Electrical Stimulation Technologies for Wound Healing

MXene-coated piezoelectric poly-L-lactic acid membrane accelerates wound healing by biomimicking low-voltage electrical pulses

Electrical stimulation therapy is effective in promoting wound healing by rescuing the decreased endogenous electrical field, where self-powered and miniaturized devices such as nanogenerators become the emerging trends. While high-voltage and unidirectional electric field may pose thermal effect and damage to the skin, nanogenerators with lower voltages, pulsed or bidirectional currents, and less invasive electrodes are preferred. Herein, we construct a polydopamine (PDA)-modified poly-L-lactic acid (PLLA) /MXene (PDMP/MXene) nanofibrous composite membrane that generates piezoelectric voltages matching the transepithelial potential (TEP) to accelerate wound healing. PDA coating not only enhances the piezoelectricity of PLLA by dipole attraction and alignment, but also increases its hydrophilicity and facilitates subsequent MXene adhesion for electrical conductivity and stability in physiological environment. When applied as wound dressings in mice, the PDMP/MXene membranes act as a nanogenerators with reduced internal resistances and satisfactory piezoelectric performances that resemble bioelectric potentials (~10 mV) responding to physical activities. The membrane significantly accelerates wound closure by facilitating fibroblast migration, collagen deposition and angiogenesis, and suppressing the expression of inflammatory responses. This piezoelectric fibrous membrane therefore provides a convenient solution for speeding up wound healing by sustained low voltage mimicking bioelectricity, better cell affinity.

Effects of low-frequency pulsed electrical stimulation at the common peroneal nerve on chronic refractory wounds of the lower limb: A randomized controlled trial

Background and aims

Electrical stimulation (ES) has been shown to substantially enhance the quality of life by alleviating pain in patients with chronic wounds. This study aimed to observe the effects of low-frequency pulsed wearable ES at the common peroneal nerve on chronic refractory wounds of the lower limb.

Methods

Forty-eight participants were randomly divided into control group (n = 24) and treatment group (n = 24) in this study. The control group received standard wound care (SWC) exclusively, whereas the treatment group was administered both SWC and the wearable low-frequency ES targeting the common peroneal nerve. Measurements of wound area, pain intensity, wound status, and quality of life scores were systematically recorded both before and after 4 weeks treatment.

Results

After 4 weeks of intervention, the percentage area reduction was significantly higher in the treatment group compared to the control group (Z = -3.9, p < 0.001), and the healing rate of the treatment group was significantly higher than that of the control group (33% vs. 4%). Moreover, the visual Analog Scale for Pain score (β = -0.65, p = 0.019), the Bates-Jensen Wound Assessment Tool score (p < 0.05), and the questionnaire on quality of life with chronic wounds (Wound-Qol) score (β = -4.23, p = 0.003) were significantly decreased in the patients in the treatment group compared to the control group.

Conclusion

The wearable low-frequency pulsed ES at the common peroneal nerve for the treatment of chronic refractory wounds showed significant improvement and were far superior compared to SWC. Future research should broaden its scope to include a diverse range of wound types and benefit from collaboration across multiple research centers.

Wireless Intelligent Patch for Closed-loop In Situ Wound Management

Wound infections pose a major healthcare issue, affecting the well-being of millions of patients worldwide. Effective intervention and on-site detection are important in wound management. However, current approaches are hindered by time-consuming analysis and a lack of technology for real-time monitoring and prompt therapy delivery. In this study, a smart wound patch system (SWPS) designed for wireless closed-loop and in-situ wound management is presented. The SWPS integrates a microfluidic structure, an organic electrochemical transistor (OECT) based sensor, an electrical stimulation module, and a miniaturized flexible printed circuit board (FPCB). The OECT incorporates a bacteria-responsive DNA hydrogel-coated gate for continuous monitoring of bacterial virulence at wound sites. Real-time detection of OECT readings and on-demand delivery of electrical cues to accelerate wound healing is facilitated by a mobile phone application linked with an FPCB containing low-power electronics equipped with parallel sensing and stimulation circuitry. In this proof-of-concept study, the functionality of the SWPS is validated and its application both in vitro and in vivo is demonstrated. This proposed system expands the arsenal of tools available for effective wound management and enables personalized treatment.

From emerging modalities to advanced applications of hydrogel piezoelectrics based on chitosan, gelatin and related biological macromolecules: A review

The rapid development of functional materials and manufacturing technologies is fostering advances in piezoelectric materials (PEMs). PEMs can convert mechanical energy into electrical energy. Unlike traditional power sources, which need to be replaced and are inconvenient to carry, PEMs have extensive potential applications in smart wearable and implantable devices. However, the application of conventional PEMs is limited by their poor flexibility, low ductility, and susceptibility to fatigue failure. Incorporating hydrogels, which are flexible, stretchable, and self-healing, providing a way to overcome these limitations of PEMs. Hydrogel-based piezoelectric materials (H-PEMs) not only resolve the shortcomings of traditional PEMs but also provide biocompatibility and more promising application potential. This paper summarizes the working principle of H-PEMs. Recent advances in the use of H-PEMs as sensors and in vitro energy harvesting devices for smart wearable devices are described in detail, with emphasis on application scenarios in human body like fingers, wrists, ankles, and feet. In addition, the recent progress of H-PEMs in implantable medical devices, especially the potential applications in human body parts such as bones, skin, and heart, are also elaborated. In addition, challenges and potential improvements in H-PEMs are discussed.

Bacterial Cellulose-Based Bandages with Integrated Antibacteria and Electrical Stimulation for Advanced Wound Management

Bandages for daily wounds are the most common medical supplies, but there are still ingrained defects in their appearance, comfort, functions, as well as environmental pollution. Here, novel bandages based on bacterial cellulose (BC) membrane for wound monitoring and advanced wound management are developed. The BC membrane is combined with silver nanowires (AgNWs) by using vacuum filtration method to achieve transparent, ultrathin (≈7 µm), breathable (389.98-547.79 g m-2  d-1 ), and sandwich-structured BC/AgNWs bandages with superior mechanical properties (108.45-202.35 MPa), antibacterial activities against Escherichia coli and Staphylococcus aureus, biocompatibility, and conductivity (9.8 × 103 -2.0 × 105  S m-1 ). Significantly, the BC/AgNWs bandage is used in the electrical stimulation (direct current, 600  microamperes for 1 h every other day) treatment of full-thickness skin defect in rats, which obviously promotes wound healing by increasing the secretion of vascular endothelial growth factor (VEGF). The BC bandage is used for monitoring wounds and achieve a high accuracy of 94.7% in classifying wound healing stages of hemostasis, inflammation, proliferation, and remodeling, by using a convolutional neural network. The outcomes of this study not only provide two BC-based bandages as multifunctional wound management, but also demonstrate a new strategy for the development of the next generation of smart bandage.

Electrostimulable polymeric films with hyaluronic acid and lipid nanoparticles for simultaneous topical delivery of macromolecules and lipophilic drugs

This study focused on developing electrically stimulable hyaluronic acid (HA) films incorporating lipid nanoparticles (NPs) designed for the topical administration of lipophilic drugs and macromolecules. Based on beeswax and medium-chain triglycerides, NPs were successfully integrated into silk fibroin/chitosan films containing HA (NP-HA films) at a density of approximately 1011 NP/cm2, ensuring a uniform distribution. This integration resulted in a 40% increase in film roughness, a twofold decrease in Young's modulus, and enhanced film flexibility and bioadhesion work. The NP-HA films, featuring Ag/AgCl electrodes, demonstrated the capability to conduct a constant electrical current of 0.2 mA/cm2 without inducing toxicity in keratinocytes and fibroblasts during a 15-min application. Moreover, the NPs facilitated the homogeneous distribution of lipophilic drugs within the film, effectively transporting them to the skin and uniformly distributing them in the stratum corneum upon film administration. The sustained release of HA from the films, following Higuchi kinetics, did not alter the macroscopic characteristics of the film. Although anodic iontophoresis did not noticeably affect the release of HA, it did enhance its penetration into the skin. This enhancement facilitated the permeation of HA with a molecular weight (MW) of up to 2 × 105 through intercellular and transcellular routes. Confocal Raman spectroscopy provided evidence of an approximate 100% increase in the presence of HA with a MW in the range of 1.5-1.8 × 106 in the viable epidermis of human skin after only 15 min of iontophoresis applied to the films. Combining iontophoresis with NP-HA films exhibits substantial potential for noninvasive treatments focused on skin rejuvenation and wound healing.

Piezoelectric dressings for advanced wound healing

The treatment of chronic refractory wounds poses significant challenges and threats to both human society and the economy. Existing research studies demonstrate that electrical stimulation fosters cell proliferation and migration and promotes the production of cytokines that expedites the wound healing process. Presently, clinical settings utilize electrical stimulation devices for wound treatment, but these devices often present issues such as limited portability and the necessity for frequent recharging. A cutting-edge wound dressing employing the piezoelectric effect could transform mechanical energy into electrical energy, thereby providing continuous electrical stimulation and accelerating wound healing, effectively addressing these concerns. This review primarily reviews the selection of piezoelectric materials and their application in wound dressing design, offering a succinct overview of these materials and their underlying mechanisms. This study also provides a perspective on the current limitations of piezoelectric wound dressings and the future development of multifunctional dressings harnessing the piezoelectric effect.

Making Sense of Electrical Stimulation: A Meta-analysis for Wound Healing

Electrical stimulation as a mode of external enhancement factor in wound healing has been explored widely. It has proven to have multidimensional effects in wound healing including antibacterial, galvanotaxis, growth factor secretion, proliferation, transdifferentiation, angiogenesis, etc. Despite such vast exploration, this modality has not yet been established as an accepted method for treatment. This article reviews and analyzes the approaches of using electrical stimulation to modulate wound healing and discusses the incoherence in approaches towards reporting the effect of stimulation on the healing process. The analysis starts by discussing various processes adapted in in vitro, in vivo, and clinical practices. Later it is focused on in vitro approaches directed to various stages of wound healing. Based on the analysis, a protocol is put forward for reporting in vitro works in such a way that the outcomes of the experiment are replicable and scalable in other setups. This work proposes a ground of unification for all the in vitro approaches in a more sensible manner, which can be further explored for translating in vitro approaches to complex tissue stimulation to establish electrical stimulation as a controlled clinical method for modulating wound healing.

Epithelial Ca2+ waves triggered by enteric neurons heal the gut

A fundamental and unresolved question in regenerative biology is how tissues return to homeostasis after injury. Answering this question is essential for understanding the etiology of chronic disorders such as inflammatory bowel diseases and cancer. We used the Drosophila midgut to investigate this question and discovered that during regeneration a subpopulation of cholinergic enteric neurons triggers Ca2+ currents among enterocytes to promote return of the epithelium to homeostasis. Specifically, we found that down-regulation of the cholinergic enzyme Acetylcholinesterase in the epithelium enables acetylcholine from defined enteric neurons, referred as ARCENs, to activate nicotinic receptors in enterocytes found near ARCEN-innervations. This activation triggers high Ca2+ influx that spreads in the epithelium through Inx2/Inx7 gap junctions promoting enterocyte maturation followed by reduction of proliferation and inflammation. Disrupting this process causes chronic injury consisting of ion imbalance, Yki activation and increase of inflammatory cytokines together with hyperplasia, reminiscent of inflammatory bowel diseases. Altogether, we found that during gut regeneration the conserved cholinergic pathway facilitates epithelial Ca2+ waves that heal the intestinal epithelium. Our findings demonstrate nerve- and bioelectric-dependent intestinal regeneration which advance the current understanding of how a tissue returns to its homeostatic state after injury and could ultimately help existing therapeutics.

Electrotaxis evokes directional separation of co-cultured keratinocytes and fibroblasts

Bioelectric communication plays a significant role in several cellular processes and biological mechanisms, such as division, differentiation, migration, cancer metastasis, and wound healing. Ion flow across cellular walls leads to potential gradients and subsequent formation of constant or time-varying electric fields(EFs), which regulate cellular processes. An EF is natively generated towards the wound center during epithelial wound healing, aiming to align and guide cell migration, particularly of macrophages, fibroblasts, and keratinocytes. While this phenomenon, known as electrotaxis or galvanotaxis, has been extensively investigated across many cell types, it is typically explored one cell type at a time, which does not accurately represent cellular interactions during complex biological processes. Here we show the co-cultured electrotaxis of epidermal keratinocytes and dermal fibroblasts with a salt-bridgeless microfluidic approach for the first time. The electrotactic response of these cells was first assessed in mono-culture to establish a baseline, resulting in the characteristic cathodic migration for keratinocytes and anodic for fibroblasts. Both cell types retained their electrotactic properties in co-culture leading to clear cellular partition even in the presence of cellular collisions. The methods leveraged here pave the way for future co-culture electrotaxis experiments where the concurrent influence of cell types can be thoroughly investigated.

Investigation of the antimicrobial effect of anodic iontophoresis on Gram-positive and Gram-negative bacteria for skin infections treatment

Iontophoresis, a non-invasive application of a constant low-intensity electric current, is a promising strategy to accelerate wound healing. Although its mechanisms are not yet fully elucidated, part of its action seems related to inhibiting bacteria growth. This work aimed to investigate the antimicrobial effect of iontophoresis using Staphylococcus epidermidis and Escherichia coli strains, Gram-positive and Gram-negative bacteria, respectively. Anodic iontophoresis was applied to each bacterial suspension using Ag/AgCl electrodes, and bacteria viability was evaluated after 24 h incubation by counting colony-forming units. A Quality-by-Design approach was performed to assess the influence of the iontophoresis' intensity and application time on bacterial viability. Cell morphology was evaluated by scanning electron microscopy. Iontophoresis showed antimicrobial effects on the Gram-positive bacteria only at 5 mA and 60 min application. However, a linear relationship was observed between intensity and application time for the Gram-negative one, causing drastic morphological changes and up to 98 % death. The cell wall of Gram-negative bacteria seems more susceptible to disorganization triggered by iontophoresis-induced ion transport than Gram-positive ones. Therefore, anodic iontophoresis can be a powerful ally in controlling Gram-negative bacteria proliferation in wounds.

Wireless, closed-loop, smart bandage with integrated sensors and stimulators for advanced wound care and accelerated healing

'Smart' bandages based on multimodal wearable devices could enable real-time physiological monitoring and active intervention to promote healing of chronic wounds. However, there has been limited development in incorporation of both sensors and stimulators for the current smart bandage technologies. Additionally, while adhesive electrodes are essential for robust signal transduction, detachment of existing adhesive dressings can lead to secondary damage to delicate wound tissues without switchable adhesion. Here we overcome these issues by developing a flexible bioelectronic system consisting of wirelessly powered, closed-loop sensing and stimulation circuits with skin-interfacing hydrogel electrodes capable of on-demand adhesion and detachment. In mice, we demonstrate that our wound care system can continuously monitor skin impedance and temperature and deliver electrical stimulation in response to the wound environment. Across preclinical wound models, the treatment group healed ~25% more rapidly and with ~50% enhancement in dermal remodeling compared with control. Further, we observed activation of proregenerative genes in monocyte and macrophage cell populations, which may enhance tissue regeneration, neovascularization and dermal recovery.

Reshaping the Endogenous Electric Field to Boost Wound Repair via Electrogenerative Dressing

The endogenous electric field (EF) generated by transepithelial potential difference plays a decisive role in wound reepithelialization. For patients with large or chronic wounds, negative-pressure wound therapy (NPWT) is the most effective clinical method in inflammation control by continuously removing the necrotic tissues or infected substances, thus creating a proproliferative microenvironment beneficial for wound reepithelialization. However, continuous negative-pressure drainage causes electrolyte loss and weakens the endogenous EF, which in turn hinders wound reepithelialization. Here, an electrogenerative dressing (EGD) is developed by integrating triboelectric nanogenerators with NPWT. By converting the negative-pressure-induced mechanical deformation into electricity, EGD produces a stable and high-safety EF that can trigger a robust epithelial electrotactic response and drive the macrophages toward a reparative M2 phenotype in vitro. Translational medicine studies confirm that EGD completely reshapes the wound EF weakened by NPWT, and promotes wound closure by facilitating an earlier transition of inflammation/proliferation and guiding epithelial migration and proliferation to accelerate reepithelialization. Long-term EGD therapy remarkably advances tissue remodeling with mature epithelium, orderly extracellular matrix, and less scar formation. Compared with the golden standard of NPWT, EGD orchestrates all the essential wound stages in a noninvasive manner, presenting an excellent prospect in clinical wound therapy.

A stretchable wireless wearable bioelectronic system for multiplexed monitoring and combination treatment of infected chronic wounds

Chronic nonhealing wounds are one of the major and rapidly growing clinical complications all over the world. Current therapies frequently require emergent surgical interventions, while abuse and misapplication of therapeutic drugs often lead to an increased morbidity and mortality rate. Here, we introduce a wearable bioelectronic system that wirelessly and continuously monitors the physiological conditions of the wound bed via a custom-developed multiplexed multimodal electrochemical biosensor array and performs noninvasive combination therapy through controlled anti-inflammatory antimicrobial treatment and electrically stimulated tissue regeneration. The wearable patch is fully biocompatible, mechanically flexible, stretchable, and can conformally adhere to the skin wound throughout the entire healing process. Real-time metabolic and inflammatory monitoring in a series of preclinical in vivo experiments showed high accuracy and electrochemical stability of the wearable patch for multiplexed spatial and temporal wound biomarker analysis. The combination therapy enabled substantially accelerated cutaneous chronic wound healing in a rodent model.

Recent Progress on Hydrogel-Based Piezoelectric Devices for Biomedical Applications

Flexible electronics have great potential in the application of wearable and implantable devices. Through suitable chemical alteration, hydrogels, which are three-dimensional polymeric networks, demonstrate amazing stretchability and flexibility. Hydrogel-based electronics have been widely used in wearable sensing devices because of their biomimetic structure, biocompatibility, and stimuli-responsive electrical properties. Recently, hydrogel-based piezoelectric devices have attracted intensive attention because of the combination of their unique piezoelectric performance and conductive hydrogel configuration. This mini review is to give a summary of this exciting topic with a new insight into the design and strategy of hydrogel-based piezoelectric devices. We first briefly review the representative synthesis methods and strategies of hydrogels. Subsequently, this review provides several promising biomedical applications, such as bio-signal sensing, energy harvesting, wound healing, and ultrasonic stimulation. In the end, we also provide a personal perspective on the future strategies and address the remaining challenges on hydrogel-based piezoelectric electronics.

Home-Based Electrical Stimulation to Accelerate Wound Healing-A Double-Blinded Randomized Control Trial

BACKGROUND

Electrical stimulation (E-Stim) may offer a unique adjunctive treatment to heal complicated diabetic foot ulcers (DFU). Our primary goal is to examine the effectiveness of daily home-based E-Stim therapy to speed-up wound healing.

METHODS

Patients with chronic DFUs and mild to severe peripheral arterial disease (PAD) were recruited and randomized to either control (CG) or intervention (IG) groups. The IG received 1-hour home-based E-Stim therapy on daily basis for 4 weeks (4W). E-Stim was delivered through electrical pads placed above the ankle joint using a bio-electric stimulation technology (BEST^®) platform (Tennant Biomodulator^® PRO). The CG was provided with an identical but non-functional device for the same period. The primary outcome included wound area reduction at 4W from baseline (BL).

RESULTS

Thirty-eight patients were recruited and 5 were removed due to non-compliance or infection, leaving 33 participants (IG, n = 16; CG, n =17). At 4W, the IG showed a significant wound area reduction of 22% (BL: 7.4 ± 8.5 cm² vs 4W: 5.8 ± 8.0 cm², P = 0.002). Average of wound area was unchanged in the CG (P = 0.982). The self-report adherence to daily home-therapy was 93.9%.

CONCLUSIONS

Daily home-based E-Stim provides early results on the feasibility, acceptability, and effectiveness of E-Stim as an adjunctive therapy to speed up wound healings in patients with chronic DFU and mild to severe PAD.

Anti-Biofilm Activity of a Tunable Hypochlorous Acid-Generating Electrochemical Bandage Controlled By a Wearable Potentiostat

Chronic wound biofilm infections represent a major clinical challenge which results in a substantial burden to patients and healthcare systems. Treatment with topical antibiotics is oftentimes ineffective as a result of antibiotic-resistant microorganisms and biofilm-specific antibiotic tolerance. Use of biocides such as hypochlorous acid (HOCl) has gained increasing attention due to the lack of known resistance mechanisms. We designed an HOCl-generating electrochemical bandage (e-bandage) that delivers HOCl continuously at low concentrations targeting infected wound beds in a similar manner to adhesive antimicrobial wound dressings. We developed a battery-operated wearable potentiostat that controls the e-bandage electrodes at potentials suitable for HOCl generation. We demonstrated that e-bandage treatment was tunable by changing the applied potential. HOCl generation on electrode surfaces was verified using microelectrodes. The developed e-bandage showed time-dependent responses against in vitro Acinetobacter baumannii and Staphylococcus aureus biofilms, reducing viable cells to non-detectable levels within 6 and 12 hours of treatment, respectively. The developed e-bandage should be further evaluated as an alternative to topical antibiotics to treat wound biofilm infections.

Multifunctional GO Hybrid Hydrogel Scaffolds for Wound Healing

Hydrogel dressings have received extensive attention for the skin wound repair, while it is still a challenge to develop a smart hydrogel for adapting the dynamic wound healing process. Herein, we develop a novel graphene oxide (GO) hybrid hydrogel scaffold with adjustable mechanical properties, controllable drug release, and antibacterial behavior for promoting wound healing. The scaffold was prepared by injecting benzaldehyde and cyanoacetate group-functionalized dextran solution containing GO into a collection pool of histidine. As the GO possesses obvious photothermal behavior, the hybrid hydrogel scaffold exhibited an obvious stiffness decrease and effectively promoted cargo release owing to the breaking of the thermosensitive C=C double bond at a high temperature under NIR light. In addition, NIR-assisted photothermal antibacterial performance of the scaffold could be also achieved with the local temperature rising after irradiation. Therefore, it is demonstrated that the GO hybrid hydrogel scaffold with vascular endothelial growth factor (VEGF) encapsulation can achieve the adjustable mechanical properties, photothermal antibacterial, and angiogenesis during the wound healing process. These features indicated that the proposed GO hybrid hydrogel scaffold is potentially valuable for promoting wound healing and other biomedical application.

Anionic polymers amplify electrokinetic perfusion through extracellular matrices

Electrical stimulation (ES) promotes healing of chronic epidermal wounds and delays degeneration of articular cartilage. Despite electrotherapeutic treatment of these non-excitable tissues, the mechanisms by which ES promotes repair are unknown. We hypothesize that a beneficial role of ES is dependent on electrokinetic perfusion in the extracellular space and that it mimics the effects of interstitial flow. In vivo, the extracellular space contains mixtures of extracellular proteins and negatively charged glycosaminoglycans and proteoglycans surrounding cells. While these anionic macromolecules promote water retention and increase mechanical support under compression, in the presence of ES they should also enhance electro-osmotic flow (EOF) to a greater extent than proteins alone. To test this hypothesis, we compare EOF rates between artificial matrices of gelatin (denatured collagen) with matrices of gelatin mixed with anionic polymers to mimic endogenous charged macromolecules. We report that addition of anionic polymers amplifies EOF and that a matrix comprised of 0.5% polyacrylate and 1.5% gelatin generates EOF with similar rates to those reported in cartilage. The enhanced EOF reduces mortality of cells at lower applied voltage compared to gelatin matrices alone. We also use modeling to describe the range of thermal changes that occur during these electrokinetic experiments and during electrokinetic perfusion of soft tissues. We conclude that the negative charge density of native extracellular matrices promotes electrokinetic perfusion during electrical therapies in soft tissues and may promote survival of artificial tissues and organs prior to vascularization and during transplantation.

Pulsed Electrical Stimulation Affects Osteoblast Adhesion and Calcium Ion Signaling

An extensive research field in regenerative medicine is electrical stimulation (ES) and its impact on tissue and cells. The mechanism of action of ES, particularly the role of electrical parameters like intensity, frequency, and duration of the electric field, is not yet fully understood. Human MG-63 osteoblasts were electrically stimulated for 10 min with a commercially available multi-channel system (IonOptix). We generated alternating current (AC) electrical fields with a voltage of 1 or 5 V and frequencies of 7.9 or 20 Hz, respectively. To exclude liquid-mediated effects, we characterized the AC-stimulated culture medium. AC stimulation did not change the medium’s pH, temperature, and oxygen content. The H2O2 level was comparable with the unstimulated samples except at 5 V_7.9 Hz, where a significant increase in H2O2 was found within the first 30 min. Pulsed electrical stimulation was beneficial for the process of attachment and initial adhesion of suspended osteoblasts. At the same time, the intracellular Ca2+ level was enhanced and highest for 20 Hz stimulated cells with 1 and 5 V, respectively. In addition, increased Ca2+ mobilization after an additional trigger (ATP) was detected at these parameters. New knowledge was provided on why electrical stimulation contributes to cell activation in bone tissue regeneration.

Conducting Composite Material Based on Chitosan and Single-Wall Carbon Nanotubes for Cellular Technologies

Biocompatible electrically conducting chitosan-based films filled with single-wall carbon nanotubes were obtained. Atomic force microscopic studies of the free surface topography revealed a change in the morphology of chitosan films filled with single-wall carbon nanotubes. Introducing 0.5 wt.% of single-wall carbon nanotubes into chitosan results in an increase in tensile strength of the films (up to ~180 MPa); the tensile strain values also rise up to ~60%. It was demonstrated that chitosan films containing 0.1–3.0 wt.% of single-wall carbon nanotubes have higher conductivity (10 S/m) than pure chitosan films (10⁻¹¹ S/m). The investigation of electrical stimulation of human dermal fibroblasts on chitosan/single-wall carbon nanotubes film scaffolds showed that the biological effect of cell electrical stimulation depends on the content of single-walled carbon nanotubes in the chitosan matrix.

Wireless microcurrent stimulation improves blood flow in burn wounds

RATIONALE

Skin breakdown, as in wounds, leads to an electric potential, defined as current of injury with the intent of wound closure. Burn wounds are defined by different zones of perfusion having a direct influence on further therapy (e.g. conservative management or skin grafting). We studied immediate, quantifiable effects of electric stimulation on skin perfusion in burn wounds.

METHOD

Wireless Microcurrent Stimulation (WMCS) was utilised as an adjunct therapeutic modality in 10 patients with partial thickness burn wounds. Microcirculation in the skin was quantified with a Laser Doppler (LDI) before and after WMCS treatment. We included a control group of 10 healthy individuals.

RESULTS

A single application of WMCS significantly increased mean flow, velocity and subsequently, haemoglobin and oxygen saturation in partial thickness burn wounds. In healthy skin these parameters increased, but were far less pronounced than in thermally injured skin.

CONCLUSION

This study revealed, for the first time that non-contact WMCS improves blood flow in critically perfused partial thickness burn wounds without disturbing the wound or systemically affecting the patient and may represent a promising adjunct tool in burn treatment, with the potential of faster healing by enhanced perfusion of burn wounds and reduction of the zone of stasis.

LEVEL OF EVIDENCE

III.

3D Printed Piezoelectric Wound Dressing with Dual Piezoelectric Response Models for Scar-Prevention Wound Healing

During the long process of wound defect repair, the bioelectric stimulation around the wound gradually decreases, which can cause gradual down-regulation of the wound healing cascade response, disordered deposition of collagen fibers, and abnormal remodeling of the extracellular matrix (ECM). All these combined will eventually result in delayed wound healing and scar tissue formation. To resolve these issues, a novel ZnO nanoparticles modified PVDF/sodium alginate (SA) piezoelectric hydrogel scaffold (ZPFSA) is prepared by 3D printing technology. The prepared ZPFSA scaffold has dual piezoelectric response models, mainly consisting of vertical swelling and horizontal friction, which can be used to simulate and amplify endogenous bioelectricity to promote wound healing and prevent scar formation. Compared with other composite scaffolds, ZPFSA 0.5 (contain 0.5% ZnO nanoparticles) exhibits good biocompatibility, excellent antimicrobial properties, and stable piezoelectric response, so that it can significantly accelerate the wound healing and effectively prevent the scar tissue formation within 2 weeks thanks to the cascade regulation in wound healing, including cell migration, vascularization, collagen remodeling, and the expression of related growth factors. The proposed dual piezoelectric response models will provide a new solution to accelerate wound healing process, prevent scar formation, and extend new application range of piezoelectric materials in wound dressing.

Electrical Shunting Prevents the Decline of Galvanotaxis After Monophasic Pulsed Microcurrent Stimulation in Human Dermal Fibroblasts

BACKGROUND

Electrical stimulation (ES) therapy is recommended for healing pressure injuries. Monophasic pulsed microcurrent stimulation promotes the migration of human dermal fibroblasts (HDFs) to the cathode, and ES potentially accelerates pressure injury healing. A reverse current is generated after ES in the human body; however, the effects of the electrical shunt in preventing the reverse current from migrating are unclear. Therefore, this study aimed to investigate the effects of an electrical shunt on the migration of HDFs.

METHODS

In the shunt groups, HDFs were electrically stimulated (0, 200, 400, and 600 µA) for 8 hours, and an electrical shunt was used to remove the electricity after ES. HDFs were observed under time-lapse microscopy for 24 hours. The migration ratio toward the cathode was calculated for each dish.

RESULTS

The migration ratio was significantly higher in the 200-µA group than in the other groups. HDFs migrated toward the anode after ES in the non-shunt groups with greater than 400 µA ES; however, HDFs did not migrate toward the anode with electrical shunting.

CONCLUSIONS

A post-ES electrical shunt is important in preventing a decline in the migration effect of ES.

Influence of Electric Field on Proliferation Activity of Human Dermal Fibroblasts

In this work, an electrically conductive composite based on thermoplastic polyimide and graphene was obtained and used as a bioelectrode for electrical stimulation of human dermal fibroblasts. The values of the electrical conductivity of the obtained composite films varied from 10-15 to 102 S/m with increasing graphene content (from 0 to 5.0 wt.%). The characteristics of ionic and electronic currents flowing through the matrix with the superposition of cyclic potentials ± 100 mV were studied. The high stability of the composite was established during prolonged cycling (130 h) in an electric field with a frequency of 0.016 Hz. It was established that the composite films based on polyimide and graphene have good biocompatibility and are not toxic to fibroblast cells. It was shown that preliminary electrical stimulation increases the proliferative activity of human dermal fibroblasts in comparison with intact cells. It is revealed that an electric field with a strength E = 0.02-0.04 V/m applied to the polyimide films containing 0.5-3.0 wt.% of the graphene nanoparticles activates cellular processes (adhesion, proliferation).

Effect of electrical stimulation on patients with diabetes-related ulcers: a systematic review and meta-analysis

BACKGROUND

This study aimed to systematically review the literature to better understand the efficacy of electrical stimulation (ES) for the treatment of patients with diabetes-related ulcers.

METHODS

We searched the Embase, Medline, and Cochrane Library databases through July 31, 2021. Original trials for ES treatment of patients with diabetes-related ulcers with placebo or standard care as the control group were included. The primary outcomes were ulcer area reduction and healing rates. Meta-analyses were performed to compare the standardized mean difference (SMD) in the percentage of ulcer reduction and risk ratio of non-healing rates between ES treatment and placebo or standard care. We used the Revised Cochrane risk-of-bias tool for randomized trials to assess the risk of bias for each included article. Funnel plots and Egger's test were used to assess publication bias.

RESULTS

Compared to placebo or standard care, ES had a significant benefit for the treatment of patients with diabetes-related ulcers in terms of percentage of ulcer reduction (SMD = 2.56, 95% CI: 1.43-3.69; P < 0.001 (Q-test), I² = 93.9%) and ulcer healing rates [risk ratio of non-healing rates for the ES group was 0.72 (95% CI: 0.54-0.96; P = 0.38 (Q-test), I² = 2.3%)]. Two, four, and three of the included studies were categorized into low risk of bias, some concerns, and high risk of bias, respectively. No publication bias was found.

CONCLUSIONS

Based on the findings of this meta-analysis, ES could be used to treat patients with diabetes-related ulcers. ES treatment was effective for ulcer area reduction and ulcer healing, although it had a high heterogeneity level among the included studies. Pulsed current ES has the potential benefit of increasing ulcer healing compared to direct current ES. Further large-scale clinical trials are needed to define the adverse events and potentiators of ES in the treatment of patients with diabetes-related ulcers.

Wearable Bioelectronics for Chronic Wound Management

Chronic wounds are a major healthcare issue and can adversely affect the lives of millions of patients around the world. The current wound management strategies have limited clinical efficacy due to labor-intensive lab analysis requirements, need for clinicians' experiences, long-term and frequent interventions, limiting therapeutic efficiency and applicability. The growing field of flexible bioelectronics enables a great potential for personalized wound care owing to its advantages such as wearability, low-cost, and rapid and simple application. Herein, recent advances in the development of wearable bioelectronics for monitoring and management of chronic wounds are comprehensively reviewed. First, the design principles and the key features of bioelectronics that can adapt to the unique wound milieu features are introduced. Next, the current state of wound biosensors and on-demand therapeutic systems are summarized and highlighted. Furthermore, we discuss the design criteria of the integrated closed loop devices. Finally, the future perspectives and challenges in wearable bioelectronics for wound care are discussed.

Piezoelectric nanogenerators for personalized healthcare

The development of flexible piezoelectric nanogenerators has experienced rapid progress in the past decade and is serving as the technological foundation of future state-of-the-art personalized healthcare. Due to their highly efficient mechanical-to-electrical energy conversion, easy implementation, and self-powering nature, these devices permit a plethora of innovative healthcare applications in the space of active sensing, electrical stimulation therapy, as well as passive human biomechanical energy harvesting to third party power on-body devices. This article gives a comprehensive review of the piezoelectric nanogenerators for personalized healthcare. After a brief introduction to the fundamental physical science of the piezoelectric effect, material engineering strategies, device structural designs, and human-body centered energy harvesting, sensing, and therapeutics applications are also systematically discussed. In addition, the challenges and opportunities of utilizing piezoelectric nanogenerators for self-powered bioelectronics and personalized healthcare are outlined in detail.

Electrical stimulation to promote osseointegration of bone anchoring implants: a topical review

Electrical stimulation has shown to be a promising approach for promoting osseointegration in bone anchoring implants, where osseointegration defines the biological bonding between the implant surface and bone tissue. Bone-anchored implants are used in the rehabilitation of hearing and limb loss, and extensively in edentulous patients. Inadequate osseointegration is one of the major factors of implant failure that could be prevented by accelerating or enhancing the osseointegration process by artificial means. In this article, we reviewed the efforts to enhance the biofunctionality at the bone-implant interface with electrical stimulation using the implant as an electrode. We reviewed articles describing different electrode configurations, power sources, and waveform-dependent stimulation parameters tested in various in vitro and in vivo models. In total 55 English-language and peer-reviewed publications were identified until April 2020 using PubMed, Google Scholar, and the Chalmers University of Technology Library discovery system using the keywords: osseointegration, electrical stimulation, direct current and titanium implant. Thirteen of those publications were within the scope of this review. We reviewed and compared studies from the last 45 years and found nonuniform protocols with disparities in cell type and animal model, implant location, experimental timeline, implant material, evaluation assays, and type of electrical stimulation. The reporting of stimulation parameters was also found to be inconsistent and incomplete throughout the literature. Studies using in vitro models showed that osteoblasts were sensitive to the magnitude of the electric field and duration of exposure, and such variables similarly affected bone quantity around implants in in vivo investigations. Most studies showed benefits of electrical stimulation in the underlying processes leading to osseointegration, and therefore we found the idea of promoting osseointegration by using electric fields to be supported by the available evidence. However, such an effect has not been demonstrated conclusively nor optimally in humans. We found that optimal stimulation parameters have not been thoroughly investigated and this remains an important step towards the clinical translation of this concept. In addition, there is a need for reporting standards to enable meta-analysis for evidence-based treatments.

Electrical waveform dependent osteogenesis on PVDF/BaTiO3 composite using a customized and programmable cell stimulator

Directing cellular functionalities using biomaterial-based bioelectronic stimulation remains a significant constraint in translating research outcomes to address specific clinical challenges. Electrical stimulation is now being clinically used as a therapeutic treatment option to promote bone tissue regeneration and to improve neuromuscular functionalities. However, the nature of the electrical waveforms during the stimulation and underlying biophysical rationale are still not scientifically well explored. Furthermore, bone-mimicking implant-based bioelectrical regulation of osteoinductivity has not been translated to clinics. The present study demonstrates the role of the waveform in electrical signal to direct differentiation of stem cells on an electroactive polymeric substrate, using monophasic DC, square wave, and biphasic wave. In this regard, an in-house electrical stimulation device has been fabricated for the uninterrupted delivery of programmed electrical signals to stem cells in culture. To provide a functional platform for stem cells to differentiate, barium titanate (BaTiO₃ , BT) reinforced PVDF has been developed with mechanical properties similar to bone. The electrical stimulation of human mesenchymal stem cells (hMSCs) on PVDF/BT composite inhibited proliferation rate at day 7, indicating early commitment for differentiation. The phenotypical characteristics of DC stimulated hMSCs provided signatures of differentiation towards osteogenic lineage, which was subsequently confirmed using ALP assay, collagen deposition, matrix mineralization, and genetic expression. Our findings suggest that DC stimulation induced early osteogenesis in hMSCs with a higher level of intracellular reactive oxygen species (ROS), whereas the stimulation with square wave directed late osteogenesis with a lower ROS regeneration. In summary, the present study critically analyzes the role of electrical stimulation and its waveforms in regulating osteogenesis, without external biochemical differentiation inducers, on a bone-mimicking functional substrate. Such a strategy can potentially be adopted to develop orthopedic implant-based bioelectronic medicine for bone regeneration. This article is protected by copyright. All rights reserved.

Electrical stimulation of titanium to promote stem cell orientation, elongation and osteogenesis

Electrical stimulation of cells allows exogenous electric signals as stimuli to manipulate cell growth, preferential orientation and bone remodelling. In this study, commercially pure titanium discs were utilised in combination with a custom-built bioreactor to investigate the cellular responses of human mesenchymal stem cells via in-vitro functional assays. Finite element analysis revealed the homogeneous delivery of electric field in the bioreactor chamber with no detection of current density fluctuation in the proposed model. The custom-built bioreactor with capacitive stimulation delivery system features long-term stimulation with homogeneous electric field, biocompatible, sterilisable, scalable design and cost-effective in the manufacturing process. Using a continuous stimulation regime of 100 and 200 mV/mm on cp Ti discs, viability tests revealed up to an approximately 5-fold increase of cell proliferation rate as compared to non-stimulated controls. The human mesenchymal stem cells showed more elongated and differentiated morphology under this regime, with evidence of nuclear elongation and cytoskeletal orientation perpendicular to the direction of electric field. The continuous stimulation did not cause pH fluctuations and hydrogen peroxide production caused by Faradic reactions, signifying the suitability for long-term toxic free stimulation as opposed to the commonly used direct stimulation regime. An approximate of 4-fold increase in alkaline phosphatase production and approximately 9-fold increase of calcium deposition were observed on 200 mV/mm exposed samples relative to non-stimulated controls. It is worth noting that early stem cell differentiation and matrix production were observed under the said electric field even without the presence of chemical inductive growth factors. STATEMENT OF SIGNIFICANCE: This manuscript presents a study on combining pure titanium (primarily preferred as medical implant materials) and electrical stimulation in a purpose-built bioreactor with capacitive stimulation delivery system. A continuous capacitive stimulation regime on titanium disc has resulted in enhanced stem cell orientation, nuclei elongation, proliferation and differentiation as compared to non-stimulated controls. We believe that this manuscript creates a paradigm for future studies on the evolution of healthcare treatments in the area of targeted therapy on implantable and wearable medical devices through tailored innovative electrical stimulation approach, thereby influencing therapeutic conductive and electroactive biomaterials research prospects and development.

Effectiveness of Lower-Extremity Electrical Stimulation to Improve Skin Perfusion

BACKGROUND

Although numerous studies suggest the benefit of electrical stimulation (E-Stim) therapy to accelerate wound healing, the underlying mechanism of action is still debated. In this pilot study, we examined the potential effectiveness of lower-extremity E-Stim therapy to improve tissue perfusion in patients with diabetic foot ulcers.

METHODS

Thirty-eight patients with diabetic foot ulcers underwent 60 min of active E-Stim therapy on acupuncture points above the level of the ankle joint using a bioelectric stimulation technology platform. Perfusion changes in response to E-Stim were assessed by measuring skin perfusion pressure (SPP) at baseline and during 30 and 60 min of therapy; retention was assessed 10 min after therapy. Tissue oxygen saturation (SatO2) was measured using a noninvasive near-infrared camera.

RESULTS

Skin perfusion pressure increased in response to E-Stim therapy (P = .02), with maximum improvement observed at 60 min (11%; P = .007) compared with baseline; SPP reduced 10 min after therapy but remained higher than baseline (9%; P = .1). Magnitude of improvement at 60 min was negatively correlated with baseline SPP values (r = -0.45; P = .01), suggesting that those with lower perfusion could benefit more from E-Stim therapy. Similar trends were observed for SatO2, with statistically significant improvement for a subsample (n = 16) with moderate-to-severe peripheral artery disease.

CONCLUSIONS

This study provides early results on the feasibility and effectiveness of E-Stim therapy to improve skin perfusion and SatO2. The magnitude of benefit is higher in those with poorer skin perfusion. Also, the effects of E-Stim could be washed out after stopping therapy, and regular daily application might be required for effective benefit in wound healing.

Biomechanical Motion-Activated Endogenous Wound Healing through LBL Self-Powered Nanocomposite Repairer with pH-Responsive Anti-Inflammatory Effect

Wound care is still worthy of concern, and effective measures such as electrical stimulating therapy (EST) have sparked compellingly for wound repair. Especially, portable and point-of-care EST devices get extremely desired but these are often limited by inevitable external power sources, lack of biological functions, and mechanical properties conforming to skin tissue. Herein, a dress-on-person self-powered nanocomposite bioactive repairer of wound is designed. As such, the cooperation of the film prepared by layer-by-layer self-assembling 2-hydroxypropyltrimethyl ammonium chloride chitosan (HTCC), alginate (ALG), and poly-dopamine/Fe³⁺ nanoparticles (PFNs), with a self-powered nanogenerator (SN) driven by motion into a nanocomposite repairer (HAP/SN-NR) is conducted. The HAP/SN-NR not only guides cell behavior (proliferation and migration rate ≈61.7%, ≈52.3%), but also facilitates neovascularization (enhanced CD31 expression >4-fold) through its self-powered EST, and the endogenous wound closure with no inflammatory in rats owing to reactive oxygen species (ROS)-clearance of HAP/SN-NR in vitro/vivo through responsively releasing poly-dopamine nanoparticles at wound pH. Enormous efforts illustrate that the repairer is endowed with high self-adhesion to tissue, self-healing, and biodegradation, accelerating wound healing (50% closure ≈5 days). This strategy sheds light on novel multifunctional portable sensor-type dressings and propels the development of intelligent medical devices.

Enhancing osteoblast survival through pulsed electrical stimulation and implications for osseointegration

Electrical stimulation has been suggested as a means for promoting the direct structural and functional bonding of bone tissue to an artificial implant, known as osseointegration. Previous work has investigated the impact of electrical stimulation in different models, both in vitro and in vivo, using various electrode configurations for inducing an electric field with a wide range of stimulation parameters. However, there is no consensus on optimal electrode configuration nor stimulation parameters. Here, we investigated a novel approach of delivering electrical stimulation to a titanium implant using parameters clinically tested in a different application, namely peripheral nerve stimulation. We propose an in vitro model comprising of Ti6Al4V implants precultured with MC3T3-E1 preosteoblasts, stimulated for 72 h at two different pulse amplitudes (10 µA and 20 µA) and at two different frequencies (50 Hz and 100 Hz). We found that asymmetric charge-balanced pulsed electrical stimulation improved cell survival and collagen production in a dose-dependent manner. Our findings suggest that pulsed electrical stimulation with characteristics similar to peripheral nerve stimulation has the potential to improve cell survival and may provide a promising approach to improve peri-implant bone healing, particularly to neuromusculoskeletal interfaces in which implanted electrodes are readily available.

Harnessing Multifaceted Next-Generation Technologies for Improved Skin Wound Healing

Dysregulation of sequential and synchronized events of skin regeneration often results in the impairment of chronic wounds. Conventional wound dressings fail to trigger the normal healing mechanism owing to the pathophysiological conditions. Tissue engineering approaches that deal with the fabrication of dressings using various biomaterials, growth factors, and stem cells have shown accelerated healing outcomes. However, most of these technologies are associated with difficulties in scalability and cost-effectiveness of the products. In this review, we survey the latest developments in wound healing strategies that have recently emerged through the multidisciplinary approaches of bioengineering, nanotechnology, 3D bioprinting, and similar cutting-edge technologies to overcome the limitations of conventional therapies. We also focus on the potential of wearable technology that supports complete monitoring of the changes occurring in the wound microenvironment. In addition, we review the role of advanced devices that can precisely enable the delivery of nanotherapeutics, oligonucleotides, and external stimuli in a controlled manner. These technological advancements offer the opportunity to actively influence the regeneration process to benefit the treatment regime further. Finally, the clinical relevance, trajectory, and prospects of this field have been discussed in brief that highlights their potential in providing a beneficial wound care solution at an affordable cost.

Come together: On-chip bioelectric wound closure

There is a growing interest in bioelectric wound treatment and electrotaxis, the process by which cells detect an electric field and orient their migration along its direction, has emerged as a potential cornerstone of the endogenous wound healing response. Despite recognition of the importance of electrotaxis in wound healing, no experimental demonstration to date has shown that the actual closing of a wound can be accelerated solely by the electrotaxis response itself, and in vivo systems are too complex to resolve cell migration from other healing stages such as proliferation and inflammation. This uncertainty has led to a lack of standardization between stimulation methods, model systems, and electrode technology required for device development. In this paper, we present a 'healing-on-chip' approach that is a standardized, low-cost, model for investigating electrically accelerated wound healing. Our device provides a biomimetic convergent field geometry that more closely resembles actual wound fields. We validate this device by using electrical stimulation to close a 1.5 mm gap between two large (30 mm2) layers of primary skin keratinocyte to completely heal the gap twice as quickly as in an unstimulated tissue. This demonstration proves that convergent electrotaxis is both possible and can accelerate healing and offers an accessible 'healing-on-a-chip' platform to explore future bioelectric interfaces.

High-Voltage, Pulsed Electric Fields Eliminate Pseudomonas aeruginosa Stable Infection in a Mouse Burn Model

Objective: The incidence of severe infectious complications after burn injury increases mortality by 40%. However, traditional approaches for managing burn infections are not always effective. High-voltage, pulsed electric field (PEF) treatment shortly after a burn injury has demonstrated an antimicrobial effect in vivo; however, the working parameters and long-term effects of PEF treatment have not yet been investigated. Approach: Nine sets of PEF parameters were investigated to optimize the applied voltage, pulse duration, and frequency or pulse repetition for disinfection of Pseudomonas aeruginosa infection in a stable mouse burn wound model. The bacterial load after PEF administration was monitored for 3 days through bioluminescence imaging. Histological assessments and inflammation response analyses were performed at 1 and 24 h after the therapy. Results: Among all tested PEF parameters, the best disinfection efficacy of P. aeruginosa infection was achieved with a combination of 500 V, 100 μs, and 200 pulses delivered at 3 Hz through two plate electrodes positioned 1 mm apart for up to 3 days after the injury. Histological examinations revealed fewer inflammatory signs in PEF-treated wounds compared with untreated infected burns. Moreover, the expression levels of multiple inflammatory-related cytokines (interleukin [IL]-1α/β, IL-6, IL-10, leukemia inhibitory factor [LIF], and tumor necrosis factor-alpha [TNF-α]), chemokines (macrophage inflammatory protein [MIP]-1α/β and monocyte chemoattractant protein-1 [MCP-1]), and inflammation-related factors (vascular endothelial growth factor [VEGF], macrophage colony-stimulating factor [M-CSF], and granulocyte-macrophage colony-stimulating factor [G-CSF]) were significantly decreased in the infected burn wound after PEF treatment. Innovation: We showed that PEF treatment on infected wounds reduces the P. aeruginosa load and modulates inflammatory responses. Conclusion: The data presented in this study suggest that PEF treatment is a potent candidate for antimicrobial therapy for P. aeruginosa burn infections.

Biofilm Management in Wound Care

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the basics of biofilm infection and be able to distinguish between planktonic and biofilm modes of growth. 2. Have a working knowledge of conventional and emerging antibiofilm therapies and their modes of action as they pertain to wound care. 3. Understand the challenges associated with testing and marketing antibiofilm strategies and the context within which these strategies may have effective value.

SUMMARY

The Centers for Disease Control and Prevention estimate for human infectious diseases caused by bacteria with a biofilm phenotype is 65 percent and the National Institutes of Health estimate is closer to 80 percent. Biofilms are hostile microbial aggregates because, within their polymeric matrix cocoons, they are protected from antimicrobial therapy and attack from host defenses. Biofilm-infected wounds, even when closed, show functional deficits such as deficient extracellular matrix and impaired barrier function, which are likely to cause wound recidivism. The management of invasive wound infection often includes systemic antimicrobial therapy in combination with débridement of wounds to a healthy tissue bed as determined by the surgeon who has no way of visualizing the biofilm. The exceedingly high incidence of false-negative cultures for bacteria in a biofilm state leads to missed diagnoses of wound infection. The use of topical and parenteral antimicrobial therapy without wound débridement have had limited impact on decreasing biofilm infection, which remains a major problem in wound care. Current claims to manage wound biofilm infection rest on limited early-stage data. In most cases, such data originate from limited experimental systems that lack host immune defense. In making decisions on the choice of commercial products to manage wound biofilm infection, it is important to critically appreciate the mechanism of action and significance of the relevant experimental system. In this work, the authors critically review different categories of antibiofilm products, with emphasis on their strengths and limitations as evident from the published literature.

Electric Factors in Wound Healing

Significance: Electric factors such as electric charges, electrodynamic field, skin battery, and interstitial exclusion permeate wound healing physiology and physiopathology from injury to re-epithelialization. The understanding of how electric factors contribute to wound healing and how treatments may interfere with them is fundamental for the development of better strategies for the management of pathological scarring and chronic wounds. Recent Advances: Angiogenesis, cell migration, macrophage activation hemorheology, and microcirculation can interfere and be interfered with electric factors. New treatments with various types of electric currents, laser, light emitting diode, acupuncture, and weak electric fields applied directly on the wound have been developed to improve wound healing. Critical Issues: Despite the basic and clinical development, pathological scars such as keloids and chronic wounds are still a challenge. Future Directions: New treatments can be developed to improve skin wound healing taking into account the influence of electrical charges. Monitoring electrical activity during skin healing and the influence of treatments on hemorheology and microcirculation are examples of how to use knowledge of electrical factors to increase their effectiveness.

Accelerated Skin Wound Healing by Electrical Stimulation

When the integrity of the skin got damaged, an endogenous electric field will be generated in the wound and a series of physiological reactions will be initiated to close the wound. The existence of the endogenous electric field of the wound has a promoting effect on all stages of wound healing. For wounds that cannot heal on their own, the exogenous electric field can assist the treatment. In this review, the effects of exogenous electrical stimulation on wound healing, such as the inflammation phase, blood flow, cell proliferation and migration, and the wound scarring is overviewed. This article also reviews the new electrical stimulation methods that have emerged in recent years, such as small power supplies, nanogenerators (NGs), and other physical, chemical or biological strategies. These new electrical stimulation methods and devices are safe, low-cost, stable, and small in size. The challenge and perspective are discussed for the future trends of the electrical stimulation treatment in accelerating skin wound healing.

Triboelectric Nanogenerators for Therapeutic Electrical Stimulation

Current solutions developed for the purpose of in and on body (IOB) electrical stimulation (ES) lack autonomous qualities necessary for comfortable, practical, and self-dependent use. Consequently, recent focus has been placed on developing self-powered IOB therapeutic devices capable of generating therapeutic ES for human use. With the recent invention of the triboelectric nanogenerator (TENG), harnessing passive human biomechanical energy to develop self-powered systems has allowed for the introduction of novel therapeutic ES solutions. TENGs are especially effective at providing ES for IOB therapeutic systems given their bioconformability, low cost, simple manufacturability, and self-powering capabilities. Due to the key role of naturally induced electrical signals in many physiological functions, TENG-induced ES holds promise to provide a novel paradigm in therapeutic interventions. The aim here is to detail research on IOB TENG devices applied for ES-based therapy in the fields of regenerative medicine, neurology, rehabilitation, and pharmaceutical engineering. Furthermore, considering TENG-produced ES can be measured for sensing applications, this technology is paving the way to provide a fully autonomous personalized healthcare system, capable of IOB energy generation, sensing, and therapeutic intervention. Considering these grounds, it seems highly relevant to review TENG-ES research and applications, as they could constitute the foundation and future of personalized healthcare.

Electrical Stimulation to Enhance Wound Healing

Electrical stimulation (ES) can serve as a therapeutic modality accelerating the healing of wounds, particularly chronic wounds which have impaired healing due to complications from underlying pathology. This review explores how ES affects the cellular mechanisms of wound healing, and its effectiveness in treating acute and chronic wounds. Literature searches with no publication date restrictions were conducted using the Cochrane Library, Medline, Web of Science, Google Scholar and PubMed databases, and 30 full-text articles met the inclusion criteria. In vitro and in vivo experiments investigating the effect of ES on the general mechanisms of healing demonstrated increased epithelialization, fibroblast migration, and vascularity around wounds. Six in vitro studies demonstrated bactericidal effects upon exposure to alternating and pulsed current. Twelve randomized controlled trials (RCTs) investigated the effect of pulsed current on chronic wound healing. All reviewed RCTs demonstrated a larger reduction in wound size and increased healing rate when compared to control groups. In conclusion, ES therapy can contribute to improved chronic wound healing and potentially reduce the financial burden associated with wound management. However, the variations in the wound characteristics, patient demographics, and ES parameters used across studies present opportunities for systematic RCT studies in the future.

SIROF stabilized PEDOT/PSS allows biocompatible and reversible direct current stimulation capable of driving electrotaxis in cells

Electrotaxis is a naturally occurring phenomenon in which ionic gradients dictate the directed migration of cells involved in different biological processes such as wound healing, embryonic development, or cancer metastasis. To investigate these processes, direct current (DC) has been used to generate electric fields capable of eliciting an electrotactic response in cells. However, the need for metallic electrodes to deliver said currents has hindered electrotaxis research and the application of DC stimulation as medical therapy. This study aimed to investigate the capability of poly(3,4-ethylenedioxythiophene) polystyrene sulfonate (PEDOT/PSS) on sputtered iridium oxide film (SIROF) electrodes to generate stable direct currents. The electrochemical properties of PEDOT/PSS allow ions to be released and reabsorbed depending on the polarity of the current flow. SIROF stabilized PEDOT/PSS electrodes demonstrated exceptional stability in voltage and current controlled DC stimulation for periods of up to 12 hours. These electrodes were capable of directing cell migration of the rat prostate cancer cell line MAT-LyLu in a microfluidic chamber without the need for chemical buffers. This material combination shows excellent promise for accelerating electrotaxis research and facilitating the translation of DC stimulation to medical applications thanks to its biocompatibility, ionic charge injection mechanisms, and recharging capabilities in a biological environment.

Electrokinetic Perfusion Through Three-Dimensional Culture Reduces Cell Mortality

Cell proliferation and survival are dependent on mass transfer. In vivo, fluid flow promotes mass transfer through the vasculature and interstitial space, providing a continuous supply of nutrients and removal of cellular waste products. In the absence of sufficient flow, mass transfer is limited by diffusion and poses significant challenges to cell survival during tissue engineering, tissue transplantation, and treatment of degenerative diseases. Artificial perfusion may overcome these challenges. In this work, we compare the efficacy of pressure driven perfusion (PDP) with electrokinetic perfusion (EKP) toward reducing cell mortality in three-dimensional cultures of Matrigel extracellular matrix. We characterize electro-osmotic flow through Matrigel to identify conditions that generate similar interstitial flow rates to those induced by pressure. We also compare changes in cell mortality induced by continuous or pulsed EKP. We report that continuous EKP significantly reduced mortality throughout the perfusion channels more consistently than PDP at similar flow rates, and pulsed EKP decreased mortality just as effectively as continuous EKP. We conclude that EKP has significant advantages over PDP for promoting tissue survival before neovascularization and angiogenesis. Impact statement Interstitial flow helps promote mass transfer and cell survival in tissues and organs. This study generated interstitial flow using pressure driven perfusion (PDP) or electrokinetic perfusion (EKP) to promote cell viability in three-dimensional cultures. EKP through charged extracellular matrices possesses significant advantages over PDP and may promote cell survival during tissue engineering, transplantations, and treatment of degenerative diseases.

Conductive Hydrogels with Dynamic Reversible Networks for Biomedical Applications

Conductive hydrogels (CHs) are emerging as a promising and well-utilized platform for 3D cell culture and tissue engineering to incorporate electron signals as biorelevant physical cues. In conventional covalently crosslinked conductive hydrogels, the network dynamics (e.g., stress relaxation, shear shining, and self-healing) required for complex cellular functions and many biomedical utilities (e.g., injection) cannot be easily realized. In contrast, dynamic conductive hydrogels (DCHs) are fabricated by dynamic and reversible crosslinks. By allowing for the breaking and reforming of the reversible linkages, DCHs can provide dynamic environments for cellular functions while maintaining matrix integrity. These dynamic materials can mimic some properties of native tissues, making them well-suited for several biotechnological and medical applications. An overview of the design, synthesis, and engineering of DCHs is presented in this review, focusing on the different dynamic crosslinking mechanisms of DCHs and their biomedical applications.

Bioelectric signaling as a unique regulator of development and regeneration

It is well known that electrical signals are deeply associated with living entities. Much of our understanding of excitable tissues is derived from studies of specialized cells of neurons or myocytes. However, electric potential is present in all cell types and results from the differential partitioning of ions across membranes. This electrical potential correlates with cell behavior and tissue organization. In recent years, there has been exciting, and broadly unexpected, evidence linking the regulation of development to bioelectric signals. However, experimental modulation of electrical potential can have multifaceted and pleiotropic effects, which makes dissecting the role of electrical signals in development difficult. Here, I review evidence that bioelectric cues play defined instructional roles in orchestrating development and regeneration, and further outline key areas in which to refine our understanding of this signaling mechanism.