - Shahriar Shahrokhi
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, D704, Toronto, ON M4N 3M5, Canada; Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Marc G Jeschke
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, D704, Toronto, ON M4N 3M5, Canada; Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Department of Immunology, University of Toronto, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada.
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7
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Campbell JM, Adanichkin N, Kurmis R, Munn Z. Intensive insulin therapy, insulin sensitisers and insulin secretagogues for burns: A systematic review of effectiveness and safety. Burns 2018; 44:1377-1394. [DOI: 10.1016/j.burns.2017.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/25/2017] [Accepted: 09/19/2017] [Indexed: 11/29/2022]
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Herndon D, Capek KD, Ross E, Jay JW, Prasai A, Ayadi AE, Foncerrada-Ortega G, Blears E, Sommerhalder C, McMullen K, Amtmann D, Cox R, Hundeshagen G, Jennings K, Sousse LE, Suman OE, Meyer WJ, Finnerty CC. Reduced Postburn Hypertrophic Scarring and Improved Physical Recovery With Yearlong Administration of Oxandrolone and Propranolol. Ann Surg 2018; 268:431-441. [PMID: 30048322 PMCID: PMC6478032 DOI: 10.1097/sla.0000000000002926] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Massive burns induce a hypermetabolic response that leads to total body wasting and impaired physical and psychosocial recovery. The administration of propranolol or oxandrolone positively affects postburn metabolism and growth. The combined administration of oxandrolone and propranolol (OxProp) for 1 year restores growth in children with large burns. Here, we investigated whether the combined administration of OxProp for 1 year would reduce scarring and improve quality of life compared with control. STUDY DESIGN Children with large burns (n = 480) were enrolled into this institutional review board-approved study; patients were randomized to control (n = 226) or administration of OxProp (n = 126) for 1 year postburn. Assessments were conducted at discharge and 6, 12, and 24 months postburn. Scar biopsies were obtained for histology. Physical scar assessments and patient reported outcome measures of physical and psychosocial function were obtained. RESULTS Reductions in cellularity, vascular structures, inflammation, and abnormal collagen (P < 0.05) occurred in OxProp-treated scars. With OxProp, scar severity was attenuated and pliability increased (both P < 0.05). Analyses of patient-reported outcomes showed improved general and emotional health within the OxProp-treated group (P < 0.05). CONCLUSIONS Here, we have shown improvements in objective and subjective measures of scarring and an increase in overall patient-reported physical function. The combined administration of OxProp for up to a year after burn injury should be considered for the reduction of postburn scarring and improvement of long-term psychosocial outcomes in children with massive burns.
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Affiliation(s)
- David Herndon
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Institute for Translational Sciences, The University of Texas Medical Branch, Galveston, TX
| | - Karel D Capek
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Evan Ross
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Jayson W Jay
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Institute for Translational Sciences, The University of Texas Medical Branch, Galveston, TX
| | - Anesh Prasai
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Amina El Ayadi
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Guillermo Foncerrada-Ortega
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Elizabeth Blears
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Institute for Translational Sciences, The University of Texas Medical Branch, Galveston, TX
| | - Christian Sommerhalder
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Kara McMullen
- Department of Rehabilitation Medicine, The University of Washington, Seattle, WA
| | - Dagmar Amtmann
- Department of Rehabilitation Medicine, The University of Washington, Seattle, WA
| | - Robert Cox
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Department of Pathology, The University of Texas Medical Branch, Galveston, TX
| | - Gabriel Hundeshagen
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Kristofer Jennings
- Department of Preventative Medicine and Community Health, The University of Texas Medical Branch, Galveston, TX
| | - Linda E Sousse
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Oscar E Suman
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Walter J Meyer
- Department of Psychiatry and Behavioral Science, The University of Texas Medical Branch, Galveston, TX
| | - Celeste C Finnerty
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Institute for Translational Sciences, The University of Texas Medical Branch, Galveston, TX
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Abstract
The widespread and rapidly increasing trend of binge drinking is accompanied by a concomitant rise in the prevalence of trauma patients under the influence of alcohol at the time of their injury. Epidemiological evidence suggests up to half of all adult burn patients are intoxicated at the time of admission, and the presence of alcohol is an independent risk factor for death in the early stages post burn. As the major site of alcohol metabolism and toxicity, the liver is a critical determinant of postburn outcome, and experimental evidence implies an injury threshold exists beyond which burn-induced hepatic derangement is observed. Alcohol may lower this threshold for postburn hepatic damage through a variety of mechanisms including modulation of extrahepatic events, alteration of the gut-liver axis, and changes in signaling pathways. The direct and indirect effects of alcohol may prime the liver for the second-hit of many overlapping physiologic responses to burn injury. In an effort to gain a deeper understanding of how alcohol potentiates postburn hepatic damage, the authors summarize possible mechanisms by which alcohol modulates the postburn hepatic response.
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The P50 Research Center in Perioperative Sciences: How the investment by the National Institute of General Medical Sciences in team science has reduced postburn mortality. J Trauma Acute Care Surg 2017; 83:532-542. [PMID: 28697015 DOI: 10.1097/ta.0000000000001644] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Since the inception of the P50 Research Center in Injury and Peri-operative Sciences (RCIPS) funding mechanism, the National Institute of General Medical Sciences has supported a team approach to science. Many advances in critical care, particularly burns, have been driven by RCIPS teams. In fact, burns that were fatal in the early 1970s, prior to the inception of the P50 RCIPS program, are now routinely survived as a result of the P50-funded research. The advances in clinical care that led to the reduction in postburn death were made by optimizing resuscitation, incorporating early excision and grafting, bolstering acute care including support for inhalation injury, modulating the hypermetabolic response, augmenting the immune response, incorporating aerobic exercise, and developing antiscarring strategies. The work of the Burn RCIPS programs advanced our understanding of the pathophysiologic response to burn injury. As a result, the effects of a large burn on all organ systems have been studied, leading to the discovery of persistent dysfunction, elucidation of the underlying molecular mechanisms, and identification of potential therapeutic targets. Survival and subsequent patient satisfaction with quality of life have increased. In this review article, we describe the contributions of the Galveston P50 RCIPS that have changed postburn care and have considerably reduced postburn mortality.
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Oryan A, Alemzadeh E. Effects of insulin on wound healing: A review of animal and human evidences. Life Sci 2017; 174:59-67. [PMID: 28263805 DOI: 10.1016/j.lfs.2017.02.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 02/02/2017] [Accepted: 02/28/2017] [Indexed: 12/11/2022]
Abstract
AIMS Several studies have indicated that insulin that is used in reducing blood glucose is also affective on wound healing by various mechanisms. To understand the outcomes of insulin therapy on wound healing, a meta-analysis and systematic review was performed. MAIN METHODS The Cochrane library, PubMed, and Science Direct were searched for the literature published from January the 1st 1990 to September the 30th 2016. Twelve animals and nine clinical studies were included. A quantitative and qualitative review was performed on the clinical trials and the animal studies were comprehensively overviewed. Statistical analysis for development of granulation tissue, microvessel density, and time of healing was conducted in this systematic review. KEY FINDINGS The animal studies revealed that treatment with topical insulin lead to faster wound contraction and re-epithelialization. Meta-analysis of wound studies revealed that insulin therapy is significantly favored for growth of granulation tissue. Based on these findings, insulin enhanced development of granulation tissue on day 7 after treatment. The meta-analysis studies indicated significant reduction in time of healing in the patients treated with insulin. These studies also disclosed that the new vessels were observable from five days after injection in the treated group, compared to the control animals that developed significantly at later stage. SIGNIFICANCE Insulin is a low cost growth factor and can be considered as a therapeutic agent in wound healing. However, further studies are necessary to gain a better understanding of the role of insulin in wound healing.
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Affiliation(s)
- Ahmad Oryan
- Department of Pathology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran.
| | - Esmat Alemzadeh
- Department of Biotechnology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
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12
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Hrynyk M, Neufeld RJ. Insulin and wound healing. Burns 2014; 40:1433-46. [PMID: 24810536 DOI: 10.1016/j.burns.2014.03.020] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 02/27/2014] [Accepted: 03/28/2014] [Indexed: 12/11/2022]
Abstract
Skin is a dynamic and complex organ that relies on the interaction of different cell types, biomacromolecules and signaling molecules. Injury triggers a cascade of events designed to quickly restore skin integrity. Depending on the size and severity of the wound, extensive physiological and metabolic changes can occur, resulting in impaired wound healing and increased morbidity resulting in higher rates of death. While wound dressings provide a temporary barrier, they are inherently incapable of significantly restoring metabolic upsets, post-burn insulin resistance, and impaired wound healing in patients with extensive burns. Exogenous insulin application has therefore been investigated as a potential therapeutic intervention for nearly a century to improve wound recovery. This review will highlight the important achievements that demonstrate insulin's ability to stimulate cellular migration and burn wound recovery, as well as providing a perspective on future therapeutic applications and research directions.
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Affiliation(s)
- Michael Hrynyk
- Department of Chemical Engineering, Queen's University, Kingston, Ontario, Canada K7L 3N6
| | - Ronald J Neufeld
- Department of Chemical Engineering, Queen's University, Kingston, Ontario, Canada K7L 3N6.
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13
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Finnerty CC, Mabvuure NT, Ali A, Kozar RA, Herndon DN. The surgically induced stress response. JPEN J Parenter Enteral Nutr 2014; 37:21S-9S. [PMID: 24009246 DOI: 10.1177/0148607113496117] [Citation(s) in RCA: 210] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The stress response to surgery, critical illness, trauma, and burns encompasses derangements of metabolic and physiological processes that induce perturbations in the inflammatory, acute phase, hormonal, and genomic responses. Hypermetabolism and hypercatabolism result, leading to muscle wasting, impaired immune function and wound healing, organ failure, and death. The surgery-induced stress response is largely similar to that triggered by traumatic injuries; the duration of the stress response, however, varies according to the severity of injury (surgical or traumatic). This spectrum of injuries and insults ranges from small lacerations to severe insults such as large poly-traumatic and burn injuries. Burn injuries provide an extreme model of trauma induced stress responses that can be used to study the long-term effects of a prolonged stress response. Although the stress response to acute trauma evolved to confer improved chances of survival following injury, in modern surgical practice the stress response can be detrimental.
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Affiliation(s)
- Celeste C Finnerty
- Department of Surgery, Shriners Hospitals for Children-Galveston and the University of Texas Medical Branch, Galveston, Texas
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14
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Xiu F, Stanojcic M, Diao L, Jeschke MG. Stress hyperglycemia, insulin treatment, and innate immune cells. Int J Endocrinol 2014; 2014:486403. [PMID: 24899891 PMCID: PMC4034653 DOI: 10.1155/2014/486403] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/06/2014] [Accepted: 04/08/2014] [Indexed: 01/04/2023] Open
Abstract
Hyperglycemia (HG) and insulin resistance are the hallmarks of a profoundly altered metabolism in critical illness resulting from the release of cortisol, catecholamines, and cytokines, as well as glucagon and growth hormone. Recent studies have proposed a fundamental role of the immune system towards the development of insulin resistance in traumatic patients. A comprehensive review of published literatures on the effects of hyperglycemia and insulin on innate immunity in critical illness was conducted. This review explored the interaction between the innate immune system and trauma-induced hypermetabolism, while providing greater insight into unraveling the relationship between innate immune cells and hyperglycemia. Critical illness substantially disturbs glucose metabolism resulting in a state of hyperglycemia. Alterations in glucose and insulin regulation affect the immune function of cellular components comprising the innate immunity system. Innate immune system dysfunction via hyperglycemia is associated with a higher morbidity and mortality in critical illness. Along with others, we hypothesize that reduction in morbidity and mortality observed in patients receiving insulin treatment is partially due to its effect on the attenuation of the immune response. However, there still remains substantial controversy regarding moderate versus intensive insulin treatment. Future studies need to determine the integrated effects of HG and insulin on the regulation of innate immunity in order to provide more effective insulin treatment regimen for these patients.
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Affiliation(s)
- Fangming Xiu
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room D704, Toronto, ON, Canada
| | - Mile Stanojcic
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room D704, Toronto, ON, Canada
- Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada M4N 3M5
| | - Li Diao
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room D704, Toronto, ON, Canada
- Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada M4N 3M5
| | - Marc G. Jeschke
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room D704, Toronto, ON, Canada
- Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada M4N 3M5
- Department of Surgery, Division of Plastic Surgery, Department of Immunology, University of Toronto, Toronto, ON, Canada
- *Marc G. Jeschke:
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15
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D'Asta F, Cianferotti L, Bhandari S, Sprini D, Rini GB, Brandi ML. The endocrine response to severe burn trauma. Expert Rev Endocrinol Metab 2014; 9:45-59. [PMID: 30743738 DOI: 10.1586/17446651.2014.868773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The endocrine system is frequently altered after a major burn trauma. Besides the endocrine response to stress characterized by hypercortisolism, several hypothalamus-hypophysis-target gland axes are rapidly perturbed within a few days. These alterations can persist in the long term and deserve an appropriate treatment. Disturbances in water clearance and glucidic metabolism are also common and need to be diagnosed and corrected to decrease morbidity in such patients. Bone and mineral metabolism is deeply compromised and requires correction of mineral abnormalities in order to improve symptoms and prevent bone loss. No large prospective and/or intervention trials are available to date to elaborate age-related, evidence-based recommendations to monitor and treat burn-related endocrine alterations.
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Affiliation(s)
- Federica D'Asta
- a Department of Neuroscience, Psychology, Drug, Research and Child Health, University of Florence, Viale Pieraccini 24, 50139 Florence, Italy
| | - Luisella Cianferotti
- b Department of Surgery and Translational Medicine, Unit of Bone and Mineral Metabolism, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy
| | - Sahil Bhandari
- c Manchester Medical School, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Delia Sprini
- d Department of Internal Medicine, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Giovam Battista Rini
- d Department of Internal Medicine, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Maria Luisa Brandi
- b Department of Surgery and Translational Medicine, Unit of Bone and Mineral Metabolism, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy
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Review of burn research for the year 2011. J Burn Care Res 2013; 34:211-8. [PMID: 23370995 DOI: 10.1097/bcr.0b013e3182839b34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The year 2011 was another robust year for burn research. Over 1100 articles were published on a wide range of burn injury and treatment topics. In this review, we highlight some of the interesting and potentially influential research in the following areas: critical care, infection, inhalation injury, epidemiology, wound characterization and treatment, nutrition and metabolism, pain management, burn reconstruction, psychology, and rehabilitation. As in years past, burn injury research reflects the multidisciplinary and holistic care that is needed to treat this challenging injury condition.
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Jeschke MG. Clinical review: Glucose control in severely burned patients - current best practice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:232. [PMID: 23890278 PMCID: PMC4056030 DOI: 10.1186/cc12678] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Tight glucose control changed the way many burn centers practice burn ICU care. However, after the initial impressive data, various clinical trials followed that showed mixed results. The objective of the present review is to discuss recent studies in the area of burn and critical care, and to identify the current best practice for current burn care providers. We reviewed relevant publications from PubMed and selected high-impact publications on tight glycemic control in various patient populations with a focus on burn patients. We conclude that in burns there seems to be a signal that insulin administration to a target range of 130 to 150 mg/dl is beneficial in terms of morbidity and mortality without the risk of hypoglycemia.
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Shi Z, Ma L, Wang H, Yang Y, Li X, Schreiber A, Sun W, Hu Z, Xue Y, Teng J, Zhao X, Lu W. Insulin and hypertonic glucose in the management of aseptic fat liquefaction of post-surgical incision: a meta-analysis and systematic review. Int Wound J 2013; 10:91-7. [PMID: 22325039 PMCID: PMC7950496 DOI: 10.1111/j.1742-481x.2012.00949.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
A meta-analysis and systematic review assessing randomised controlled trials (RCTs) was sought to determine whether subcutaneous injection of insulin with hypertonic glucose promotes healing in postoperative incisions with aseptic fat liquefaction. We searched the Cochrane library, Pubmed, EMBASE, National Science Digital Library (NSDL) and China Biological Medicine Database (CBMdisc) for literature published from 1 January 1990 to 30 September 2011. RCTs that evaluated subcutaneous injection of insulin with hypertonic glucose as a treatment for postoperative wound with fat liquefaction were sought. Wound healing was the primary endpoint. Jadad score and Cochrane Collaboration's tool were used for assessing quality of studies and risk of bias. We abstracted data regarding time to wound healing, cost and adverse effects. The random-effects inverse variance model was used for all analyses using weighted mean difference and 95% confidence interval. Eight trials (414 participants) were identified that met the inclusion criteria. Subcutaneous injection of insulin with hypertonic glucose significantly reduces time to healing by 6·33 days compared with conventional drainage, with less cost. There was no report concerning adverse effects. Subcutaneous injection of insulin with hypertonic glucose may improve the healing process in postoperative wounds with aseptic fat liquefaction.
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Affiliation(s)
- Zhongjie Shi
- Department of Cancer Biology, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Berlanga-Acosta J, Schultz GS, López-Mola E, Guillen-Nieto G, García-Siverio M, Herrera-Martínez L. Glucose toxic effects on granulation tissue productive cells: the diabetics' impaired healing. BIOMED RESEARCH INTERNATIONAL 2012; 2013:256043. [PMID: 23484099 PMCID: PMC3591209 DOI: 10.1155/2013/256043] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 11/24/2012] [Indexed: 12/15/2022]
Abstract
Type 2 diabetes mellitus is a metabolic noncommunicable disease with an expanding pandemic magnitude. Diabetes predisposes to lower extremities ulceration and impairs the healing process leading to wound chronification. Diabetes also dismantles innate immunity favoring wound infection. Amputation is therefore acknowledged as one of the disease's complications. Hyperglycemia is the proximal detonator of systemic and local toxic effectors including proinflammation, acute-phase proteins elevation, and spillover of reactive oxygen and nitrogen species. Insulin axis deficiency weakens wounds' anabolism and predisposes to inflammation. The systemic accumulation of advanced glycation end-products irreversibly impairs the entire physiology from cells-to-organs. These factors in concert hamper fibroblasts and endothelial cells proliferation, migration, homing, secretion, and organization of a productive granulation tissue. Diabetic wound bed may turn chronically inflammed, procatabolic, and an additional source of circulating pro-inflammatory cytokines, establishing a self-perpetuating loop. Diabetic fibroblasts and endothelial cells may bear mitochondrial damages becoming prone to apoptosis, which impairs granulation tissue cellularity and perfusion. Endothelial progenitor cells recruitment and tubulogenesis are also impaired. Failure of wound reepithelialization remains a clinical challenge while it appears to be biologically multifactorial. Ulcer prevention by primary care surveillance, education, and attention programs is of outmost importance to reduce worldwide amputation figures.
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Affiliation(s)
- Jorge Berlanga-Acosta
- Tissue Repair and Cytoprotection Research Group, Center for Genetic Engineering and Biotechnology, Playa, CP 10600 Havana, Cuba.
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Rojas Y, Finnerty CC, Radhakrishnan RS, Herndon DN. Burns: an update on current pharmacotherapy. Expert Opin Pharmacother 2012; 13:2485-94. [PMID: 23121414 DOI: 10.1517/14656566.2012.738195] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The worldwide occurrence of burn injuries remains high despite efforts to reduce injury incidence through public awareness campaigns and improvements in living conditions. In 2004, almost 11 million people experienced burns severe enough to warrant medical treatment. Advances over the past several decades in aggressive resuscitation, nutrition, excision and grafting have reduced morbidity and mortality. Incorporation of pharmacotherapeutics into treatment regimens may further reduce complications of severe burn injuries. AREAS COVERED Severe burn injuries, as well as other forms of stress and trauma, trigger a hypermetabolic response that, if left untreated, impedes recovery. In the past two decades, use of anabolic agents, β-adrenergic receptor antagonists and anti-hyperglycemic agents has successfully counteracted post-burn morbidities including catabolism, the catecholamine-mediated response and insulin resistance. Here, the authors review the most up-to-date information on currently used pharmacotherapies in the treatment of these sequelae of severe burns and the insights that have expanded the understanding of the pathophysiology of severe burns. EXPERT OPINION Existing drugs offer promising advances in the care of burn injuries. Continued gains in the understanding of the molecular mechanisms driving the hypermetabolic response will enable the application of additional existing drugs to be broadened to further attenuate the hypermetabolic response.
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Affiliation(s)
- Yesenia Rojas
- Shriners Hospitals for Children, Galveston, TX 77550, USA
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Abstract
For 2011, approximately 1746 original research articles in burns were published in English in scientific journals. This article reviews those with the most potential impact on for burn therapeutics and outcomes according to the Editor of one of the major journals (Burns) and his colleague. As done previously, articles were found and divided into these topic areas: epidemiology of injury and burn prevention, wound and scar characterisation, acute care and critical care, inhalation injury, infection, psychological considerations, pain and itching management, rehabilitation and long-term outcomes, and burn reconstruction. Each selected article is mentioned briefly with editorial comment.
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Affiliation(s)
- Steven E Wolf
- Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas - Southwestern Medical Center, United States.
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Cancio LC, Lundy JB, Sheridan RL. Evolving changes in the management of burns and environmental injuries. Surg Clin North Am 2012; 92:959-86, ix. [PMID: 22850157 DOI: 10.1016/j.suc.2012.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Burns and environmental injuries are common as primary or secondary problems in survivors of natural disasters, terrorist incidents, and combat operations. In recent years, intensive military medical experience has resulted in substantial progress in treatment of these important problems. This article reviews practical applications of this new knowledge.
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Affiliation(s)
- Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX 78234-6315, USA
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