Inflammatory mediators in wound healing

Frail but Resilient: Frailty in Autologous Breast Reconstruction is Associated with Worse Surgical Outcomes but Equivalent Long-Term Patient-Reported Outcomes

BACKGROUND

Frailty is associated with higher risk of complications following breast reconstruction, but its impact on long-term surgical and patient-reported outcomes has not been investigated. We examined the association of the five-item modified frailty index (MFI) score with long-term surgical and patient-reported outcomes in autologous breast reconstruction.

PATIENTS AND METHODS

We conducted a retrospective cohort study of consecutive patients who underwent mastectomy and autologous breast reconstruction between January 2016 and April 2022. Primary outcome was any flap-related complication. Secondary outcomes were patient-reported outcomes and predictors of complications in the frail cohort.

RESULTS

We identified 1640 reconstructions (mean follow-up 24.2 ± 19.2 months). In patients with MFI ≥ 2, the odds of surgical [odds ratio (OR) 2.13, p = 0.023] and medical (OR 17.02, p < 0.001) complications were higher than in nonfrail patients. We found no significant difference in satisfaction with the breast (p = 0.287), psychosocial well-being (p = 0.119), or sexual well-being (p = 0.314) according to MFI score. Chronic obstructive pulmonary disease was an independent predictor of infection (OR 3.70, p = 0.002). Tobacco use (OR 7.13, p = 0.002) and contralateral prophylactic mastectomy (OR 2.36, p = 0.014) were independent predictors of wound dehiscence. Dependent functional status (OR 2.36, p = 0.007) and immediate reconstruction (compared with delayed reconstruction; OR 3.16, p = 0.026) were independent predictors of skin flap necrosis. Dependent functional status was also independently associated with higher odds of reoperation (OR 2.64, p = 0.011).

CONCLUSION

Frailty is associated with higher risk of complications in breast reconstruction, but there is no significant difference in long-term patient-reported outcomes. MFI should be considered in breast reconstruction to improve outcomes in high-risk frail patients.

Matrisomal components involved in regenerative wound healing in axolotl and Acomys: implications for biomaterial development

Achieving regeneration in humans has been a long-standing goal of many researchers. Whereas amphibians like the axolotl (Ambystoma mexicanum) are capable of regenerating whole organs and even limbs, most mammals heal their wounds via fibrotic scarring. Recently, the African spiny mouse (Acomys sp.) has been shown to be injury resistant and capable of regenerating several tissue types. A major focal point of research with Acomys has been the identification of drivers of regeneration. In this search, the matrisome components related to the extracellular matrix (ECM) are often overlooked. In this review, we compare Acomys and axolotl skin wound healing and blastema-mediated regeneration by examining their wound healing responses and comparing the expression pattern of matrisome genes, including glycosaminoglycan (GAG) related genes. The goal of this review is to identify matrisome genes that are upregulated during regeneration and could be potential candidates for inclusion in pro-regenerative biomaterials. Research papers describing transcriptomic or proteomic coverage of either skin regeneration or blastema formation in Acomys and axolotl were selected. Matrisome and GAG related genes were extracted from each dataset and the resulting lists of genes were compared. In our analysis, we found several genes that were consistently upregulated, suggesting possible involvement in regenerative processes. Most of the components have been implicated in regulation of cell behavior, extracellular matrix remodeling and wound healing. Incorporation of such pro-regenerative factors into biomaterials may help to shift pro-fibrotic processes to regenerative responses in treated wounds.

Pulmonary Fibrosis: Unveiling the Pathogenesis, Exploring Therapeutic Targets, and Advancements in Drug Delivery Strategies

Idiopathic pulmonary fibrosis (IPF) is an ailment with no cure and a very high rate of progression that ultimately leads to death. The exact reason for this disease is still not acknowledged. Many underlying mechanisms of wound healing and various types of stimuli that trigger the pathogenesis of IPF continue to be intensively explored. The exact therapy for the reversal of this disease is not yet known and is constantly in progress. Existing treatments only slow down the process or mitigate the symptoms to enhance the patient's healthcare system. The only two Food and Drug Administration-approved oral medications include pirfenidone and nintedanib whose high dose and systemic circulation can have side effects to a greater extent. Further research on restorative and extra-curative therapies for IPF is necessary due to the absence of viable therapeutic choices. To assure minimum off-targeted site delivery and longer duration of action, techniques that offer a sustainable release of the drug, better bioavailability, and patient compliance can be used.The work is an overview of the main therapeutic targets and pertinent developing therapies for the management of IPF. This study is an attempt to focus on various drug delivery systems that are responsible for showing effectiveness in defense mechanisms against IPF.

Ethanol Sclerotherapy for Postoperative Seroma of the Breast and Axilla

OBJECTIVE

Evaluate the effectiveness of alcohol sclerotherapy in postoperative breast and axillary seromas.

METHODS

This was an IRB-approved retrospective review of consecutive patients from 2017 to 2021. The procedure involves aspiration of seroma fluid, injection of ethanol for 15 to 30 minutes, and then aspiration of the injected ethanol. Following review of the medical record, patient and procedure data were recorded. Success was defined as no recurrence of seroma. Statistical analysis was performed using a chi-square or t-test, as appropriate.

RESULTS

Twenty seromas were treated in 19 patients (mean age, 63 years; range, 49-79) following mastectomy (9/20, 45%), lumpectomy (25%, 5/20), axillary nodal dissection (5/20, 25%), or chest wall surgery (1/20, 5%). The mean seroma volume was 146 ± 165 mL. There was a mean of 1.4 prior aspiration attempts (range, 0-3). Mean injected ethanol volume was 39 mL (range, 8-60 mL) for a mean of 26 ± 5 minutes. Seromas recurred in 85% (17/20) of cases, and repeat aspiration was performed in 35% (6/17). The mean recurrence time was 34 ± 29 days. The recurrent seromas were 31% smaller (mean, 80 ± 48 mL). Only a smaller pre-ablation seroma was associated with successful ablation (P < 0.01), as the mean pre-ablation volume was 36 ± 24 mL for successful ablations and 119 ± 56 mL for unsuccessful ablations. There were no post-procedural complications.

CONCLUSION

Single-treatment ethanol sclerotherapy is typically unsuccessful in ablating breast and axillary seromas. Only a smaller pre-ablation seroma size was associated with successful ablation.

An Updated Review of Hypertrophic Scarring

Hypertrophic scarring (HTS) is an aberrant form of wound healing that is associated with excessive deposition of extracellular matrix and connective tissue at the site of injury. In this review article, we provide an overview of normal (acute) wound healing phases (hemostasis, inflammation, proliferation, and remodeling). We next discuss the dysregulated and/or impaired mechanisms in wound healing phases that are associated with HTS development. We next discuss the animal models of HTS and their limitations, and review the current and emerging treatments of HTS.

Wound healing properties of a new formulated flavonoid-rich fraction from Dodonaea viscosa Jacq. leaves extract

Background: Dodonaea viscosa Jacq. (D. viscosa) belongs to the family of Sapindaceae, commonly known as "Sinatha," and is used as a traditional medicine for treating wounds due to its high flavonoids content. However, to date there is no experimental evidence on its flavonoid-rich fraction of D. viscosa formulation as an agent for healing wounds. Objective: The present study aimed to evaluate the wound healing effect of ethyl acetate fraction of D. viscosa leaves on dermal wounds. Methods: The ethyl acetate fraction was produced from a water-ethanol extract of D. viscosa leaves and was quantitatively evaluated using the HPLC technique. The in-vivo wound healing ability of the ethyl acetate fraction of D. viscosa ointment (DVFO, 2.5%w/w and 5%w/w) was investigated in Sprague-Dawley rats utilizing an incision and excision paradigm with povidone-iodine ointment (5% w/w) as a control. The percentage of wound closure, hydroxyproline and hexosamine concentrations, tensile strength and epithelialization duration were measured. Subsequently, histopathology analysis of skin samples as well as western blots were performed for collagen type 3 (COL3A1), basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF). Results: The ethyl acetate fraction of D. viscosa revealed flavonoids with high concentrations of quercetin (6.46% w/w) and kaempferol (0.132% w/w). Compared to the control group, the DVFO (2.5% and 5.0% w/w) significantly accelerated wound healing in both models, as demonstrated by quicker wound contraction, epithelialization, elevated hydroxyproline levels and increased tensile strength. Histopathological investigations also revealed that DVFO treatment improved wound healing by re-epithelialization, collagen formation and vascularization of damaged skin samples. Western blot analysis further demonstrated an up-regulation of COL3A, vascular endothelial growth factor and bFGF protein in wound granulation tissue of the DVFO-treated group (p < 0.01). Conclusion: It is concluded that flavonoid-rich D. viscosa ethyl acetate fraction promotes wound healing by up-regulating the expressions of COL3A, VEGF and bFGF protein in wound granulation tissue. However, extensive clinical and pre-clinical research on the flavonoid-rich fraction of D. viscosa is needed to determine its significant impact in the healing of human wounds.

Enhanced healing efficacy of an optimized gabapentin-melittin nanoconjugate gel-loaded formulation in excised wounds of diabetic rats

The present study aimed to design and optimize, a nanoconjugate of gabapentin (GPN)-melittin (MLT) and to evaluate its healing activity in rat diabetic wounds. To explore the wound healing potency of GPN-MLT nanoconjugate, an in vivo study was carried out. Diabetic rats were subjected to excision wounds and received daily topical treatment with conventional formulations of GPN, MLT, GPN-MLT nanoconjugate and a marketed formula. The outcome of the in vivo study showed an expedited wound contraction in GPN-MLT-treated animals. This was confirmed histologically. The nanoconjugate formula exhibited antioxidant activities as evidenced by preventing malondialdehyde (MDA) accumulation and superoxide dismutase (SOD) and glutathione peroxidase (GPx) enzymatic exhaustion. Further, the nanoconjugate showed superior anti-inflammatory activity as it inhibited the expression of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α). This is in addition to enhancement of proliferation as indicated by increased expression of transforming growth factor-β (TGF- β), vascular endothelial growth factor-A (VEGF-A) and platelet-derived growth factor receptor-β (PDGFRB). Also, nanoconjugate enhanced hydroxyproline concentration and mRNA expression of collagen type 1 alpha 1 (Col 1A1). In conclusion, a GPN-MLT nanoconjugate was optimized with respect to particle size. Analysis of pharmacokinetic attributes showed the mean particle size of optimized nanoconjugate as 156.9 nm. The nanoconjugate exhibited potent wound healing activities in diabetic rats. This, at least partly, involve enhanced antioxidant, anti-inflammatory, proliferative and pro-collagen activities. This may help to develop novel formulae that could accelerate wound healing in diabetes.

Role of Iron Oxide (Fe2O3) Nanocomposites in Advanced Biomedical Applications: A State-of-the-Art Review

Nanomaterials have demonstrated a wide range of applications and recently, novel biomedical studies are devoted to improving the functionality and effectivity of traditional and unmodified systems, either drug carriers and common scaffolds for tissue engineering or advanced hydrogels for wound healing purposes. In this regard, metal oxide nanoparticles show great potential as versatile tools in biomedical science. In particular, iron oxide nanoparticles with different shape and sizes hold outstanding physiochemical characteristics, such as high specific area and porous structure that make them idoneous nanomaterials to be used in diverse aspects of medicine and biological systems. Moreover, due to the high thermal stability and mechanical strength of Fe₂O₃, they have been combined with several polymers and employed for various nano-treatments for specific human diseases. This review is focused on summarizing the applications of Fe₂O₃-based nanocomposites in the biomedical field, including nanocarriers for drug delivery, tissue engineering, and wound healing. Additionally, their structure, magnetic properties, biocompatibility, and toxicity will be discussed.

Novel application of microdissection tungsten needle in total thyroidectomy with central neck dissection for papillary thyroid carcinoma

Background

Energy-based devices (EBD) have been popularized in thyroidectomy worldwide. Microdissection tungsten needle (MDTN) is characterized by the ultra-sharp tip providing safe and meticulous dissection with effective hemostasis. However, little study has applied MDTN in thyroidectomy.

Methods

This retrospective study compared clinical data of the patients who underwent total thyroidectomy (TT) with central neck dissection (CND) using MDTN, harmonic scalpel (HS), and conventional electrocautery (CE). We assessed outcomes related to surgical efficacy and safety. The injury degree of tissue was assessed by biochemical indicators and early-stage inflammatory factors in the drainage fluid. Histological sections of the thyroid specimens were evaluated to compare levels of thermal damage by the three EBD.

Results

There was a significant decrease in the intraoperative blood loss, operation time and 24-hour drainage volume in the MDTN group compared to the CE group. The total drainage volume, duration of drainage, and average length of stay of the MDTN group were less compared to the CE group though they did not reach statistical significance. No disparity was observed between the MDTN group and HS group in these variables. Total costs were not significantly different among these groups. The incidence of recurrent laryngeal nerve (RLN) injury was the lowest using MDTN compared to the CE (P = 0.034) and HS (not significant). No statistical differences were observed among these groups regarding postoperative wound pain and infection, hypoparathyroidism, and postoperative hemorrhage. Analysis of biochemical indicators showed a lower level of hemoglobin in the MDTN and HS group than the CE group (P = 0.046 and 0.038, respectively) and less triglyceride in the HS group than the MDTN and CE group (P = 0.002 and 0.029, respectively) but no significant difference in cholesterol level in these groups. Early-stage inflammatory factors including TNF-α and IL-6 showed significantly higher concentration in the CE group than the MDTN and HS group. Histological sections of thyroid specimens revealed that MDTN caused the lowest degree of thermal damage followed by HS then CE.

Conclusion

MDTN exhibited comparable surgical efficacy and safety outcomes as HS in thyroidectomy. Therefore, MDTN is a safe and viable alternative for hemostasis in thyroidectomy.

Review of Early Signs of Breast Implant Infection

BACKGROUND

Breast implant infection remains a problem despite various prevention methods. Common pathogens such as staphylococcus aureus typically present acutely with fever, erythema, swelling, and pain. However, with the increasing occurrence of mycobacterial infections, associated early signs and symptoms are typically absent, making early detection difficult.

METHOD

A retrospective chart review of patients who underwent esthetic breast augmentation by senior surgeon FDP in an outpatient surgical facility from 1992 to 2021 was conducted. Cases of infections and related information including infection onset, presenting signs and symptoms, and culture results were recorded. Presentation differences between infections caused by common pathogens and mycobacteria were compared.

RESULTS

A total of nine infections were reported in 365 patients. Seven cases were due to common pathogens: staphylococcus aureus, pseudomonas aeruginosa, methicillin-resistant staphylococcus aureus (MRSA), and staphylococcus epidermidis. Fever, erythema was presented within an average of 10 days after surgery. Two cases were due to mycobacterium chelonae (non-tuberculous mycobacterium) infection. In the latter, the earliest signs and symptoms consisted of mild pain and swelling in the absence of fever and erythema, which began on average of 54 days after the operation.

CONCLUSION

Common breast implant infection pathogens usually present early with fever and erythema. However, our study found that non-tuberculous mycobacteria infections occur much later and fever and erythema are typically absent. The purpose of this study is to increase the awareness of clinicians with this rare but rapidly increasing variety of infections and to advise the operating surgeon to include mycobacteria infections in the differential diagnosis.

LEVEL OF EVIDENCE IV

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

Fetal surgery has no additional effect to general anesthesia on brain development in neonatal rabbits

BACKGROUND

Fetal surgery is part of modern fetal medicine, and some procedures, such as fetal spina bifida repair, are performed under general anesthesia. Fetuses are operated on in a time window when the developing brain is extremely vulnerable to external, potentially harmful factors. To date, little is known about the effect of fetal surgery on fetal brain development.

OBJECTIVE

This study aimed to assess the effect of fetal surgery on the developing fetal brain in the rabbit model.

STUDY DESIGN

This was a randomized, sham-controlled study in time-mated pregnant does at 28 days' gestation (term, 31 days), which corresponds to the start of the peak of brain development and end of the second trimester of pregnancy in humans. We included 4 different groups in this experiment: no-surgery, general anesthesia, general anesthesia+hysterotomy, and general anesthesia+fetal surgery. In 11 does, anesthesia was induced using propofol and maintained for 75 minutes with 3.6 vol% (4% is the equivalent of 1 minimum alveolar concentration) sevoflurane. Maternal blood pressure, heart rate, oxygen saturation, temperature, end-tidal CO2 were continuously monitored. For each operated doe, 6 fetuses were part of the experiment. Randomization determined which cornual sac and what opposing third sac were assigned to fetal surgery: hysterotomy, fetal injection (atropine, fentanyl, and cisatracurium), fetal skin incision, and suturing. Only hysterotomy was performed on the opposing cornual and third amniotic sacs of the does. The fetus in these experimental sacs was used as internal unmanipulated control (general anesthesia). All fetuses (n=38) from unmanipulated does (n=4) served as external controls (no-surgery). At term, the does were delivered by cesarean delivery under ketamine-medetomidine sedation and local anesthesia. The pups underwent standardized motoric and sensory neurologic testing on day 1 followed by euthanasia and brain harvesting for histologic assessment of neurons, synapses, proliferation, and glial cells.

RESULTS

Maternal vital signs were stable during surgery. Survival was similar in the 4 groups (75%-94%), and brain-to-body weight ratio was comparable; only the no-surgery pups had a higher brain weight. On postnatal day 1, the pups in the 4 groups had a comparable neurobehavioral outcome on both motoric and sensory testing. In the prefrontal cortex, no-surgery pups had significantly higher neuron density than pups who underwent maternal surgery, but there was no difference among pups that underwent general anesthesia, hysterotomy, or fetal surgery. The measurements of proliferation had a similar outcome: a higher proliferation rate in the prefrontal cortex of no-surgery pups. Moreover, synaptic density values were higher in the no-surgery pups, but there was no difference observed among pups who underwent general anesthesia, hysterotomy, and fetal surgery. Lastly, there was no difference in gliosis among the 4 groups.

CONCLUSION

In rabbits, fetal surgery through hysterotomy under maternal general anesthesia did not affect brain development, in addition to the effects of general anesthesia per se.

Cold Atmospheric Pressure Microplasma Pipette for Disinfection of Methicillin-Resistant Staphylococcus aureus

Microbial infections should be controlled and prevented for successful wound healing and tissue regeneration. Various disinfection methods exist that use antibiotics, ultraviolet (UV), heat, radiation, or chemical disinfectants; however, cold atmospheric pressure plasma has exhibited a unique and effective antibacterial ability that is not affected by antibiotic resistance or pain. This study develops a cold atmospheric pressure microplasma pipette (CAPMP) that outputs an Ar plasma plume through a tube with an inner radius of 180 μm for disinfection in a small area. The CAPMP was evaluated using Staphylococcus aureus and methicillin-resistant Staphylococcus aureus diluted in liquid media, spread on solid agar, or covered by dressing gauze. An increase in the treatment time of CAPMP resulted in a decrease in the number of colonies of the grown microorganism (colony forming unit) and an increase in the disinfected area for both bacteria. The disinfection ability of CAPMP was observed when the bacteria were covered with dressing gauze and was dependent on the number of gauze layers.

Keratinocyte Growth Factor-based Strategies for Wound Re-epithelialization

Wound re-epithelialization is a dynamic process that comprises the formation of new epithelium through an active signaling network between several growth factors and various cell types. The main players are keratinocytes that migrate from the wound edges onto the wound bed, to restore the epidermal barrier. One of the most important molecules involved in the re-epithelialization process is Keratinocyte Growth Factor (KGF), since it is central on promoting both migration and proliferation of keratinocytes. Stromal cells, like dermal fibroblasts, are the main producers of this factor, acting on keratinocytes through paracrine signaling. Multiple therapeutic strategies to delivery KGF have been proposed in order to boost wound healing by targeting re-epithelialization. This has been achieved through a range of different approaches, such as topical application, using controlled release-based methods with different biomaterials (hydrogels, nanoparticles and membranes) and also through gene therapy techniques. Among these strategies, KGF delivery via biomaterials and genetic-based strategies show great effectiveness in sustained KGF levels at the wound site, leading to efficient wound closure. Under this scope, this review aims at highlighting the importance of KGF as one of the key molecules on wound re-epithelialization, as well as to provide a critical overview of the different potential therapeutic strategies exploited so far.

Evaluation of Wound-Healing and Antioxidant Effects of Marantodes pumilum (Blume) Kuntze in an Excision Wound Model

Marantodes pumilum (MP) is a great source of herbal medicine used traditionally by both men and women for various purposes. MP may have potential wound-healing effects due to its diverse biological properties. An extensive study was conducted in a normal male rat model for determining the effects of MP var. pumila (MPvp) and var. alata (MPva) on the wound healing process. Here, 126 male Sprague-Dawley rats were divided randomly into seven groups as follows: sham-operated (SH), vehicle dressing (VD), flavine dressing (FD), MPvp leaves (PL), MPvp roots (PR), MPva leaves (AL), and MPva roots (AR). The parameters studied were the percentage of wound contraction, histomorphology study by hematoxylin and eosin (H&E), Masson–Goldner trichrome (MGT), and immunohistochemistry (IHC) staining. In addition, the levels of enzymatic antioxidants and malondialdehyde were also measured in the wound tissue homogenates. Wounds treated with extracts (PL, PR, AL, and AR) showed significantly faster healing (p < 0.05) compared to untreated and control groups (SH, VD, and FD). Histological analysis among MP-treated groups revealed better re-epithelialization, higher collagen deposition, enhanced fibronectin content and fibroblast cells, and higher fiber transformation from collagen-III to collagen-I, accompanied with a significant surge in enzymatic antioxidant activities and a decline in lipid peroxidation. MP has antioxidant effects that may enhance wound healing in the rat model.

Beneficial effects of cold atmospheric plasma on inflammatory phase of diabetic foot ulcers; a randomized clinical trial

Purpose

The healing process is impaired in diabetic wounds like the other types of chronic wounds. Cytokines, and growth factors are valuable candidates for determination of wound vitality or duration. The aim of this study is to introduce a beneficial method to stop the inflammatory phase and infection in the wound healing process for accelerating the treatment of diabetic foot ulcers.

Methods

As a randomized controlled trial, 44 patients with diabetic foot ulcers were selected and randomized. Twenty-two patients received standard care and rest of them received SC (standard care) + CAP (cold atmospheric plasma), n = 22). Clinical examination was performed to assess the status of peripheral nerves and arteries for all patients. Cold plasma jet was used as a source of helium gas plasma generator. Plasma was irradiated on the wound 5 min, 3 times a week for 3 consecutive weeks.

Results

Applying a plasma jet was effective in wound healing. The level of inflammatory cytokines was changed. Moreover, after applying plasma the mean expression of these variables was significantly decreased (P = 0.001). Following the plasma treatment, the level of cytokines such as IL-1 (39.44 ± 7.67), IL-8 (368.30 ± 82.43), INF-γ (17.03 ± 2.62), TNFα (22.75 ± 4.02) has decreased, inflammatory factors have ameliorated over three weeks, and accelerate wound healing. After CAP exposure, the mean of the mean fraction of bacterial load counts was significantly decreased.

Conclusion

The effect of plasma irradiation on infectious diabetic foot ulcer was decreased bacterial load then accelerated wound healing by effecting on inflammatory phase in diabetic foot ulcers.

Management of surgical wound dehiscence by oxygen-ozone therapy in a FIV-positive cat – a case report

Patients infected with the feline immunodeficiency virus (FIV) are frequently victims of postoperative wound dehiscence due to low efficiency of the immune system that predisposes to delayed scaring and epithelization processes. This case report aimed to describe the successful use of medical ozone in the treatment of a dehisced wound in a feline patient that presented this type of FIV-associated complication. Here we present a case of a 12-year-old, mixed-breed, male, FIV-positive cat with purulent arthritis affecting the shoulder, elbow, and the carpal joints with subsequent periostitis and arthrogryposis affecting the right forelimb. After a thorough investigation (clinical examination, X-rays) it was decided that limb amputation would be the proper choice. The surgical wound did not tend to heal, followed by rejection of the suture material, skin necrosis, and wound dehiscence. After 13 days following the surgery with allopathic treatment and no improvement, oxygen-ozone-therapy was started. Clinically, oxygen-ozone therapy showed significant results after the first session: borders of the wound got into the contraction phase, got attached to the underlying tissues, and exudates were significantly diminished. The therapy continued every 2 days showing improved blood perfusion of the affected area and a visible advancement of the contraction phase daily with complete healing in 1.5 months.

Autologously transplanted dermal fibroblasts improved diabetic wound in rat model

Healing of diabetic wounds are delayed due to late initiation and prolongation of the inflammatory phase, and inadequate growth factor synthesis, which may lead to chronic ulcers that may cause limb amputation, besides making the patients vulnerable to infections. In recent years, it has been extensively discussed whether different cell types transplanted to diabetic wound models accelerate wound healing. In this study, the effect of dermis-derived cells on Streptozotocin (STZ) induced experimental diabetic Sprague-Dawley rats were investigated. Animals were divided into 3 groups. First group was control, second group included diabetic animals with wounds. In the third group, firstly, skin specimens were obtained from animal's back, and then primary explant culture was performed. STZ induced experimental diabetes was applied to these animals and then wound was opened. The cells grown in primary culture were transplanted autologously. In all three groups, the samples taken from the wound areas on the 5th and 15th days of the wound were examined at the level of histochemical and immunohistochemical and electron microscopy. In the study, it was observed that the decreasing α-SMA and KGF (FGF-7) expression in the early period especially in the case of experimental diabetes increased as a result of cell transplantation, and in the sections belonging to the experimental diabetic group, a large number of inflammatory cells in the wound area were removed from the environment. In the cell transplanted group, the collagen fiber bundles as if in the control group. As a result, healthy cells of dermis can act as mesenchymal stem cells under certain conditions and have a positive effect on diabetic wound healing.

Effect of Hydrogen Sulfide on the Mitogen-Activated Protein Kinase Signaling Pathway in Cultured Skin Macrophages of Burned Rats

BACKGROUND

This study aims to investigate the effect of hydrogen sulfide on the mitogen-activated protein kinases signaling pathway in in vitro cultured skin macrophages of burned rats.

MATERIALS AND METHODS

Thirteen healthy Sprague-Dawley rats were divided into five groups: normal control group, burned control group, sodium hydrogen sulfide group, glibenclamide group, and sodium hydrogen sulfide + glibenclamide group. The burned rats were made into a deep II° 5% total body surface area flame burn injury model. The skin basement macrophages were separated from the skin of normal rats and the wound skin of burned rats and cultured. At 1, 6, and 12 h after intervention, extracellular signal-regulated kinase (ERK), c-Jun N-terminal kinase (JNK), and p38 protein levels were detected by Western blot, and ERK, p38, and JNK messenger RNA (mRNA) levels were detected by reverse transcription polymerase chain reaction.

RESULTS

Differences in ERK, p38, and JNK mRNA and protein levels between the normal control group and burned control group were statistically significant (P < 0.05). At the same time point, the ERK, p38, and JNK mRNA and protein levels in the NaSH group were different from those in other groups, and the differences were statistically significant (P < 0.05).

CONCLUSIONS

Hydrogen sulfide has a regulatory effect on ERK, JNK, and p38 in the mitogen-activated protein kinases signaling pathway in macrophages of burned rats.

EPR Spectroscopic Examination of Different Types of Paramagnetic Centers in the Blood in the Course of Burn Healing

The multicomponent electron paramagnetic resonance spectra of the blood during healing of skin burned wounds treated with a new generation biodegradable dressings containing poly(lactide-co-glycolide) were analysed. The evolution of different types of paramagnetic centers in the blood with time of healing was determined. The EPR spectra of the blood samples at 230 K temperature were measured at 1, 10, and 21 days after burning of the pig skin. The EPR lines of the following paramagnetic centers: the high-spin Fe³⁺ in methemoglobin (line I), high-spin Fe³⁺ in transferrin (line II), and Cu²⁺ in ceruloplasmin and free radicals (line III) were observed in the X-band (9.3 GHz) spectra of the blood. The multicomponent structure of the EPR spectra of the tested blood samples depended on the time of the healing of the burned wounds. The amount of the high-spin Fe³⁺ in methemoglobin (line I) in the blood decreased after 21 days of the healing of the burned wounds. The amount of the high-spin Fe³⁺ in transferrin (line II) slightly increased after 21 days of therapy with the basis. The amount of Cu²⁺ in ceruloplasmin and free radicals (line III) in the blood was very high after 10 days of therapy. At the first day of the healing of the burned wounds, the highest amount of the high-spin Fe³⁺ in methemoglobin (line I), the relatively lower amounts of the high-spin Fe³⁺ in transferrin (line II), and Cu²⁺ in ceruloplasmin and free radicals (line III) existed in the blood. In the medium phase (after 10 days) of the healing of the burned wounds, the extremely higher amounts of Cu²⁺ in ceruloplasmin and free radicals (line III) appeared in the blood. In the last phase (after 21 days), only the low differences between the amounts of the high-spin Fe³⁺ in methemoglobin (line I), the high-spin Fe³⁺ in transferrin (line II), and Cu²⁺ in ceruloplasmin and free radicals (line III) were observed. The present study may serve as a starting point for the development of a new technique for monitoring molecular complexes containing iron Fe³⁺ (methemoglobin, transferrin) or copper Cu²⁺ ions (ceruloplasmin) and free radicals in the blood during wound healing.

Endocrine-Metabolic Response in Patients Undergoing Multiple Body Contouring Surgeries After Massive Weight Loss

BACKGROUND

The endocrine-metabolic response to trauma is directly related to its magnitude, but little is known about the adverse effects of combined surgical procedures on morbidity.

OBJECTIVES

The authors sought to evaluate risk factors by measuring the endocrine-metabolic response in patients who underwent multiple body-contouring surgeries after massive weight loss.

METHODS

This prospective, randomized, interventional study included 46 massive weight loss patients who experienced a weight loss >30% of their body mass index (BMI) and were referred for body contouring surgery. Patients were randomly allocated to the control group (n = 10) or intervention group (n = 36), which in turn was divided into 3 subgroups (n = 12, each) according to BMI, surgical time, and scar length values. Blood samples were collected from all patients at different time points to assess biological stress markers.

RESULTS

Levels of IL-6 in patients in the higher ranges of BMI and operating time and with more extensive scar length were significantly higher in the immediate postoperative period compared with baseline. Concentrations of noradrenaline were significantly higher 24 hours after surgery compared with baseline only in patients in the higher range of operating time. A higher level of IL-6 at 72 hours after surgery compared with baseline was associated with more extensive scar length. Levels of other biological stress markers did not significantly differ.

CONCLUSIONS

The combination of surgical procedures did not significantly affect the concentrations of most biological stress markers. The variable of operating time most influenced increase in plasma concentrations of stress markers.

LEVEL OF EVIDENCE: 1

Immunohistochemical Expression of Cyclooxygenases in Hypertrophic Scars and Keloids

Background:

There are studies demonstrating an increased expression of cyclooxygenase (COX) in keloids and hypertrophic scars, suggesting that anti-inflammatory drugs could be used in their treatment. However, a precise relationship between COX and pathological scarring has not been established in the literature yet. This study aims to evaluate the immunohistochemical expression of COXs in these scars.

Methods:

Prospective study, including 54 patients (aged 18–60 years) undergoing scar excision: 18 normal scars (group 1), 18 hypertrophic scar (group 2), and 18 keloids (group 3). The group classification was performed by clinical criteria. Scars samples were collected and anatomopathological examination (through hematoxylin-eosin method) was performed to confirm the scar type. Immunohistochemistry was performed to assess the expression of COX1 and COX2 in epidermis and dermis. Results were compared among all groups and between group I versus II and III together (abnormal scars).

Results:

For COX1, in the epidermis, there was no significant difference in the immunohistochemical expression when comparing the 3 groups. In the dermis, groups 2 and 3 had greater expression than group 1, with a significant difference being found when comparing all groups (P = 0.014), and in the comparison between normal versus abnormal scars (P = 0.004). For COX2, there was no significant difference between the groups in both the epidermis and dermis.

Conclusions:

The immunohistochemical expression of COX1 was greater in the dermis of abnormal scars when compared with normal scars. Future studies can be performed involving COX blockade as a perspective of these scars treatment.

Analysis of TNF-α and interleukin-6 in seroma of patients undergoing mastectomy with or without flap fixation: is there a predictive value for seroma formation and its sequelae?

BACKGROUND

Seroma formation is a common complication after mastectomy. Flap fixation has the potential to prevent seroma formation, but identifying patients that are at risk of developing seroma, remains challenging. The aim of this study was to assess the association between pro-inflammatory cytokines in seroma fluid one day after surgery and seroma formation and it sequelae.

METHODS

Patients undergoing mastectomy were randomized into one of three groups: no flap fixation, flap fixation using sutures or flap fixation using tissue glue. Seroma samples from 40 consecutive patients undergoing mastectomy were collected on the first postoperative day for analysis of interleukin-6 and tumor necrosis factor-α. Seroma formation and its sequelae were assessed in the outpatient clinic ten days, six weeks and three months after surgery.

RESULTS

TNF-α concentrations were not detectable in the seroma samples of any of the 40 patients. BMI (p = 0.001) and weight of the resected surgical specimen (p = 0.003) were associated with higher IL-6 levels in seroma on the first postoperative day after mastectomy. A higher seroma concentration of IL-6 was associated with significantly fewer patients with clinical seroma formation three months after surgery (p = 0.027).

CONCLUSION

IL-6 is associated with clinical seroma formation three months after surgery. There is however no evident association between IL-6 and complications related to seroma formation. Higher IL-6 levels are predictive of less long-term seroma formation. Application of flap fixation does not seem to influence the level of IL-6.

Hypertrophic Scars: Are Vitamins and Inflammatory Biomarkers Related with the Pathophysiology of Wound Healing?

BACKGROUND

Hypertrophic scars are a consequence of wound healing.

OBJECTIVE

The objective of the present study is to evaluate vitamin D and inflammatory biomarker plasma levels during wound healing.

METHODS

A prospective study was performed in patients (n = 63) submitted to body contouring surgery. Blood samples were collected before (t ₀) and 5 days after surgery (t ₅). Blood cell count, protein inflammatory biomarkers, and circulating plasma levels of 25(OH)D, vitamin A and vitamin E were quantified. Six months after surgery, scars were evaluated and classified as normal or hypertrophic.

RESULTS

At the end of the study, 73% of the patients developed a normal scar (control group, n = 46) and 27% of the patients presented hypertrophic scars (HT group, n = 17). The patients in the HT group presented higher eosinophil (0.145 × 10⁹ /L vs. 0.104 × 10⁹ /L, p = 0.028) and basophil count (0.031 × 10⁹ /L vs. 0.22 × 10⁹ /L, p = 0.049) and C-reactive protein levels (6.12 mg/L vs. 2.30 mg/L, p = 0.015) in t ₀ than the patients in the control group. At t ₅, the patients in the HT group showed a decrease in neutrophil (3.144 × 10^9/L vs. 4.03 × 10⁹/L, p = 0.031) and an increase in basophil (0.024 × 10⁹/L vs. 0.015 × 10⁹/L, p = 0.005) and lymphocyte count (1.836 × 10⁹ /L vs. 1.557 × 10⁹/L; p = 0.028). Before surgery, vitamin D plasma levels were found to be decreased by almost 50% (23.52 ng/mL vs. 15.46 ng/mL, p = 0.031) in the patients who developed hypertrophic scars. Thirty-one percent of the patients submitted to bariatric surgery had more hypertrophic scars, versus 24% of the patients with no previous bariatric surgery.

CONCLUSION

There is a different systemic inflammatory profile response in the patients during the formation of hypertrophic scars. Vitamin D plasma levels are marked reduced in these patients. Considering the powerful anti-inflammatory effect of vitamin D, these findings could be related.

Phytochemical screening and anti-inflammatory properties of Algerian Hertia cheirifolia methanol extract

CONTEXT

Hertia cheirifolia L. (Asteraceae) is traditionally used in Northern Africa to treat various inflammatory infections. However, few studies on this plant have been reported.

OBJECTIVE

The anti-inflammatory activity of methanol extract of H. cheirifolia leaves was investigated using different experimental models.

MATERIALS AND METHODS

Phytochemical analysis was performed to determine phenolic compounds. Acute toxicity of the extract (2000 mg/kg) was examined in Swiss albino mice for 14 days, before croton oil-induced ear oedema in mice, carrageenan-induced paw oedema in Swiss albino rats, cotton pellet-induced granuloma in rats and carrageenan-induced air pouch in mice were conducted. The IL-1β and TNF-α release from concanavalin A-stimulated monocytes was measured by ELISA.

RESULTS

Methanol extract of H. cheirifolia is rich in polyphenols and flavonoids. Cinnamic acid and rutin represent the major constituents. Methanol extract up to 2000 mg/kg did not produce any toxic effects. Topical application of 2 mg/ear of the extract produced 78.7% of inhibition on ear swilling. Oral pre-treatment of rats with 200 and 400 mg/kg of the extract inhibited paw oedema by 70% and 89%, respectively. At 200 mg/kg, granuloma dry and wet weights were reduced by 41.85% and 61.72%, respectively. Moreover, the treatment with methanol extract at 1 mg/kg exerted 62.7% of inhibition on leucocytes migrated into the ear pouch. TNF-α and IL-1β release was reduced by 69% and 78%, respectively, with 1 μg/mL of the extract.

CONCLUSION

Methanol extract of H. cheirifolia possesses a strong anti-inflammatory activity and may be considered an interesting source of effective anti-inflammatory compounds.

Can Human Recombinant Epidermal Growth Factor Improve Ischemia and Induce Healing of Anastomosis in an Experimental Study in a Rabbit Model?

PURPOSE

Anastomotic leaks following intestinal operations may cause devastating effects on patients. Ischemia may also occur at the intestinal walls in the presence of strangulations. In this study, we examined the effects of human recombinant (Hr)-epidermal growth factor (EGF) given at a single intramural dose into the intestinal walls and daily intraperitoneal cavity on ischemia and the healing process of anastomosis.

MATERIALS AND METHODS

Sixteen male New Zeland white rabbits were randomly divided into four groups (n = 4 in each group). In Group 1, two different segments of ileum were identified and, then, transected and the free ends were sutured each other. In the other groups, ischemia was induced by ligating the mesenteric vascular arcade. After the ischemic induction, Group 2 received intramural injections of %0.9 saline, Group 3 received intramural injections of a single dose of EGF, and Group 4 received intramural and intraperitoneal injections of EGF. Bursting pressures and tissue hydroxyproline levels were analyzed. Necrosis, fibroblastic activity, collagen deposition and neovascularization were also studied.

RESULTS

The mean levels of bursting pressures in Group 4 (148.6 ± 25.3 mmHg) were higher than Group 2 (70 ± 21.5 mmHg) (p = 0.001). The mean level of bursting pressures was not statistically significant between Group 1 (170.1 ± 35 mmHg) and Group 4 (p = 0.073). Hydroxyproline levels in Group 2 were lower than Groups 3 and 4. There was a statistically significant difference in the mucosal ischemia, mucosal healing and degree of adhesion, but not in the mural anastomotic healing among the groups.

CONCLUSIONS

Intramural injection with daily intraperitoneal administration of low-dose EGF enhances the bursting pressure and collagen accumulation in ischemic anastomosis, improving many histological variables associated with ischemic intestinal anastomosis.

The effects of Arnebia euchroma ointment on second-degree burn wounds: a randomized clinical trial

ETHNOBOTANICAL RELEVANCE

Burn injuries can cause detrimental long-term consequences and call for immediate management. Avicenna's Canon of Medicine, describing the use of Abu-Khalsa (Arnebia euchroma) (AE) as being effective for burn healing. The purpose of this study was to evaluate the healing effects of AE ointment (AEO) on patients with a second-degree burn wound and compare its results with silver sulfadiazine cream (SSD).

MATERIALS AND METHODS

In this prospective, single-blind clinical trial, 45 patients with similar types of second-degree burns at two different sites of the body were randomly assigned to the two treatment groups. One burn wound site of the patient was treated with SSD and another similar burn wound site with AEO once a day until complete healing was achieved. Wound size and percentage of wound healing were evaluated at 15 days. Satisfaction, clinical adverse events such as pain, burning, warming, erythema, edema, infection, inflammation, and general wound area were assessed on a visual analogue scales, and 6-point scales.

RESULTS

The healing time was significantly shorter in the site treated with AEO than SSD (13.9±5.3 vs. 17.5±6.9 days, respectively). The severity of pain and burning were reduced in the AEO site compared with SSD site at the time of dressing change, while the warming score was significantly higher in the AEO wound area. Side-effects were lower in the site treated with AEO.

CONCLUSION

In this clinical study, we demonstrated that AEO has benefits over SSD in the treatment of second-degree burn wounds and wound healing and is a viable medication for the management of second-degree burns.

Pharmacotherapy of Diabetic Foot Ulcers

The incidence of diabetes and diabetic foot ulcers is increasing significantly in the United States. These ulcers and infections are the result of long-term complications of diabetes including neuropathy and vascular insufficiency. These infections can be classified into mild, limb threatening, and life threatening. This classification helps clarify the expected organisms involved and consequently appropriate, empiric antibiotic therapy. Mild infections are generally caused by Gram-positive organisms and can usually be treated as an outpatient with oral antibiotics. Antibiotics used for mild infections-include cephalexin, clindamycin, and amoxicillin/ clavulanate. Moderate to severe or limb-threatening infections are usually polymicrobial and frequently require hospitalization. These infections are typically treated with more broad-spectrum antibiotics including ampicillin/sulbactam, imipenem, or the combination of clindamycin and a fluoroquinolone. Severe or life-threatening infections also require broad-spectrum antibiotics. Other therapeutic options besides antibiotics include growth factors, such as becaplermin, and various skin substitutes.

Shikonin Promotes Skin Cell Proliferation and Inhibits Nuclear Factor-κB Translocation via Proteasome Inhibition In Vitro

BACKGROUND

Shikonin is a major active chemical component extracted from Lithospermi Radix, an effective traditional herb in various types of wound healing. Shikonin can accelerate granulomatous tissue formation by the rat cotton pellet method and induce neovascularization in granulomatous tissue. The purpose of the study was to investigate its mechanism of action in human skin cells.

METHODS

MTS assay was used to measure cell growth. The collagen type I (COL1 ) mRNA expression and procollagen type I C-peptide (PIP) production were detected by real-time quantitative reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay, respectively. Immunofluorescence and western blot analyses were carried out to investigate nuclear factor-κB (NF-κB) signaling pathway. Cell-based proteasome activity assay was used to determine proteasome activity.

RESULTS

In this study, we found that 10 μmol/L shikonin stimulated the growth of normal human keratinocytes and 1 μmol/L shikonin promoted growth of human dermal fibroblasts. However, shikonin did not directly induce COL1 mRNA expression and PIP production in dermal fibroblasts in vitro. In addition, 1 μmol/L shikonin inhibited translocation of NF-κB p65 from cytoplasm to nucleus induced by tumor necrosis factor-α stimulation in dermal fibroblasts. Furthermore, shikonin inhibited chymotrypsin-like activity of proteasome and was associated with accumulation of phosphorylated inhibitor κB-α in dermal fibroblasts.

CONCLUSIONS

These results suggested that shikonin may promote wound healing via its cell growth promoting activity and suppress skin inflammation via inhibitory activity on proteasome. Thus, shikonin may be a potential therapeutic reagent both in wound healing and inflammatory skin diseases.

Early Detection of Pressure Ulcer Development Following Traumatic Spinal Cord Injury Using Inflammatory Mediators

OBJECTIVE

To identify changes in concentrations of inflammatory mediators in plasma and urine after traumatic spinal cord injury (SCI) and before the occurrence of a first pressure ulcer.

DESIGN

Retrospective; secondary analysis of existing data.

SETTING

Acute hospitalization and inpatient rehabilitation sites at a university medical center.

PARTICIPANTS

Individuals with a pressure ulcer and plasma samples (n=17) and individuals with a pressure ulcer and urine samples (n=15) were matched by age and plasma/urine sample days to individuals with SCI and no pressure ulcer (N=35).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Plasma and urine samples were assayed in patients with SCI, capturing samples within 4 days after the SCI to a week before the formation of the first pressure ulcer. The Wilcoxon signed-rank test was performed to identify changes in the inflammatory mediators between the 2 time points.

RESULTS

An increase in concentration of the chemokine interferon-γ-induced protein of 10kd/CXCL10 in plasma (P<.01) and a decrease in concentration of the cytokine interferon-α in urine (P=.01) were observed before occurrence of a first pressure ulcer (∼4d) compared with matched controls.

CONCLUSIONS

Altered levels of inflammatory mediators in plasma and urine may be associated with pressure ulcer development after traumatic SCI. These inflammatory mediators should be explored as possible biomarkers for identifying individuals at risk for pressure ulcer formation.

Extracorporeal Shock Wave Therapy: An Emerging Treatment Modality for Retracting Scars of the Hands

Prolonged and abnormal scarring after trauma, burns and surgical procedures often results in a pathologic scar. We evaluated the efficacy of unfocused shock wave treatment, alone or in combination with manual therapy, on retracting scars on the hands. Scar appearance was assessed by means of the modified Vancouver Scar Scale; functional hand mobility was evaluated using a range-of-motion scale, whereas a visual analogue score was implemented for detecting any improvements in referred pain. Additionally, biopsy specimens were collected for clinico-pathologic correlation. For each active treatment group, statistically significant improvements in modified Vancouver Scar Scale were recorded as early as five treatment sessions and confirmed 2 wk after the last treatment session. Analogous results were observed when assessing pain and range of movement. Histopathological examination revealed significant increases in dermal fibroblasts in each active treatment group, as well as in neoangiogenetic response and type-I collagen concentration.

Modeling acute traumatic injury

Acute traumatic injury is a complex disease that has remained a leading cause of death, which affects all ages in our society. Direct mechanical insult to tissues may result in physiological and immunologic disturbances brought about by blood loss, coagulopathy, as well as ischemia and reperfusion insults. This inappropriate response leads to an abnormal release of endogenous mediators of inflammation that synergistically contribute to the incidence of morbidity and mortality. This aberrant activation and suppression of the immune system follows a bimodal pattern, wherein activation of the innate immune responses is followed by an anti-inflammatory response with suppression of the adaptive immunity, which can subsequently lead secondary insults and multiple organ dysfunction. Traumatic injury rodent and swine models have been used to describe many of the underlying pathologic mechanisms, which have led to an improved understanding of the morbidity and mortality associated with critically ill trauma patients. The enigmatic immunopathology of the human immunologic response after severe trauma, however, has never more been apparent and there grows a need for a clinically relevant animal model, which mimics this immune physiology to enhance the care of the most severely injured. This has necessitated preclinical studies in a more closely related model system, the nonhuman primate. In this review article, we summarize animal models of trauma that have provided insight into the clinical response and understanding of cellular mechanisms involved in the onset and progression of ischemia-reperfusion injury as well as describe future treatment options using immunomodulation-based strategies.

Fibromodulin-deficiency alters temporospatial expression patterns of transforming growth factor-β ligands and receptors during adult mouse skin wound healing

Fibromodulin (FMOD) is a small leucine-rich proteoglycan required for scarless fetal cutaneous wound repair. Interestingly, increased FMOD levels have been correlated with decreased transforming growth factor (TGF)-β1 expression in multiple fetal and adult rodent models. Our previous studies demonstrated that FMOD-deficiency in adult animals results in delayed wound closure and increased scar size accompanied by loose package collagen fiber networks with increased fibril diameter. In addition, we found that FMOD modulates in vitro expression and activities of TGF-β ligands in an isoform-specific manner. In this study, temporospatial expression profiles of TGF-β ligands and receptors in FMOD-null and wild-type (WT) mice were compared by immunohistochemical staining and quantitative reverse transcriptase-polymerase chain reaction using a full-thickness, primary intention wound closure model. During the inflammatory stage, elevated inflammatory infiltration accompanied by increased type I TGF-β receptor levels in individual inflammatory cells was observed in FMOD-null wounds. This increased inflammation was correlated with accelerated epithelial migration during the proliferative stage. On the other hand, significantly more robust expression of TGF-β3 and TGF-β receptors in FMOD-null wounds during the proliferative stage was associated with delayed dermal cell migration and proliferation, which led to postponed granulation tissue formation and wound closure and increased scar size. Compared with WT controls, expression of TGF-β ligands and receptors by FMOD-null dermal cells was markedly reduced during the remodeling stage, which may have contributed to the declined collagen synthesis capability and unordinary collagen architecture. Taken together, this study demonstrates that a single missing gene, FMOD, leads to conspicuous alternations in TGF-β ligand and receptor expression at all stages of wound repair in various cell types. Therefore, FMOD critically coordinates temporospatial distribution of TGF-β ligands and receptors in vivo, suggesting that FMOD modulates TGF-β bioactivity in a complex way beyond simple physical binding to promote proper wound healing.

Effect of β-glucan on drain fluid and amount of drainage following modified radical mastectomy

INTRODUCTION

To reduce the seroma formation following mastectomy and axillary dissection, many different techniques and drugs have been investigated. The aim of this study is to evaluate the effects of oral β-glucan on drain fluid and efficacy of daily drainage and drain removal day in mastectomy patients.

METHODS

One hundred and thirty breast cancer patients of Ankara Oncology Training and Research Hospital were divided into 2 groups by consecutive randomization (n = 65 each). β-glucan 10 mg capsules were administered to Group 1 twice a day for 10 days. Group 2 took placebos in the same manner. Age, menarche age, menopause, parity, history of oral contraceptives, comorbidities, postoperative daily drainage volumes and drain removal days were recorded and compared. Seroma samples during the first and second day of drainage were taken for analysis of Interleukin-6 (IL-6) and Tumor Necrosis Factor (TNF-α).

RESULTS

There was no difference between groups in terms of age, menarche age, menopause period, parity, oral contraceptive use and comorbidities. Group 1 showed significantly lower daily drainage volumes between days 2 and 8. Mean drain removal day was 7.16 ± 1.72 in Group 1 and 8.59 ± 2.27 in Group 2. The difference was significant (p < 0.001). TNF-α and IL-6 levels on days 1 and 2 in Group 1 were significantly lower (p < 0.001). In addition, β-glucan significantly shortened the number of days required for the drain removal in patients who have comorbidities (p = 0.018). The earliest removal was in patients without comorbidity and who received β-glucan (p = 0.002).

CONCLUSION

β-glucan decreased drain discharges after mastectomy. The drains were removed earlier in β-glucan administered patients.

Nanofiber-expanded human umbilical cord blood-derived CD34+ cell therapy accelerates murine cutaneous wound closure by attenuating pro-inflammatory factors and secreting IL-10

Nanofiber-expanded human umbilical cord blood-derived CD34+ cell therapy is under consideration for treating peripheral and cardiac ischemia. However, the therapeutic efficacy of nanofiber-expanded human umbilical cord blood-derived (NEHUCB) CD34+ cell therapy for wound healing and its mechanisms are yet to be established. Using an excision wound model in NOD/SCID mice, we show herein that NEHUCB-CD34+ cells home to the wound site and significantly accelerate the wound-healing process compared to vehicle-treated control. Histological analysis reveals that accelerated wound closure is associated with the re-epithelialization and increased angiogenesis. Additionally, NEHUCB-CD34+ cell-therapy decreases expression of pro-inflammatory cytokines, such as TNF-α, IL-1β, IL-6 and NOS2A in the wound bed, and concomitantly increases expression of IL-10 compared to vehicle-treated control. These findings were recapitulated in vitro using primary dermal fibroblasts and NEHUCB-CD34+ cells. Moreover, NEHUCB-CD34+ cells attenuate NF-κB activation and nuclear translocation in dermal fibroblasts through enhanced secretion of IL-10, which is known to bind to NF-κB and suppress transcriptional activity. Collectively, these data provide novel mechanistic evidence of NEHUCB-CD34+ cell-mediated accelerated wound healing.

Vocal exercise may attenuate acute vocal fold inflammation

OBJECTIVES/HYPOTHESES

The objective was to assess the utility of selected "resonant voice" (RV) exercises for the reduction of acute vocal fold inflammation. The hypothesis was that relatively large-amplitude, low-impact vocal fold exercises associated with RV would reduce inflammation more than spontaneous speech (SS) and possibly more than voice rest.

STUDY DESIGN

The study design was prospective, randomized, and double blind.

METHODS

Nine vocally healthy adults underwent a 1-hour vocal loading procedure, followed by randomization to a SS condition, vocal rest condition, or RV exercise condition. Treatments were monitored in clinic for 4 hours and continued extraclinically until the next morning. At baseline (BL), immediately after loading, after the 4-hour in-clinic treatment, and 24 hours post-BL, secretions were suctioned from the vocal folds bilaterally and submitted to enzyme-linked immunosorbent assay to estimate concentrations of key markers of tissue injury and inflammation: interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor α, matrix metalloproteinase (MMP)-8, and IL-10.

RESULTS

Complete data sets were obtained for three markers--IL-1β, IL-6, and MMP-8--for one subject in each treatment condition. For these markers, results were poorest at 24-hour follow-up in the SS condition, sharply improved in the voice rest condition, and was the best in the RV condition. Average results for all markers and responsive subjects with normal BL mediator concentrations revealed an almost identical pattern.

CONCLUSIONS

Some forms of tissue mobilization may be useful to attenuate acute vocal fold inflammation.

Auto/paracrine nicotinergic peptides participate in cutaneous stress response to wounding

Restoration of epidermal barrier (epithelialization), is a major component of cutaneous response to stress imposed by wounding. Learning physiologic regulation of epithelialization may lead to novel treatments of chronic wounds. The non-canonical ligands of nicotinic acetylcholine receptors SLURP (secreted mammalian Ly-6/urokinase-type plasminogen activator receptor-related proteins)-1 and -2 are produced by keratinocytes (KCs) and inflammatory cells to augment physiologic responses to non-neuronal acetylcholine, suggesting that they can affect wound epithelialization and inflammation. In this study, recombinant (r)SLURP-1 and -2 exhibited dose dependent effects on migration of cultured KCs, and monoclonal antibodies inactivating auto/paracrine SLURPs in mouse skin delayed wound epithelialization. While effects of rSLURPs on migration were opposite, with rSLURP-1 inhibiting and rSLURP-2 stimulating migration of KCs, each anti-SLURP antibody produced a negative effect on epithelialization in vivo, suggesting their more extensive than regulation of keratinocyte migration involvement in wound repair. Since inflammation plays an important role in stress response to wounding, we measured inflammation biomarkers in wounds treated with anti-SLURP antibodies. Both anti-SLURP-1 and -2 antibodies, or their mixture, caused significant elevation of wound myeloperoxidase, IL-1β, IL-6 and TNFα. Taken together, results of this study demonstrated that SLURP-1 slows crawling locomotion of KCs, and exhibits a strong anti-inflammatory activity in wound tissue. In contrast, SLURP-2 facilitates lateral migration of KCs, but shows a lesser anti-inflammatory capacity. Thus, combined biologic activities of both SLURPs may be required for normal stress response to skin wounding, which favors clinical trial of rSLURP-1 and -2 in wounds that fail to heal.

A prospective evaluation of the risk factors for development of wound dehiscence and incisional hernia

OBJECTIVE

Post-laparotomy wound dehiscence, evantration and evisceration are important complications leading to an increase in both morbidity and mortality. Incisional hernias are frequently observed following abdominal surgeries and their occurrence is related to various local and systemic factors. This study aims to analyze the factors affecting wound healing by investigating the parameters that may cause wound dehiscence, incisional hernia, sinus formation and chronic incisional pain.

MATERIAL AND METHODS

The records of 265 patients who underwent major abdominal surgery were analyzed. The data on patient characteristics, medication, surgical procedure type, type of suture and surgical instruments used and complications were recorded. The patients were followed up with respect to sinus formation, incisional hernia occurrence and presence of chronic incision pain. Statistical analysis was performed using SPSS 10.00 program. The groups were compared via chi-square tests. Significance was determined as p<0.05. Multi-variate analysis was done by forward logistic regression analysis.

RESULTS

115 (43.4%) patients were female and 150 (56.6%) were male. Ninety-four (35.5%) patients were under 50 years old and 171 (64.5%) were older than 50 years. The median follow-up period was 28 months (0-48). Factors affecting wound dehiscence were found to be; creation of an ostomy (p=0.002), postoperative pulmonary problems (p=0.001) and wound infection (p=0.001). Factors leading to incisional hernia were; incision type (p=0.002), formation of an ostomy (p=0.002), postoperative bowel obstruction (p=0.027), postoperative pulmonary problems (p=0.017) and wound infection (p=0.011).

CONCLUSION

Awareness of the factors causing wound dehiscence and incisional hernia in abdominal surgery, means of intervention to the risk factors and taking relevant measures may prevent complications. Surgical complications that occur in the postoperative period are especially related to wound healing problems.

Cyclooxygenase-2 inhibition for the prevention of subglottic stenosis

OBJECTIVE

To evaluate the role of targeted cyclooxygenase-2 inhibition in reducing scarring associated with a subglottic airway mucosal injury.

DESIGN

Thirty-four New Zealand white rabbits underwent anterior cricothyroidotomy. Subglottic stenosis (SGS) was created by carbon dioxide laser injury.

INTERVENTION

Treatment consisted of intraperitoneal injection of celecoxib or vehicle for 4 days. Endoscopies were performed to assess injury and healing. Subglottic mucosal secretions were collected with Gelfoam swabs (Pfizer Inc) before and after injury and at subsequent time points. Animals were humanely killed at 3 or 8 weeks after injury and airways were excised, followed by gross examination and histologic analysis to assess the severity of SGS. Secretions were analyzed for interleukin-1β, prostaglandin E2 (PGE2), and matrix metalloproteinase-8 by enzyme-linked immunosorbent assays.

RESULTS

Endoscopy showed mild to moderate stenosis in the celecoxib group, but mild to severe stenosis in the vehicle group. Histologic assessment confirmed and quantified reduction in stenosis and scarring as well as advanced reepithelialization. In the healing tissue, mucosal thickening (stenosis) was reduced significantly (P = .02) in celecoxib-treated animals compared with those treated with vehicle, at 3 and 8 weeks (decrease in thickness by 32% and 49%, respectively). Collagen density (fibrosis) was also reduced 25% at both 3 and 8 weeks but the difference was not statistically significant (P = .20). Reduced level of PGE2 in the subglottic mucosal secretions was correlated with mucosal thickness at 8 weeks (P = .02).

CONCLUSION

Short-duration, anti-inflammatory therapy resulted in reduced stenosis and fibrosis with correlation of PGE2 levels in subglottic mucosal secretions.

Extremity Trauma, Dressings, and Wound Infection

The manner in which high-energy transfer limb injuries are dressed can alter the wound environment through manipulation of the bacterial burden, thus minimizing tissue degradation and influencing healing potential. Infection is the principal complication of such wounds, and antiseptic soaked gauze is accepted in early coverage of extremity wounds despite a lack of evidence to support this practice. There has been resurgence in the use of silver in acute wounds, through dressings manipulated to deliver sustained elemental silver to the wound interface. In vitro and in vivo experimentation of silver dressings are characterized however by methodological compromise, primarily through lack of similarity of models to the physiology of the healing wound. Results from in vitro studies caution against the use of silver because of evidence of cytotoxicity, but this is not reproduced in in vivo or clinical experimentation, leading to ambiguity. Review of silver dressing application in burns and chronic wound studies fails to support its use over other dressing systems. Similarly, evidence for the use of silver in acute limb wounds is lacking. This article provides a comprehensive overview of the use of silver dressings in acute wound care and highlights in particular the paucity of evidence regarding its routine use in extremity injury.

The developing Xenopus limb as a model for studies on the balance between inflammation and regeneration

The roles of inflammation and immune cell reactivity triggered by amputation have only recently begun to be addressed in investigations of epimorphic regeneration, although studies of tissue repair in mammals clearly show the importance of the immune system in determining the quality of the repair process. Here, we first review inflammation-related work in non-mammalian systems of epimorphic regeneration which suggests that regeneration of an amputated appendage requires continuous modulation of the local immune response, from the first hours after amputation through the period of blastema patterning. We then present data on the effects of anti-inflammatory and proinflammatory agents on regeneration of larval Xenopus hindlimbs. Treatment with the glucocorticoid beclomethasone immediately after amputation inhibits regeneration in regeneration-complete stage 53 limbs. Other anti-inflammatory agents, including the inhibitors of cyclooxygenase-2 (COX-2) activity celecoxib and diclofenac, applied similarly to larvae amputated at stage 55, when the capacity for limb regeneration is normally being lost, restore regenerative capacity. This suggests that although injury-related events sensitive to glucocorticoids are necessary for regeneration, resolution of the inflammatory response may also be required to allow the complete regenerative response and normal blastema patterning. Conversely, if resolution of inflammation is prevented by local treatment of amputated limbs with beryllium, a strong immunoadjuvant, regeneration is inhibited, and gene expression data suggest that this inhibition results from a failure of normal blastema patterning. Both positive and negative effects of immune- or inflammation-related activities occur during anuran limb regeneration and this underscores the importance of considering immune cells in studies of epimorphic regeneration.

Acceleration of Wound Healing by Multiple Growth Factors and Cytokines Secreted from Multipotential Stromal Cells/Mesenchymal Stem Cells

BACKGROUND

Although multipotential stromal cells/mesenchymal stem cell (MSCs) initially gained attention because of their ability to differentiate into multiple cell lineages, it is their capacity to produce and secrete growth factors and cytokines that makes them particularly valuable as potential cell therapeutics.

THE PROBLEM

Wound healing is an intricate process consisting of several integrated stages, including angiogenesis, collagen production, and cell migration and proliferation. Coordinating these processes to ensure rapid and thorough wound healing is necessary when developing therapeutics. This coordination, however, is disrupted in chronic nonhealing wounds, wherein the impaired blood supply and resulting ischemia compromise cellular functions and make it difficult to deliver the necessary signaling molecules.

BASIC/CLINICAL SCIENCE ADVANCES

MSCs secrete a combination of growth factors and cytokines, which have been shown to promote wound repair. This combination of growth factors and cytokines successfully induces angiogenesis, reduces inflammation, and promotes fibroblast migration and collagen production.

CLINICAL CARE RELEVANCE

The growth factors and cytokines secreted by MSCs can be administered to wounds by either transplanting cells or, as a safer alternative, using the conditioned medium of MSCs, which contains these secreted bioactive molecules. For their success in reducing wound closure time, MSCs offer a promising option for treating chronic wounds. Still, possible undesirable effects of MSC-based therapeutics, such as keloid formation, need to be carefully studied.

CONCLUSION

With its strong ability to secrete diverse growth factors and cytokines, MSC-based therapeutics, either with cell transplantation or the conditioned medium, offers a novel approach toward chronic nonhealing wounds.