A Practical Guide to Wound Healing:

Effectiveness of APG and Honey Gauze in Pressure Injury of Elderly: A Randomized Control Trial

This study was designed to evaluate the efficiency of the combination of autologous platelet-rich plasma gel (APG) and Manuka honey gauze in the treatment of Stages 3-4 pressure injury of older adults. Patients were divided into four groups: Manuka honey gauze and APG (M + A), Manuka honey gauze (M), APG (A), and a control group (C). Different treatments were given, then wound bed coverage with granulation tissue, wound size reduction, and Pressure Ulcer Scale for Healing (PUSH) score were examined. Paraffin-embedded sections of wound tissues were analyzed and wound swab cultures were assessed. Kruskal-Wallis test and Mann-Whitney U test were performed in statistical analysis at a 5% significance level. A total of 42 patients were accepted. Significant increase of wound bed coverage with granulation tissue (51.24%, P = .004, Kruskal-Wallis test) and decrease of PUSH score (-5) were observed in the M + A group at the end of the observation (P = .032, Mann-Whitney U test). The hematoxylin-eosin staining of wound tissues showed that typical squamous epithelium was seen in wound bed of patient in M + A group. Manuka honey gauze and APG were proved to be superior treatments for pressure injury of old patient. Increase of granulation tissue coverage, reduction of PUSH score, and improved growth of epithelium were observed in M + A group. There was no side-effect, and the treatment would not cause infection.

Data Requirement for Animal-Derived Wound Care Devices: Limitations of the 510(k) Regulatory Pathway

BACKGROUND

Device classification and preclinical data requirements for animal-derived wound care products were recently reviewed by the FDA. Given the possible performance differences for these products, we evaluated the FDA data requirements as well as the published literature for all animal-derived wound care products ever cleared through the FDA.

STUDY DESIGN

The publicly available online database was queried for all animal-derived wound products; premarket data requirements for each product were recorded. A PubMed search was conducted to determine the number of published clinical studies for each product, and manufacturer websites were accessed to obtain the price for each product.

RESULTS

A total of 132 animal-derived wound products have been cleared by the FDA since the Center for Devices and Radiological Health was established in 1976. Of these, 114 had a publicly available clearance statement online. Preclinical biocompatibility testing was performed in 85 products (74.6%) and referenced in 10 (8.8%). Preclinical animal wound healing testing took place in 17 (14.9%). Only 9 products (7.9%) had clinical safety testing, and no products had clinical effectiveness data. We found no published peer-reviewed clinical data for 97 products (73%). Cost was infrequently available but ranged from $4.79 to $2,178 per unit.

CONCLUSIONS

Although the current pathway is appropriate for efficiently clearing new wound care products, clinical effectiveness is not included in the regulatory review process. Wound care products are primarily evaluated by the FDA for safety and biocompatibility. Thus, any claims of clinical effectiveness require independent validation, which is often lacking.

Practical Review on Delayed Primary Closure: Basic Science and Clinical Applications

Wound healing complications present a significant burden on both patients and health-care systems, and understanding wound healing principles is crucial across medical and surgical specialties to help mitigate such complications. One of these longstanding principles, specifically delayed primary closure (DPC), described as mechanically closing a wound after several days of secondary intention healing, lacks clear consensus on its definition, indications, and outcomes. This practical review examines wound healing fundamentals, focusing on DPC, its execution, indications, and comparative outcomes. A PubMed literature search was conducted to retrieve studies on DPC. Inclusion criteria included comparative studies assessing outcomes and complications between DPC and other closure techniques, as well as articles investigating DPC's underlying physiology. Twenty-three comparative studies met inclusion criteria. DPC wounds have significantly higher partial pressure of oxygen, higher blood flow, and higher rates of collagen synthesis and remodeling activity, all of which help explain DPC wounds' superior mechanical strength. DPC seems most beneficial in contaminated wounds, such as complicated appendectomies, postcardiac surgery wounds, and complicated abdominal wall reconstructions, where it has been associated with lower rates of surgical site infections. This practical review provides an evidence-based approach to DPC, its physiology, technique, and indications. Based on the existing literature, the authors recommend that DPC wounds should be dressed in saline/betadine soaks, changed and irrigated daily, with delayed closure lasting between 3 and 5 days or until the infection has resolved. The clearest indications for DPC are in the context of contaminated abdominal surgery and sternal wound dehiscence post cardiac surgery.

The effect of stromal vascular fraction in an experimental frostbite injury model

BACKGROUND

Despite current treatment modalities, frostbite remains an injury with a poor prognosis which may cause functional morbidities. Several experimental and clinical studies have demonstrated that stromal vascular fraction is an autologous mixture, which can improve wound healing and vasculogenesis. The aim of this study was to show the beneficial effects of stromal vascular fraction on experimental frostbite healing.

MATERIAL AND METHODS

Stromal vascular fraction (SVF) was harvested from 5 rats after excision of the inguinal fat pads. Another 20 rats were separated into 2 groups of 10 as the SVF group and the control group. A frostbite injury was created on each rat using a cryoprobe frozen with liquid nitrogen (-196 °C). SVF was applied to the SVF group and phosphate-buffered saline to the control group. All injections were performed subcutaneously within the frostbite injury area. Biopsies were performed on days 5 and 14 for histopathological and immunochemical evaluations. The tissue perfusion rates of both groups were assessed on day 14 using indocyanine green angiography (SPY system).

RESULTS

The increase in mean tissue perfusion was 373.3% ( ± 32.1) in the SVF group and 123.8% ( ± 16.3) in the control group (p < 0.001). The macroscopic wound reduction rates of the SVF and control groups were 25.5% ( ± 19.1) and 18.0% ( ± 5.9), respectively on day 5%, and 78.2% ( ± 9.2) and 57.3% ( ± 16.7) on day 14 (p = 0.007; p = 0.003). Acute inflammation and the fibrosis gradient were significantly decreased in the SVF group compared to the control group (p = 0.004, p = 0.054 respectively on day 14). Granulation tissue amount, re-epithelialization score and neovascularization were significantly increased in the SVF group (p = 0.006, p = 0.010 and p = 0.021, respectively on day 14).

CONCLUSIONS

The study results demonstrated that SVF increases frostbite wound healing by increasing tissue perfusion rate, neovascularization and re-epithelialization, and modulating acute inflammation and fibrosis.

A Prospective Multicenter Randomized Controlled Trial to Evaluate the Efficacy of Chitosan Hydrogel Paste in Comparison to Commercial Hydroactive Gel as a Wound Bed Preparation

Background This clinical trial aimed to evaluate the clinical efficacy of chitosan derivative hydrogel paste (CDHP) as a wound bed preparation for wounds with cavities.

Methods This study enrolled 287 patients, with 143 patients randomized into the CDHP group (treatment) and 144 patients randomized into the commercial hydroactive gel (CHG) group (control). The granulation tissue, necrotic tissue, patient comfort, clinical signs, symptoms, and patient convenience during the application and removal of the dressing were assessed.

Results The study was completed by 111 and 105 patients from the treatment and control groups, respectively. Both groups showed an increasing mean percentage of wound granulation over time when the initial wound size and comorbidity were adjusted (F(10,198) = 4.61; p < 0.001), but no significant difference was found between the groups (F(1,207) = 0.043; p = 0.953). The adjusted mean percentage of necrotic tissue of both groups showed a significant decrease over time (F(10,235) = 5.65; p <0.001), but no significant differences were found between the groups (F (1,244) = 0.487; p = 0.486).

Conclusion CDHP is equivalent to CHG and is an alternative in wound management and wound bed preparation for wounds with cavities.

Adaptive multi-degree-of-freedom in situ bioprinting robot for hair-follicle-inclusive skin repair: A preliminary study conducted in mice

Skin acts as an essential barrier, protecting organisms from their environment. For skin trauma caused by accidental injuries, rapid healing, personalization, and functionality are vital requirements in clinical, which are the bottlenecks hindering the translation of skin repair from benchside to bedside. Herein, we described a novel design and a proof-of-concept demonstration of an adaptive bioprinting robot to proceed rapid in situ bioprinting on a full-thickness excisional wound in mice. The three-dimensional (3D) scanning and closed-loop visual system integrated in the robot and the multi-degree-of-freedom mechanism provide immediate, precise, and complete wound coverage through stereotactic bioprinting, which hits the key requirements of rapid-healing and personalization in skin repair. Combined with the robot, epidermal stem cells and skin-derived precursors isolated from neonatal mice mixed with Matrigel were directly printed into the injured area to replicate the skin structure. Excisional wounds after bioprinting showed complete wound healing and functional skin tissue regeneration that closely resembling native skin, including epidermis, dermis, blood vessels, hair follicles and sebaceous glands etc. This study provides an effective strategy for skin repair through the combination of the novel robot and a bioactive bioink, and has a promising clinical translational potential for further applications.

Adjuvant Radiotherapy for Keloids

Radiotherapy is one of the therapeutic methods for keloids, and the irradiation technique has innovated from superficial X-ray to brachytherapy after decades of clinical practice. At present, the application of adjuvant radiotherapy has been widely accepted by clinicians, while the consensus of optimal adjuvant radiotherapy strategies for keloids has not been reached. Factors such as radiation timing, dose, fractions, and lesion locations may be associated with the clinical outcomes of patients with keloids after radiotherapy while a comprehensive review is lacking. Herein, this review summarized the published literature of adjuvant radiotherapy for keloids involving mechanism, timing, dose, fractions, and complications, etc., which may facilitate clinical decision making.Level of Evidence III 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 .

Reconstructive Techniques in Melanoma for the Surgical Oncologist

Wounds resulting from wide local excision of melanoma vary in size and complexity, and require individualized solutions to achieve satisfactory closure. Goals of reconstruction include restoration of form, function, and aesthetics while minimizing donor site morbidity without compromising the effectiveness and safety of oncologic melanoma treatment. Optimal reconstruction relies on an in-depth understanding of the defect, locoregional anatomy and vasculature, available donor tissues, and basic wound healing and surgical principles. This article provides a broad overview of preoperative patient, timing, and wound considerations; various surgical techniques for complex reconstruction throughout the body; and postoperative care and complication management.

The Horse as a Model for the Study of Cutaneous Wound Healing

Significance: Cutaneous wounds are a major problem in both human and equine medicine. The economic cost of treating skin wounds and related complications in humans and horses is high, and in both species, particular types of chronic wounds do not respond well to current therapies, leading to suffering and morbidity. Recent Advances: Conventional methods for the treatment of cutaneous wounds are generic and have not changed significantly in decades. However, as more is learned about the mechanisms involved in normal skin wound healing, and how failure of these processes leads to chronic nonhealing wounds, novel therapies targeting the specific pathologies of hard-to-heal wounds are being developed and evaluated. Critical Issues: Physiologically relevant animal models are needed to (1) study the mechanisms involved in normal and impaired skin wound healing and (2) test newly developed therapies. Future Directions: Similarities in normal wound healing in humans and horses, and the natural development of distinct types of hard-to-heal chronic wounds in both species, make the horse a physiologically relevant model for the study of mechanisms involved in wound repair. Horses are also well-suited models to test novel therapies. In addition, studies in horses have the potential to benefit veterinary, as well as human medicine.

Challenges and Management in Wound Care

SUMMARY

Wounds have been one of the most prominent pathologies since the beginning of humanity. For the last 5 decades, a drastic improvement of healing has been observed, thanks to new medical devices based on fluid aspiration capacities and the development of negative pressure wound therapy. Negative-pressure wound therapy was initially designed for a double action, fluid aspiration and mechanical stimulation of wound edges by a foam. Successive technical evolutions of negative pressure wound therapy were declined since 1997 when Argenta and Morykwas first presented their solution. The adjunct of instillation in 2009 was considered as the first interactive dressing, allowing topical wound solutions to sequentially reach the wound, in alternance with negative pressure. Other devices based on the same principle were designed to prevent postoperative infections when placed over a suture after surgery. This long evolution could enhance the armamentarium of possible solutions, considerably reducing the wound healing time.

Assessment of Human Gingival Fibroblast Proliferation after Laser Stimulation In Vitro Using Different Laser Types and Wavelengths (1064, 980, 635, 450, and 405 nm)-Preliminary Report

PURPOSE

to assess the effect of photobiomodulation (PBM) on human gingival fibroblast proliferation.

METHODS

The study was conducted using the primary cell cultures of human fibroblasts collected from systemically healthy donors. Three different laser types, Nd:YAG (1064 nm), infrared diode laser (980 nm), and prototype led laser emitting 405, 450, and 635 nm were used to irradiate the fibroblasts. Due to the patented structure of that laser, it was possible to irradiate fibroblasts with a beam combining two or three wavelengths. The energy density was 3 J/cm2, 25 J/cm2, 64 J/cm2. The viability and proliferation of cells were determined using the (Thiazolyl Blue Tetrazolium Blue) (MTT) test conducted 24, 48, and 72 h after laser irradiation.

RESULTS

The highest percentage of mitochondrial activity (MA = 122.1%) was observed in the group irradiated with the 635 nm laser, with an energy density of 64 J/cm2 after 48 h. The lowest percentage of MA (94.0%) was observed in the group simultaneously irradiated with three wavelengths (405 + 450 + 635 nm). The use of the 405 nm laser at 25 J/cm2 gave similar results to the 635 nm laser.

CONCLUSIONS

The application of the 635 nm and 405 nm irradiation caused a statistically significant increase in the proliferation of gingival fibroblasts.

PINE NANOCELLULOSE AND BACTERIAL NANOCELLULOSE DRESSINGS ARE SIMILAR IN THE TREATMENT OF SECOND-DEGREE BURN? EXPERIMENTAL STUDY IN RATS

Background: Despite all the advances in medicine and the wide variety of dressings available, the treatment of burn wounds still represents an important medical challenge. The pinus cellulose membrane dressing is a biomaterial with characteristics similar to those of bacterial cellulose, but with lower cost.

Recent Developments Are Changing Extensor Tendon Management

LEARNING OBJECTIVES

After reviewing this article, the participant should be able to: Start early protected movement at 3 to 5 days after surgery with relative motion extension splinting for zone 5 extensor tendon lacerations over the hand. Allow patients to resume regular activities much sooner than the conventional 3 to 4 weeks of splinting after extensor tendon repair. Improve the rehabilitation of boutonniere deformities with relative motion splinting.

SUMMARY

This article focuses on surgery and rehabilitation of extensor tendon injuries from the proximal interphalangeal joint (boutonniere) to the wrist. Relative motion flexion and extension splinting and wide awake, local anesthesia, no tourniquet surgery have revolutionized the management of these lesions, with early protected movement, sooner return to regular activities, and improved rehabilitation. This article explains and illustrates these new advances in extensor tendon management.

A New Suturing Method for Optimal Wound Healing: Technique and Experience

Background

Wound closure utilizing barbed sutures has been associated with healing problems, such as thread extrusion, infection, and the increase of an inflammatory response around the scar.

Objectives

In our study, the senior author described a novel technique of skin incision and wound closure based on de-epithelization and bi-layer tension-free closure that minimizes complications.

Methods

In this retrospective study, the authors reviewed the evolution of wound healing for the novel technique developed by the senior author by analyzing clinical reports of 817 patients who underwent surgery for abdominoplasty or breast reduction utilizing power-assisted liposuction mammaplasty with the new incision and closure technique. In addition, three separate plastic surgeons reviewed the wound characteristics and overall appearance by analyzing photographs that were taken over the course of 12 months to document the healing process.

Results

The overall complication rate was 14.1%, with 0.4% hematoma, 1.25% infection, 0.8% seroma, 1.5% necrosis, 3.75% erythema, 3.3% delayed wound healing, and 3.1% suture extrusion. The authors reported the rate of step-off border (9%), contour irregularities (6.5%), margin separation (1.25%), edge inversion (3.2%), excessive distortion (0.9%), and bad overall appearance (6.4%) of the cases.

Conclusions

This new technique in wound incision and closure based on de-epithelization and bilayer tension-free closure reduces the complications associated with barbed sutures.

Diagnosis and Treatment of Keloids and Hypertrophic Scars-Japan Scar Workshop Consensus Document 2018

There has been a long-standing need for guidelines on the diagnosis and treatment of keloids and hypertrophic scars that are based on an understanding of the pathomechanisms that underlie these skin fibrotic diseases. This is particularly true for clinicians who deal with Asian and African patients because these ethnicities are highly prone to these diseases. By contrast, Caucasians are less likely to develop keloids and hypertrophic scars, and if they do, the scars tend not to be severe. This ethnic disparity also means that countries vary in terms of their differential diagnostic algorithms. The lack of clear treatment guidelines also means that primary care physicians are currently applying a hotchpotch of treatments, with uneven outcomes. To overcome these issues, the Japan Scar Workshop (JSW) has created a tool that allows clinicians to objectively diagnose and distinguish between keloids, hypertrophic scars, and mature scars. This tool is called the JSW Scar Scale (JSS) and it involves scoring the risk factors of the individual patients and the affected areas. The tool is simple and easy to use. As a result, even physicians who are not accustomed to keloids and hypertrophic scars can easily diagnose them and judge their severity. The JSW has also established a committee that, in cooperation with outside experts in various fields, has prepared a Consensus Document on keloid and hypertrophic scar treatment guidelines. These guidelines are simple and will allow even inexperienced clinicians to choose the most appropriate treatment strategy. The Consensus Document is provided in this article. It describes (1) the diagnostic algorithm for pathological scars and how to differentiate them from clinically similar benign and malignant tumors, (2) the general treatment algorithms for keloids and hypertrophic scars at different medical facilities, (3) the rationale behind each treatment for keloids and hypertrophic scars, and (4) the body site-specific treatment protocols for these scars. We believe that this Consensus Document will be helpful for physicians from all over the world who treat keloids and hypertrophic scars.

Simple Effective Ways to Care for Skin Wounds and Incisions

Plastic surgeons are medicine's wound experts. Many of the world's poor cannot afford expensive wound management programs. All humans suffer open and closed wounds at some point in their life and must look after them. The purpose of this paper is to provide basic information to the public in very simple terms on how to safely and inexpensively manage wounds. This paper is directed to all nonmedical people, medical students, and other doctors who may not be content experts in this field.

Complex Open Abdominal Wall Reconstruction: Management of the Skin and Subcutaneous Tissue

Optimal skin and soft tissue management in complex open abdominal wall reconstruction is an integral element of the operation to achieve optimal outcomes. Failure to provide stable, well-vascularized soft tissue coverage over the hernia repair can jeopardize the reconstruction through association with nonhealing wounds, mesh exposure, and even possible hernia recurrence. The literature has shown that careful attention to the skin and soft tissue, especially when part of a multidisciplinary approach to complex abdominal wall reconstruction, improves patient outcomes significantly.

Biodegradable copolypeptide hydrogel prodrug accelerates dermal wound regeneration by enhanced angiogenesis and epithelialization

Hydrogels are one of the most promising wound dressings. However, their effectiveness on wound healing is still largely limited due to either the non-degradability or the release of non-therapeutic degradable products. Herein, a biodegradable copolypeptide hydrogel based on the glutamic acid and lysine was synthesized and applied as both wound dressing and therapeutic prodrug. The hydrogel can degrade in the existence of elevated degradative enzymes in a wound environment, which will release therapeutic amino acids to enhance the wound healing. In vivo results found that the hydrogel could effectively promote wound regeneration in both macroscopic and microscopic scales. Further investigation revealed that the wound healing effect of the hydrogel was highly attributed to its enhanced impact on angiogenesis, cell proliferation and re-epithelialization of the wound. All in all, the present study proves that the degradable copolypeptide hydrogel can efficiently improve wound healing and indicates its potent clinical application for wound regeneration.

Connexin 43: Key roles in the skin

Gap junctions are tightly packed intercellular channels that serve a common purpose of allowing the intercellular exchange of small metabolites, second messengers and electrical signals. Connexins (Cxs) are gap junction proteins. Currently, 20 and 21 members of Cxs have been characterized in mice and humans, respectively. Connexin 43 (Cx43) is the most ubiquitously expressed type of Cx in the skin. It is produced by various different types of skin cell, such as keratinocytes, fibroblasts, endothelial and basal cells, melanocytes and dermal papilla cells. At present, more evidence indicates that Cx43 has an important role in skin repair and skin tumor development, as well as in skin cell invasion and metastasis. In this review, current knowledge regarding the regulation and function of Cx43 is summarized and the therapeutic potential of regulating Cx43 activity is discussed.

Cell infiltrative hydrogel fibrous scaffolds for accelerated wound healing

Development of natural protein-based fibrous scaffolds with tunable physical properties and biocompatibility is highly desirable to construct three-dimensional (3D), fully cellularized scaffolds for wound healing. Herein, we demonstrated a simple and effective technique to construct electrospun 3D fibrous scaffolds for accelerated wound healing using a photocrosslinkable hydrogel based on gelatin methacryloyl (GelMA). We found that the physical properties of the photocrosslinkable hydrogel including water retention, stiffness, strength, elasticity and degradation can be tailored by changing the light exposure time. We further observed that the optimized hydrogel fibrous scaffolds which were soft and elastic could support cell adhesion, proliferation and migration into the whole scaffolds, facilitating regeneration and formation of cutaneous tissues within two weeks. Such tunable characteristics of the fibrous GelMA scaffolds distinguished them from other reported substrates developed for reconstruction of wound defects including glutaraldehyde-crosslinked gelatin or poly (lactic-co-glycolic acid) (PLGA), whose physical and chemical properties were difficult to modify to allow cell infiltration into the 3D scaffolds for tissue regeneration. We anticipate that the ability to become fully cellularized will make the engineered GelMA fibrous scaffolds suitable for widespread applications as skin substitutes or wound dressings.

STATEMENT OF SIGNIFICANCE

In present study, we generate three-dimensional photocrosslinkable gelatin (GelMA)-based fibrous scaffolds with tunable physical and biological properties by using a combined photocrosslinking/electrospinning approach. The developed GelMA fibrous scaffolds can not only support cell viability and cell adhesion, but also facilitate cell migration and proliferation, accelerating regeneration and formation of cutaneous tissues. In addition, the physical properties of the engineered fibrous GelMA hydrogel including water retention capability, mechanical properties and biodegradability can be tuned to accommodate different patients' needs, making it a promising candidate for skin tissue engineering.

Dressing Wear Time after Breast Reconstruction: A Randomized Clinical Trial

Background

The evidence to support dressing standards for breast surgery wounds is empiric and scarce.

Objective

This two-arm randomized clinical trial was designed to assess the effect of dressing wear time on surgical site infection (SSI) rates, skin colonization and patient perceptions.

Methods

A total of 200 breast cancer patients undergoing breast reconstruction were prospectively enrolled. Patients were randomly allocated to group I (dressing removed on the first postoperative day, n = 100) or group II (dressing removed on the sixth postoperative day, n = 100). SSIs were defined and classified according to criteria from the Centers for Disease Control and Prevention. Samples collected before placing the dressing and after 1 day (group I) and 6 days (both groups) were cultured for skin colonization assessments. Patients preferences and perceptions with regard to safety, comfort and convenience were recorded and analyzed.

Results

A total of 186 patients completed the follow-up. The global SSI rate was 4.5%. Six patients in group I and three in group II had SSI (p = 0.497). Before dressing, the groups were similar with regard to skin colonization. At the sixth day, there was a higher colonization by coagulase-negative staphylococci in group I (p<0.0001). Patients preferred to keep dressing for six days (p<0.0001), and considered this a safer choice (p<0.05).

Conclusions

Despite group I had a higher skin colonization by coagulase-negative staphylococci on the sixth postoperative day, there was no difference in SSI rates. Patients preferred keeping dressing for six days and considered it a safer choice.

Trial Registration

ClinicalTrials.gov NCT01148823

Effect of Nd:YAG Low Level Laser Therapy on Human Gingival Fibroblasts

Aim. To evaluate the effect of Low Level Laser Therapy (LLLT) on human gingival fibroblasts in terms of proliferation and growth factors' secretion (EGF, bFGF, and VEGF). Materials and Methods. Primary cultures of keratinized mucosa fibroblasts were irradiated by a Nd:YAG laser 1064 nm with the following energy densities: 2.6 J/cm², 5.3 J/cm², 7.9 J/cm², and 15.8 J/cm². Controls were not irradiated. Cultures were examined for cell proliferation and growth factors' secretion after 24, 48, and 72 hours. All experimental procedures were performed in duplicate. Data were analyzed by Student's t-test (p < 0.05). Results. All laser-irradiation doses applied promoted a higher cell proliferation at 48 hours in a dose-response relationship compared to controls. This difference reached statistical significance for the cultures receiving 15.8 J/cm² (p = 0.03). Regarding EGF, all laser irradiation doses applied promoted a higher secretion at 48 hours in a reverse dose-response pattern compared to controls. This difference reached statistical significance for the cultures receiving 2.6 J/cm² (p = 0.04). EGF levels at the other time points, bFGF, and VEGF showed a random variation between the groups. Conclusion. Within the limits of this study, LLLT (Nd:YAG) may induce gingival fibroblasts' proliferation and upregulate the secretion of EGF. Further studies are needed to confirm these results.

Anti-Angiogenic Drugs: Involvement in Cutaneous Side Effects and Wound-Healing Complication

Significance: The uses of anti-angiogenic drugs have not only made an impact on the battle to eliminate cancer but are also responsible for a number of medical complications. The long-term use of these drugs has increased the spectrum and incidence of cutaneous side effects and wound-healing complications. It is, therefore, necessary to understand the overall impact that these drugs have on patient care. Recent Advances: This review highlights the role of vascular endothelial growth factor and fibroblast growth factor in angiogenesis and wound healing and looks at how angiogenic inhibitors promote wound-healing complications. Critical Issues: With an increased use of anti-angiogenic drugs for the treatment of various cancers and ocular diseases, there is an increased need for clinicians to define the risks and to optimize the usage of these drugs to reduce the incidence of cutaneous side effects and wound-healing complications. In addition, awareness is needed when treating patients on anti-angiogenic drugs so as not to exacerbate potential wound-healing complications when performing surgical procedures. Future Directions: Clinicians and surgeons will need to develop management guidelines to optimize patient care to reduce the risk of morbidity. When performing a surgical procedure, the impact of adverse effects from the use of anti-angiogenic drugs should be considered to ensure the welfare of the patient. In addition, the development of more specific inhibitors is necessary to reduce target effects to reduce the occurrence of adverse effects.

Evidence-based medicine: pressure sores

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Cite risk factors for pressure sore development. 2. Detail the pathophysiology of pressure sores. 3. List the types and classification of pressure sores. 4. Consider the various nonsurgical conservative wound management strategies. 5. Describe the appropriate surgical interventions for each pressure sore type. 6. Understand the causes of recurrent pressure sores and methods of avoiding recurrence.

SUMMARY

Pressure sores are the result of unrelieved pressure, usually over a bony prominence. With an estimated 2.5 million pressure ulcers treated annually in the United States at a cost of $11 billion, pressure sores represent a costly and labor-intensive challenge to the health care system. A comprehensive team approach can address both prevention and treatment of these recalcitrant wounds. Consideration must be given to the patient's medical and socioeconomic condition, as these factors are significantly related to outcomes. Mechanical prophylaxis, nutritional optimization, treatment of underlying infection, and spasm control are essential in management. A variety of pressure sore patterns exist, with surgical approaches directed to maximize future coverage options. A comprehensive approach is detailed in this article to provide the reader with the range of treatment options available.

Methodological recommendations for comparative research on the treatment of chronic wounds

OBJECTIVE

To provide specific recommendations to product developers and clinical researchers on the design of comparative effectiveness studies for the treatment of chronic wounds, specifically those pertaining to arterial and venous-disease related ulcers, diabetic foot ulcers, pressure ulcers and burn wounds.

METHOD

The recommendations were developed based on a process defined by the Center for Medical Technology Policy (CMTP). After selecting the subject area, semi-structured phone interviews were conducted by one of the authors (SSS) with representatives of payers, manufacturers, clinicians, clinician/researchers and patient advocates. Next, a broad range of stakeholders participated in a meeting convened by CMTP to determine their needs. A technical working group comprising key stakeholders then participated in clarifying recommendations developed by CMTP staff and adding important considerations for their implementation. The resulting draft document was finalised based on public and solicited comment from individual manufacturers; a consortium of product developers and manufacturers; and an alliance of physicians, providers, manufacturers and patient organisations. This article is a summary of the full effectiveness guidance document.

RESULTS

To address the needs of patients, clinicians, guideline developers, payers and other post-regulatory decision makers, this work makes ten recommendations to guide comparative effectiveness research for chronic wound care. These recommendations fall into four categories: study design, population, comparators and outcomes.

CONCLUSION

This paper suggests that using the recommendations outlined to conduct comparative effectiveness research on treatments for chronic wound therapies would facilitate trials that provide patients, clinicians, and payers with the information they need to make optimal treatment decisions. These recommendations focus on design changes that would have the largest impact in improving the usability of the results by decision makers and provide specific guidance on the design of prospective studies intended to inform decision making by patients, clinicians and payers.

DECLARATION OF INTEREST

There were no external sources of funding for these recommendations. The Value Institute and the Center for Medical Technology Policy (CMTP) are both private, non-profit organisations. The authors have no financial, commercial or social conflicts of interest to declare with respect to the article or its content.

Microdialysis sampling techniques applied to studies of the foreign body reaction

Implanted materials including drug delivery devices and chemical sensors undergo what is termed the foreign body reaction (FBR). Depending on the device and its intended application, the FBR can have differing consequences. An extensive scientific research effort has been devoted to elucidating the cellular and molecular mechanisms that drive the FBR. Important, yet relatively unexplored, research includes the localized tissue biochemistry and the chemical signaling events that occur throughout the FBR. This review provides an overview of the mechanisms of the FBR, describes how the FBR affects different implanted devices, and illustrates the role that microdialysis sampling can play in further elucidating the chemical communication processes that drive FBR outcomes.

Flap survival after previous vascular pedicle division and preexisting scar formation at the pedicle site: an experimental study

BACKGROUND

We conducted an experimental study to investigate if it would be possible to re-elevate a flap at a standard flap site if its vascular pedicle was mutilated previously and there was a preexisting scar formation at the pedicle site.

MATERIALS AND METHODS

Thirty-five male Sprague-Dawley rats were divided into 3 groups. In the control group (n = 5), animals received a procedure in which unilateral axial pattern abdominal flap was elevated, and then sutured to its original place. The remaining 2 groups underwent 2-stage procedures. In the first stage, scar tissue was created with either a skin incision (group 2, n = 15) or excision (group 3, n = 15) at the prospective pedicle site of the abdominal flap. In the second stage, abdominal flap was raised in 5 rats as a scar-pedicled flap at day 7, day 21, and day 42. Flaps were sutured in their places. Seven days later, flap survival was evaluated.

RESULTS

Control flaps had complete survival (day 7, 95.5%; day 21, 94.8%; and day 42, 94.5%). Group 2 and group 3 flaps raised on day 7 (group 2, 65.4%; group 3, 63.9%) and on day 21 (group 2, 65.7%; group 3, 66.7%) showed decreased survival compared to control group flaps (P < 0.05). On day 42, group 1 flaps had better survival when compared to group 2 flaps (82.6% vs 70.0%, P < 0.05). Group 1 flaps showed progressive vascular network formation as evidenced by contrast medium first in the proximal two thirds of the flaps on day 7, and later via visualization of the axial pattern vascular tree on day 42. In group 3, approximately half of the flap was filled with barium contrast and no single pedicle was identified on day 42.

CONCLUSIONS

Preexisting scar tissue and pedicle division in the pedicle site of a standard flap diminished dimensions of surviving flap when compared to control flaps. Incision-scar-pedicled flaps achieved better survival compared to excision-group flaps, particularly in the late postoperative period. The study findings showed that it may be possible to raise a flap from previously mutilated site secondary to scar formation and pedicle injury.

An assay to quantify chemotactic properties of degradation products from extracellular matrix

The endogenous chemotaxis of cells toward sites of tissue injury and/or biomaterial implantation is an important component of the host response. Implanted biomaterials capable of recruiting host stem/progenitor cells to a site of interest may obviate challenges associated with cell transplantation. An assay for the identification and quantification of chemotaxis induced by surgically placed biologic scaffolds composed of extracellular matrix is described herein.

Basic Plastic Surgery Skills Training Program on Inanimate Bench Models during Medical Graduation

Due to ethical and medical-legal drawbacks, high costs, and difficulties of accessibility that are inherent to the practice of basic surgical skills on living patients, fresh human cadaver, and live animals, the search for alternative forms of training is needed. In this study, the teaching and learning process of basic surgical skills pertinent to plastic surgery during medical education on different inanimate bench models as a form of alternative and complementary training to the teaching programs already established is proposed.

Electrospun emodin polyvinylpyrrolidone blended nanofibrous membrane: a novel medicated biomaterial for drug delivery and accelerated wound healing

In this work, blended nanofibrous membranes were prepared by an electrospinning technique with polyvinylpyrrolidone (PVP) K90 as the filament-forming polymer, and emodin, an extract of polygonum cuspidate known as a medicinal plant, as the treatment drug. Detailed analysis of the blended nanofibrous membrane by scanning electron microscopy, Differential scanning calorimetry and X-ray diffraction revealed that emodin was well distributed in the ultrafine fibers in the form of amorphous nanosolid dispersions. Results from attenuated total reflectance Fourier transform infrared spectra suggested that the main interactions between PVP and emodin might be mediated through hydrogen bonding. In vitro dissolution tests proved that the blended nanofibrous membrane produced more desired release kinetics of the entrapped drug (emodin) as compared to the pure drug. Furthermore, wound healing test and histological evaluation revealed that the emodin loaded nanofibrous membrane to be more effective as a healing accelerator thereby proving potential strategies to develop composite drug delivery system as well as promising materials for future therapeutic biomedical applications.

Adaptation of evidence-based surgical wound care algorithm

PURPOSE

This study was designed to adapt a surgical wound care algorithm that is used to provide evidence-based surgical wound care in a critical care unit.

METHODS

This study used, the 'ADAPTE process', an international clinical practice guideline development method. The 'Bonnie Sue wound care algorithm' was used as a draft for the new algorithm. A content validity index (CVI) targeting 135 critical care nurses was conducted. A 5-point Likert scale was applied to the CVI test using a statistical criterion of .75.

RESULTS

A surgical wound care algorithm comprised 9 components: wound assessment, infection control, necrotic tissue management, wound classification by exudates and depths, dressing selection, consideration of systemic factors, wound expected outcome, reevaluate non-healing wounds, and special treatment for non-healing wounds. All of the CVI tests were ≥.75. Compared to existing wound care guidelines, the new wound care algorithm provides precise wound assessment, reliabilities of wound care, expands applicability of wound care to critically ill patients, and provides evidence and strength of recommendations.

CONCLUSION

The new surgical wound care algorithm will contribute to the advancement of evidence-based nursing care, and its use is expected as a nursing intervention in critical care.

Proper care of early wounds to optimize healing and prevent complications

Proper wound care has broad applications for all clinicians. Much of the future direction for enhancing wound repair focuses on key cells and growth factors, which is why possessing a strong understanding of the basic physiology of wound healing is imperative. This article first provides a thorough review of the phases of wound healing followed by a discussion on the latest wound management strategies. Wound conditions and surgical techniques are important components for optimizing wound healing and preventing complications. Special consideration has been given to the unique settings of contaminated wounds, open wounds, or avulsed tissue.

Please close this skin wound

Acute cutaneous wounds following trauma are commonly encountered in the emergency department. This article explains the principles of their closure and provides advice on optimal management. Wound healing occurs in four phases: haemostatic, inflammatory, proliferative and maturation (Janis et al, 2010). The guidance below is based on the authors' personal practice, designed to promote transition through these stages and result in optimized healing with minimal scarring. It is intended to guide the reader through what can be a daunting prospect for many doctors in training: the acute closure of simple wounds.

Expression of a novel dual-functional protein--the antimicrobial peptide LL-37 fused with human acidic fibroblast growth factor in Escherichia coli

Human acidic fibroblast growth factor (haFGF) stimulates repair of delayed healing which still remains a tremendously world-wide issue. However, most of the patients with delayed healings have to face another creeping problem - microbial infection, which is one of the most frequent complications that still lead to wound healing failure. LL-37/hCAP-18 is the only cathelicidin-derived antimicrobial peptide found in human with a wide range of antimicrobial activities. In the present study, a novel hybrid protein combining LL-37 with haFGF was designed. The DNA sequence encoding recombination fusion protein LL-37-haFGF was subcloned into the pET-21b vector for protein expression in Escherichia coli strain BL21 (DE3). The recombinant protein was expressed as a His-tagged protein and purified using a combination of Ni affinity and CM-Sepharose chromatography at a purity of 95.43% as detected by RP-HPLC and sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). Antimicrobial activity assays showed that the purified LL-37-haFGF had improved antimicrobial activities in vitro compared with LL-37. Methylthiazoletetrazolium (MTT) assay showed that the purified LL-37-haFGF also had a distinct mitogenic activity in NIH 3T3 cells. These data suggests the recombinant protein LL-37-haFGF has pharmaceutical potential for applications in wound healing.

Vitamins and cutaneous wound healing

BACKGROUND

Vitamins have long been thought to modulate the various stages of wound healing through a variety of proposed mechanisms. Our goal was to investigate relevant studies examining the role of different vitamins in wound healing.

METHODS

MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched for basic science and clinical studies examining the role of vitamins as adjuncts in wound healing.

RESULTS

Mechanisms of action for each of the vitamins are reviewed. It was suggested by many of the studies that the major vitamins A, C, E, D, K, and B have demonstrated utility as adjuncts in wound care in basic science and clinical trials.

CONCLUSION

There is a vast amount of literature on the effect of vitamins on wound healing at the basic science level. Further understanding and controlled trials will help better understand how to utilize vitamins in wound care.

DECLARATION OF INTEREST

None.

Wound repair: toward understanding and integration of single-cell and multicellular wound responses

The importance of wound healing to medicine and biology has long been evident, and consequently, wound healing has been the subject of intense investigation for many years. However, several relatively recent developments have added new impetus to wound repair research: the increasing application of model systems; the growing recognition that single cells have a robust, complex, and medically relevant wound healing response; and the emerging recognition that different modes of wound repair bear an uncanny resemblance to other basic biological processes such as morphogenesis and cytokinesis. In this review, each of these developments is described, and their significance for wound healing research is considered. In addition, overlapping mechanisms of single-cell and multicellular wound healing are highlighted, and it is argued that they are more similar than is often recognized. Based on this and other information, a simple model to explain the evolutionary relationships of cytokinesis, single-cell wound repair, multicellular wound repair, and developmental morphogenesis is proposed. Finally, a series of important, but as yet unanswered, questions is posed.

Protein C deficiency: a case review

Protein C (PC) deficiency is a rare but life-threatening bleeding disorder that can present in the immediate neonatal period. This article presents the case of a baby girl with acute and progressive neonatal purpura fulminans as the presenting feature of PC deficiency. Other common complications of this disease include ophthalmic problems and central nervous system (CNS) changes. Management consists of correcting the coagulopathy, intensive wound care including negative-pressure dressings and skin grafting, and supportive care for the ophthalmic and CNS issues. Long-term follow-up consists of lifelong anticoagulant therapy to avoid recurrence of these complications.