Medications affecting healing: an evidence-based analysis

Multifunctional photothermally responsive hydrogel as an effective whole-process management platform to accelerate chronic diabetic wound healing

The management of chronic diabetic wounds is a complex issue that requires wound repair, regulation of inflammatory levels, and intervention to prevent bacterial infection. To address this issue, we developed a multifunctional photothermally responsive hydrogel (PAG-CuS) as an effective platform for managing the entire wound-healing process, including promoting wound healing, providing anti-inflammatory therapy, and performing photothermal sterilization. Constructed through copolymerization of acrylic acid (AA), methacrylic anhydride-modified gelatin (GelMA), and lipoic acid sodium (LAS) coated copper sulfide nanoparticles (CuS@LAS), PAG-CuS possessed a porous three-dimensional structure that promoted cell adhesion and had a substantial water-holding capacity. Additionally, the internal CuS@LAS not only conferred photothermal antibacterial properties to the hydrogel but also served as physical cross-linking agents, thus enhancing its mechanical strength. Under the NIR-induced photothermal effect, the porous hydrogel liberates CuS@LAS, and later CuS@LAS expels LAS via micelle deassembly to eliminate intracellular ROS. This results in the down-regulation of MMP-9 expression, promoting ECM production and facilitating wound healing. Meanwhile, the release of Cu2+ from PAG-CuS could enhance CD31 expression in endothelial cells, promoting microvessel formation, which is crucial for wound healing. In the diabetic wound model of GK rats, the PAG-CuS hydrogel reduced ROS levels, increased microvessel count, improved epithelialization, and enhanced wound healing. Therefore, this versatile photothermal hydrogel has the potential to be applied in sterilization, scavenging free radicals, and promoting angiogenesis, making it an effective and comprehensive solution to manage the challenges of diabetic wounds. STATEMENT OF SIGNIFICANCE: Assessment of functional recovery and timely adjustment of treatment strategy is critical in the management of chronic diabetic wounds. In this work, we prepared PAG-CuS composite hydrogels by integrating in situ reduction, chemical crosslinking, and nanoenhancement techniques. The near-infrared light-induced photothermal effect of PAG-CuS gel rapidly kills bacteria at the lesion site, and the generated heat simultaneously promotes the multilevel release of LAS from the gel, which could regulate the levels of ROS and MMP-9 to promote extracellular matrix formation. In addition, the Cu2+ released from the gel can promote the formation of blood vessels to improve blood oxygenation. Therefore, this project proposes a synergistic solution to realize the whole process of management to accelerate chronic diabetic wound healing.

Outcomes of Chronically Anticoagulated Patients Undergoing Split-Thickness Skin Grafting for Diabetic Foot Ulcers

OBJECTIVE

Split-thickness skin grafting (STSG) is commonly used for wound closure in diabetic foot ulcers (DFUs). In many cases, patients with diabetes present on long-term anticoagulation therapy. The complications associated with anticoagulants can be discouraging to surgeons considering STSG. The goal of this study was to evaluate STSG outcomes in the setting of chronic anticoagulation across a large, multicenter database.

METHODS

The authors queried the TriNetX Network, which provides access to electronic medical records for more than 75 million patients, to search for patients with a history of DFUs treated with STSG. They divided those found into two groups: long-term anticoagulant use prior to grafting and no long-term anticoagulant use. After matching, the researchers evaluated outcomes following STSG after 1 month and 5 years.

RESULTS

The authors identified 722 patients on chronic anticoagulation with DFUs who were treated with STSG; 446 of these patients were matched to 446 patients with no prior anticoagulation. One month following STSG, the anticoagulated group showed no significant increase in death, graft failure, or regrafting. At 5 years, there was no significant increase in mortality, graft failure, regrafting, or lower extremity amputation rates.

CONCLUSIONS

Chronic anticoagulation therapy does not lead to increased short- or long-term postoperative complications such as graft failure, regrafting, or increased amputation rates following STSG for wound closure. Negative outcomes following STSG for DFUs in chronically anticoagulated individuals are minimal, and grafting should be performed without hesitation.

Cellular and Molecular Processes in Wound Healing

This review summarizes the recent knowledge of the cellular and molecular processes that occur during wound healing. However, these biological mechanisms have yet to be defined in detail; this is demonstrated by the fact that alterations of events to pathological states, such as keloids, consisting of the excessive formation of scars, have consequences yet to be defined in detail. Attention is also dedicated to new therapies proposed for these kinds of pathologies. Awareness of these scientific problems is important for experts of various disciplines who are confronted with these kinds of presentations daily.

Recent technological advances in the management of chronic wounds: A literature review

Background

Wound treatment comprises a substantial portion of the healthcare budgets in developed countries. Studies suggest that about 50% of patients admitted to hospitals have wounds, while 1%−2% of the general population in the developed world suffers from chronic wounds. Chronic wounds fail to repair themselves within the expected period of 30 days. Technologies have been developed to address challenges encountered during wound care with the aim of alleviating pain, promoting healing, or controlling wound infections.

Objective

The objective of this study was to explore the technological improvements that have been made in this field over time.

Methods

To gain insight into the future of wound management, a systematic review of literature on the subject was conducted in scientific databases (PubMed, Scopus, Web of Science, Medline, and Clinical Trials).

Results and Discussion

Results indicate that wound dressings have evolved from the traditional cotton gauze to composite materials embedded with appropriate ingredients such as metal‐based nanoparticles. Studies on biodegradable dressing materials are also underway to explore their applicability in dressing large and irregular wounds. On the other hand, conventional drugs and traditional formulations for the management of pain, inflammation, infections, and accelerating healing have been developed. However, more research needs to be carried out to address the issue of microbial resistance to drugs. Drugs for managing other ailments also need to be designed in such a way that they can augment wound healing. In addition, it has been demonstrated that a coordinated integration of conventional and traditional medicine can produce laudable results in chronic wound management.

Conclusion

Accordingly, collaborative efforts and ingenuity of all players in the field can accelerate technological advances in the wound care market to the benefit of the patients.

Wounds affect about 50% of patients admitted to hospitals.

Technologies have been developed including biodegradable dressing materials to address underlying challenges.

Technological advancement, rising incidences of chronic wounds, growing government support, and a rising elderly population will drive wound market growth.

A careful combination of recent research outputs can greatly change wound care technologies.

This review highlights the recent research advances and opportunities in the wound care field.

The future lies in biodegradable dressing materials, probably embedded with selected nanoparticles and which shall be combined in predetermined ratios.

Skeletal regeneration for segmental bone loss: Vascularised grafts, analogues and surrogates

Massive segmental bone defects (SBD) are mostly treated by removing the fibula and transplanting it complete with blood supply. While revolutionary 50 years ago, this remains the standard treatment. This review considers different strategies to repair SBD and emerging potential replacements for this highly invasive procedure. Prior to the technical breakthrough of microsurgery, researchers in the 1960s and 1970s had begun to make considerable progress in developing non autologous routes to repairing SBD. While the breaktthrough of vascularised bone transplantation solved the immediate problem of a lack of reliable repair strategies, much of their prior work is still relevant today. We challenge the assumption that mimicry is necessary or likely to be successful and instead point to the utility of quite crude (from a materials technology perspective), approaches. Together there are quite compelling indications that the body can regenerate entire bone segments with few or no exogenous factors. This is important, as there is a limit to how expensive a bone repair can be and still be widely available to all patients since cost restraints within healthcare systems are not likely to diminish in the near future. STATEMENT OF SIGNIFICANCE: This review is significant because it is a multidisciplinary view of several surgeons and scientists as to what is driving improvement in segmental bone defect repair, why many approaches to date have not succeeded and why some quite basic approaches can be as effective as they are. While there are many reviews of the literature of grafting and bone repair the relative lack of substantial improvement and slow rate of progress in clinical translation is often overlooked and we seek to challenge the reader to consider the issue more broadly.

Surgical Management of Patients with Snakebite-Related Musculoskeletal Complication-A Single Institution Experience in Cambodia

BACKGROUND

Snakebite-related injury is a serious public health issue. In Cambodia, it is estimated that up to 21,500 cases of envenoming occurs from snakebites annually. Musculoskeletal disability is a major long-term complication associated with the injury. In this study, we aim to describe surgical management and rehabilitation in snakebite-related musculoskeletal injuries at Children's Surgical Centre, Phnom Penh, Cambodia.

METHODS

We conducted a retrospective case series analysis of patients with snakebite-related injury who were treated between January 1, 2002 and December 31, 2018. Surgical patients were divided into the early and late presenting groups (= < one year vs. > one year, respectively) based on their time interval from snake bite to time of presentation.

RESULTS

There were 88 patients who presented with snakebite-related musculoskeletal injury during the cohort study period. Majority of them were male (n = 62, 71%) and had a median age of 24 years old (IQR 17-44). The injuries were all in the upper and lower limbs though lower limb injury was more common in female patients (81% vs. 48%, Fisher's test p = 0.005). The median time interval from snakebite to time of treatment was 3 years (IQR 3 months-11 years). In this study, 65 patients received surgical interventions. An ulcerated wound was the most common symptom among the early presenting group (78% vs. 24%), while scar contracture was most common among the late group (76% vs. 22%) (Fisher's test p < 0.0001). For management, surgical debridement was the most common primary intervention for the early group (52% vs. 19%), and contracture release was the most common for patients in the late group (62% vs. 15%) (Fisher's test p = 0.0004). Overall, the postoperative complication rate was highest in the late presenting group (34% vs. 3%, Fisher's test p = 0.005).

CONCLUSION

More than half of the patients presented with musculoskeletal injury require surgical correction. Our study demonstrated that scar contracture is the most common complaint among the late presenting group and is associated with high postoperative complication rate.

Peptide-coated polyurethane material reduces wound infection and inflammation

There is an urgent need for treatments that not only reduce bacterial infection that occurs during wounding but that also target the accompanying excessive inflammatory response. TCP-25, a thrombin-derived antibacterial peptide, scavenges toll-like receptor agonists such as endotoxins and lipoteichoic acid and prevents toll-like receptor-4 dimerization to reduce infection-related inflammation in vivo. Using a combination of biophysical, cellular, and microbiological assays followed by experimental studies in mouse and pig models, we show that TCP-25, when delivered from a polyurethane (PU) material, exerts anti-infective and anti-inflammatory effects in vitro and in vivo. Specifically, TCP-25 killed the common wound pathogens, Pseudomonas aeruginosa and Staphylococcus aureus, in both in vitro and in vivo assays. Furthermore, after its release from the PU material, the peptide retained its capacity to induce its helical conformation upon endotoxin interaction, yielding reduced activation of NF-κB in THP-1 reporter cells, and diminished accumulation of inflammatory cells and subsequent release of IL-6 and TNF-α in subcutaneous implant models in vivo. Moreover, in a porcine partial thickness wound infection model, TCP-25 treated infection with S. aureus, and reduced the concomitant inflammatory response. Taken together, these findings demonstrate a combined antibacterial and anti-inflammatory effect of TCP-25 delivered from PU in vitro, and in mouse and porcine in vivo models of localized infection-inflammation. STATEMENT OF SIGNIFICANCE: Local wound infections may result in systemic complications and can be difficult to treat due to increasing antimicrobial resistance. Surgical site infections and biomaterial-related infections present a major challenge for hospitals. In recent years, various antimicrobial coatings have been developed for infection prevention and current concepts focus on various matrices with added anti-infective components, including various antibiotics and antiseptics. We have developed a dual action wound dressing concept where the host defense peptide TCP-25, when delivered from a PU material, targets both bacterial infection and the accompanying inflammation. TCP-25 PU showed efficacy in in vitro and experimental wound models in mouse and minipigs.

Tooth extraction without discontinuation of oral antithrombotic treatment: A prospective study

OBJECTIVE

To identify which variable, among those related to surgeries, to patients, or to antithrombotic treatments, could be considered as a bleeding indicator, and to analyze effectiveness of the local hemostatic protocols used, incidence of bleeding and healing index, depending on the number of extracted teeth, and patient antithrombotic treatment.

METHODS

Patients who underwent tooth extractions without interruption or reduction of antithrombotic treatment were prospectively followed. The exact two-tailed Fisher test was used to investigate the relationship between presence/absence of bleeding and type of hemostatic material. The effect of variables on the probability of bleeding and healing index was assessed by means of a multivariate logistic regression.

RESULTS

Two hundred and fifty-four procedures were analyzed. The incidence of bleeding was 15.75%. Severe bleeding occurred in only 6 patients (2.34%). The number of involved dental quadrants and pre-surgical antibiotic treatments were found to be positively related with bleeding. The use of vasoconstrictors during surgery resulted in a reduction of healing index scores.

CONCLUSIONS

Tooth extractions in patients on antithrombotic treatment were found to be free from significant bleeding although the involvement of more than 1 quadrant in the same procedure should be avoided.

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.