Wound healing: a review. III. Nutritional factors affecting wound healing

Electrospinning of cyanoacrylate tissue adhesives for human dural repair in endonasal surgery

Cerebral spinal fluid (CSF) leakage is a major postoperative complication requiring surgical intervention, resulting in prolonged healing and higher costs. Biocompatible polymers, such as cyanoacrylates, are currently used as tissue adhesives for closing surgical defects and incisions. Coupling these polymers with nanofiber technology shows promising results for generating nanofibers used in wound care, tissue engineering, and drug delivery. Fiber membranes formed by electrospinning of n-octyl-2-cyanoacrylate (NOCA) are investigated for in situ dural closures after neurosurgery to improve the quality of the closure and prevent post-surgical CSF leaks. Electrospun NOCA fiber membranes showed significantly higher sealing capabilities of defects in human dura, with an average burst pressure of 149 mmHg, compared with that of an FDA-approved common dural sealant that had an average burst pressure of 37 mmHg. In this study, microfabrication of NOCA fibers demonstrates a promising technique for dural repairs.

Nutraceuticals in Periodontal Health: A Systematic Review on the Role of Vitamins in Periodontal Health Maintenance

Periodontal disease, a relevant public health problem worldwide, is generally considered a common pathology of elderly people. In this respect, there is agreement about that nutritional status may be a modifying factor in the progression and healing of the periodontal tissues. Vitamins have been recommended as nutraceuticals for prevention and treatment of some pathological conditions, such as cardiovascular diseases, obesity or cancer. Thus, a systematic approach to determining how the different vitamin type could ameliorate periodontal risks or improve periodontal health is necessary to further the understanding of the potential benefits and risks of vitamins supplementation use. For this, a systematic review of English-written literature in PubMed until February 2018, which included both human and animal research on the relationship of each vitamin with periodontal disease, was conducted. Among all the analyzed vitamins those with antioxidant capacity and effects on immune system seem to be useful for prevention or improvement of periodontal disease, as well as those implicated in bone metabolism. In the first case, there are quite information in favor of various vitamins, mainly vitamin C, that is the most studied. In the second case, vitamin D seems to have the most relevant role.

A prospective study of predictors for post laparotomy abdominal wound dehiscence

INTRODUCTION

Break in continuity of the skin with or without deeper tissues, following laparotomy, results in abdominal wound dehiscence. This study was done to evaluate the risk factors that lead to wound dehiscence in post-operative period.

MATERIAL AND METHODS

This was a prospective study done on 50 patients who developed wound dehiscence (partial or complete) following laparotomy. The pre-operative investigations, intra-operative findings and any post-operative complications were recorded in a specified Performa. Results : The highest incidence of wound dehiscence was found to be in patients of fourth decade, with male preponderance. 16 patients were found to be obese (BMI>30) and 13 patients were anemic. Twelve had low serum albumin, 16% had raised serum bilirubin while 4 patients were diabetics. Renal failure was found in 19 of 50 patients. 92% patients were with ASA score I E. In 88% of patients, laparotomy wounds were either contaminated or dirty. Post-operative nausea and vomiting was found in 10 patients and cough in 9 patients.

CONCLUSIONS

Abdominal wound dehiscence after laparotomy is a surgical emergency with high morbidity and mortality leading to escalation in hospital costs and prolonged illness. This complication can be avoided if the factors involved in wound dehiscence are properly addressed.

Association between dietary fat content and outcomes in pediatric burn patients

BACKGROUND

The aim of the study was to compare a low fat/high-carbohydrate diet and a high-fat diet on clinical outcomes by a retrospective cohort study.

METHODS

Nine hundred forty-four children with burns ≥ 40% of their total body surface area (TBSA) were divided into two groups: patients receiving Vivonex T.E.N. (low-fat/high-carbohydrate diet; n = 518) and patients receiving milk (high-fat diet; n = 426). Patient demographics, caloric intake, length of hospital stay, and incidence of sepsis, mortality, hepatic steatosis, and organomegaly at autopsy were determined.

RESULTS

Demographics and caloric intake were similar in both groups. Patients receiving Vivonex T.E.N. had shorter (intensive care unit) ICU stays (Vivonex T.E.N.: 31 ± 2 d; milk: 47 ± 2 d; P < 0.01), shorter ICU stay per % TBSA burn (Vivonex T.E.N.: 0.51 ± 0.02 d/%; milk: 0.77 ± 0.03 d/%; P < 0.01), lower incidence of sepsis (Vivonex T.E.N.: 11%; milk: 20%; P < 0.01), and lived significantly longer until death than those receiving milk (Vivonex T.E.N.: 20 ± 3 d; milk: 10 ± 2 d; P < 0.01). There was no difference in overall mortality between the two groups (Vivonex T.E.N.:15% versus milk: 13%; P < 0.9). Autopsies revealed decreased hepatic steatosis and decreased enlargement of kidney and spleen in patients receiving Vivonex T.E.N.

CONCLUSIONS

The period with a low-fat/high-carbohydrate diet was associated with lower LOS, decreased incidence of organomegaly, infection, and hepatic steatosis post-burn compared with the period when a high-fat diet was used. These associations indicate the benefit of high carbohydrate/low fat nutrition; however, the findings in these time periods can also be likely due to the multifactorial effects of advances in burn care. We believe that these results have some relevance because high fat is associated with poorer outcomes compared with low fat.

Extraordinary Implant Failure

Every attempt must be made to keep implant failures to a minimum. Dental implant failure can roughly be divided into 3 broad categories: bacterial factors, occlusal (mechanical factors), and systemic and psychologic factors. All failures should be carefully analyzed and evaluated to identify their causes in order to prevent future reoccurrence. Failures should be documented and used to advantage when treatment planning future implant cases. A panoramic radiograph, mounted diagnostic casts, medical and dental histories, and surgical guides are accepted standards of care prior to beginning oral implant procedures. The identification and management of nutritional deficiencies is a useful adjunct to successful implant treatment.

Nutritional considerations in institutionalized elders

PURPOSE OF REVIEW

The aim of this article is to emphasize the importance of malnutrition in frail institutionalized elderly and discuss recent interventions that have been shown to decrease its prevalence.

RECENT FINDINGS

A Medline search was conducted from 1968 to 2007 under the search terms aging, nutrition, and nursing homes. The most current reviews relevant to the care of institutionalized elders were selected for inclusion in this report. Recent reports have shown that application of screening protocols in long-tem care institutions improved nutritional status. A complete physical assessment, with special attention to the oral cavity, should be conducted. Monitoring of weight and intake should be part of the institutional routine, recognizing that there may be differences between prescribed diet and actual intake. Nutritional interventions should be tried as early as possible, including enhancement of environment and increasing staff to assist with feeding, as malnutrition in this population is associated with falls (particularly with deficient vitamin D) and increased morbidity and mortality. To optimally facilitate nutritional care of nursing home patients reforms are needed to facilitate optimal staffing in the institutional setting.

SUMMARY

It is important to educate healthcare workers in the nursing home about simple interventions that could improve nutritional status.

Rat epigastric flap survival and VEGF expression after local copper application

BACKGROUND

Copper has been used in wound healing since ancient times, and copper insufficiency seems to impair wound healing. Much less is known about the local effects of copper application on wound healing.

METHODS

The authors studied 30 male Sprague-Dawley rats weighing between 250 and 350 g for 5 days. Full-thickness random skin flaps, measuring 1.5 x 7.5 cm, were elevated on the epigastric region. The rats were randomized into two groups according to the local treatment that was used. In group 1 (20 animals), 1 ml of copper ointment was applied on the flap bed after flap suturing. In group 2 (10 animals), 1 ml of placebo ointment (petroleum jelly) was used. Intraperitoneal injection of 30 mg/kg body weight of Hypoxyprobe-1 was performed in each rat on the fourth postoperative day and all animals were killed 3 hours later. Histologic examination of the distal end of the flaps was used for detection of hypoxic tissue changes. Expression, density, and extent of vascular endothelial growth factor activity was detected with the aid of immunocytochemistry.

RESULTS

All rats survived throughout the study period. This experimental study showed that local application of copper at the random flap bed may promote wound-related angiogenesis by inducing vascular endothelial growth factor expression. The authors demonstrated statistically significant flap survival after local copper application at the flap bed.

CONCLUSION

The marked benefits of copper application in flap survival in this experimental model may guarantee its clinical application in flaps with questionable viability.

Chronic wounds

Chronic wounds are a challenge to treat for the clinician. We present a current overview of intrinsic and extrinsic factors in the development chronic nonhealing wounds. Solutions to some of these difficult problems are presented.

Perioperative Pharmacotherapy in Patients with Left Ventricular Assist Devices

Heart failure remains the leading cause of death in Western countries, affecting 4.9 million individuals and causing >300 000 deaths annually in the US alone. The disease is highly prevalent in the elderly population and often follows a course of progressive disability and deterioration. An estimated 15 000 patients with end-stage heart failure could benefit from heart transplant each year. Yet, as a result of a significant shortage of donor organs, only 2500 hearts are donated annually, and approximately one-third of patients awaiting heart transplant die each year. Mechanical circulatory support, primarily in the form of left ventricular assist devices (LVADs), has come to the forefront of treatment for severe congestive heart failure by providing a feasible alternative to patients who might otherwise die awaiting heart transplant. The arrival of LVADs has resulted in a dramatic shift in the management of heart failure, one that will undoubtedly affect and include a vast proportion of elderly patients. While LVADs represent a surgical approach to a disease that has traditionally been managed medically, the pharmacological application throughout the perioperative period remains of critical importance. Five primary classes of drugs bear specific application to the LVAD population: (i) drugs that provide haemodynamic support; (ii) antimicrobials; (iii) anticoagulants and antiplatelets; (iv) agents that promote myocardial recovery; and (v) miscellaneous other medications. Drugs that provide haemodynamic support are subdivided into inotropes, vasopressors and pulmonary vasodilators. Some combination of these medications is usually administered within the perioperative period in order to maintain stable patient haemodynamics and assure proper LVAD function. Antimicrobials are of paramount importance in the pre-, intra- and postoperative periods to minimise the risk of infection, an unfortunately common complication of LVAD therapy that can have potentially morbid consequences. Anticoagulants and antiplatelet medications are necessary for certain types of LVADs and serve to curb the incidence of device thrombus formation and associated embolic phenomena. Pharmacotherapeutic agents that facilitate myocardial recovery are being investigated as adjuncts to LVAD support so that bridge to recovery can become a realistic outcome for a growing number of LVAD patients. The miscellaneous class of medications used with LVADs includes those that minimise the risk of bleeding in select patients and those that enhance proper vitamin and nutrient status in the postoperative period, the attainment of which may serve vital to a successful recovery.

Effects of specific nutrients on periodontal disease onset, progression and treatment

OBJECTIVES

The aim of this paper is to review the available literature pertaining to the effects of specific nutritional elements (e.g. vitamin B-complex, vitamin C and dietary calcium) on general wound healing, periodontal disease status and response to periodontal therapy.

METHODS

Critical appraisal of various studies that have evaluated the effects of calcium, ascorbic acid and vitamin B-complex in wound healing and periodontal treatment.

RESULTS

Periodontal disease onset, progression and response to therapeutic interventions have been shown to be influenced by several systemic, local and environmental modifying factors. Nutritional supplementation has been suggested as a possible influencing factor on periodontal status and wound healing. Several studies have reported various degrees of association between nutritional elements/supplements and periodontal status, and others have reported possible positive influences of nutritional supplementation on periodontal therapeutic outcomes. Future research needs to more fully explore the presence and strength of association between nutrition and periodontal health.

CONCLUSIONS

Data collected from the literature suggests that nutrient supplementation causes minimal or no side effects. However, the efficacy of prophylactic nutrient supplementation for the prevention of the onset and progression of periodontal disease, or for the enhancement of periodontal wound healing, remains to be determined.

Physiology of wound healing and surgical wound care

Wound healing is a systemic process, which occurs stepwise and involves the stages of hemostasis, inflammation, and repair. Hemostasis with fibrin formation creates a protective wound scab. The scab provides a surface beneath which cell migration and movement of the wound edges can occur. Inflammation brings nutrients to the area of the wound, removes debris and bacteria, and provides chemical stimuli for wound repair. Repair begins immediately after wounding and proceeds rapidly through the processes of epithelialization, fibroplasia, and capillary proliferation into the healing area. Different tissues have their own normal rates of growth during the process of healing. The optimal rate of healing is approached when factors advantageous to healing are present and factors having the ability to disturb or retard the healing processes are controlled or absent. These factors are discussed.

Nutritional requirements of an aging population with emphasis on subacute care patients

Life expectancy in the United States has increased dramatically during the past century, creating a large population of people with potentially compromised nutritional status. Although requirements were previously believed to decline with aging, recent data suggest that requirements for protein and energy often do not decline and may actually increase during disease exacerbations. Optimal intake of vitamins and minerals is also under reevaluation, and significant segments of the population may have deficiencies based on limited intake or absorption. Social and psychological factors and difficulty chewing and swallowing may interfere with adequate intake. At the end of a hospital stay, many patients need continued skilled transitional care before discharge home. Many patients who have existing nutritional deficits, including weight loss, decreased serum proteins and pressure ulcers are admitted to subacute nursing facilities. Careful initial and periodic reassessment of nutritional status and aggressive nutritional management must be used to prepare patients for optimal independence after discharge. Improved clinical outcome can be achieved with prevention of malnutrition and timely correction of nutritional problems.

Impediments to wound healing

Chronic wounds will often heal in a short period of time if factors that inhibit wound healing are identified and managed. Recombinant growth factor therapy may provide an added stimulus to healing in certain types of chronic wounds. However, there remains no substitute for a physiologic environment conducive to tissue repair and regeneration, without which the efficacy of growth factor therapy is questionable. Some of the most commonly encountered and clinically significant impediments to wound healing include wound hypoxia, infection, presence of debris and necrotic tissue, use of anti-inflammatory medications, a diet deficient in vitamins or minerals, or general nutritional deficiencies, tumors, environmental factors, and metabolic disorders, such as diabetes mellitus. Treatment of chronic wounds should be directed against the main etiologic factors responsible for the wound. Moreover, factors that may impede healing must be identified and, if possible, corrected, for healing to occur.

Effects of nutrition on wound healing

Optimal wound healing and its close relationship to a patient's positive nutritional balance is well known. For years, physicians have attempted to improve the metabolic status of patients after surgery or trauma. Currently, major emphasis is placed on perioperative nutritional status and its effect on postoperative wound healing. The intricacies of metabolism and healing are areas of current active research, in an effort to advance the quality of patient care. For the head and neck surgeon, wound healing is of paramount concern in areas of tumor extirpation, head and neck reconstruction, and maximization of postoperative functional recovery. To better explain why adequate nutrition is important in postoperative wound healing, we will provide a brief synopsis of nutrition and its relationship to wound healing.

Leg ulcers

The treatment of leg ulcers is a common and sometimes difficult problem. They can be costly to treat and are associated with loss of working capacity and sometimes significant morbidity. In the western world, leg ulcers are most frequently caused by venous insufficiency, arterial insufficiency, neuropathy (usually diabetic), or a combination of these factors. The pathogenesis, clinical features, and management of these types of leg ulcers are emphasized in this review.

Effect of early postoperative nutritional support on skin wound and colon anastomosis healing

Improved healing occurs in nutritionally depleted rats given early postoperative compared with delayed feeding. The present study was designed to test the hypothesis that delay in postoperative feeding of rats normally nourished at the time of operation would also be detrimental to wound healing. Fully nourished rats weighing 288 to 342 g were divided into three groups (10 rats per group). All rats had central vein catheters inserted, celiotomy with division and reanastomsis of the colon and dorsal skin incisions, under ip pentobarbital anesthesia. With no oral intake allowed postoperatively, group 1 rats were maintained in iv 5% Dextrose electrolytes and vitamins (5% DSV); group 2 was given the 5% D/SV until the third postoperative day when they were placed on TPN (4.5% amino acids 15% Dextrose, 10% Intralipids); and group 3 was given TPN from the first postoperative day. Rats were sacrificed 6 days postoperatively and final weight, skin wound breaking strength (WBS) and colon anastomosis bursting pressure (CBP) were measured. Findings were % weight change -27.8 +/- 1.5 for Group 1, -12.6 +/- 1.0 for Group 2, and -6.9 +/- 8 for group 3 (p less than 0.0001). Wound measurements for STS on fresh specimens were 88.6 +/- 10.0 g for group 1, 89.1 +/- 8.4 g for group 2, and 87.1 +/- 11.1 g for group 3. WBS for formalin-fixed specimens were 313.5 +/- 29.7 g for group 1, 323.4 +/- 38.4 g for group 2, and 382 +/- 25.2 g for group 3 (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Feeding the rat intravenously with ketone bodies following colon anastomosis

Ketone bodies are an important metabolic fuel for the gastrointestinal system and as a consequence may promote colonic healing. Ketone bodies and glucose were compared in a dose dependent manner as nonprotein fuels for support of resected colon. Rats had their descending colons resected and received all nutrients by vein for 5 days postoperation. Colonic healing was evaluated from the air pressure required to break the wound. All rats received constant nutrients except for non-protein energy which was fed at 10.5, 21, 31.5, and 42 kcal/day using either glucose or monoacetoacetin as substrate. Colonic bursting pressure was measured on day 5 after surgery. When energy intake was 21 kcal/day or greater, the bursting pressure was two-thirds of nonwounded tissue and was independent of energy quantity and source. At 10.5 kcal/day, bursting pressure for glucose-fed animals was similar to that for animals with no added nonprotein energy while, in contrast, bursting pressure for animals fed monoacetoacetin was similar to that for animals fed 42 kcal/day. It was concluded that bursting pressure was influenced by dietary intake only if the energy intake was sufficiently low, and then ketone bodies were better than glucose for support of colonic healing.

Wound healing for the dermatologic surgeon

An understanding of the basic science of cutaneous wound repair is essential to the dermatologic surgeon for the management of the postoperative wound. This review discusses the stages of wound healing and then applies these principles to the preoperative, intraoperative, and postoperative management of the surgical patient.

Effects of pantothenic acid on fibroblastic cell cultures

To evaluate the effects of pantothenic acid during wound healing processes, fibroblastic cell cultures originating from foreskin were established and subcultured by trypsinization. PA (40 micrograms/ml) was added to the basal culture medium. The cell proliferation was estimated by cell count and determination of 3H-thymidine incorporation. The protein synthesis and secretion were determined by dosage in the cells and in the culture medium. When PA was added to the medium, a significant increase of cell proliferation and of 3H-thymidine incorporation was observed mainly during the first few days. PA also stimulated intracellular protein synthesis, but did not induce a release of proteins in the culture medium. The exact mechanism involved in this phenomenon remains unclear at this time.

Wound healing response in surgical patients: recent food intake is more important than nutritional status

We have recently found that an impairment of the wound healing response (WHR) occurs in surgical patients with protein-energy malnutrition before there are any measurable changes in body fat and protein stores. The hypothesis of this study was that the patients' recent food intake is more important in determining the WHR than the patients' overall nutritional status. We have measured the recent food intake (by dietary recall), the WHR (by hydroxyproline accumulation in subcutaneous GORE-TEX implants), the pre-operative weight loss (per cent), and body fat and protein stores (by in vivo neutron activation analysis) in 83 patients awaiting a major elective gastrointestinal resection, and divided them into two groups: adequate recent food intake (n = 59) and inadequate recent food intake (n = 24). There was no significant difference between these two groups for age, sex, diagnosis, surgical procedure, weight loss (per cent), or the amount of body fat and protein stores but there was a significant difference in the WHR (1.81 +/- 0.16 s.e.m. versus 1.04 +/- 0.22 s.e.m. nmol hydroxyproline/mg GORE-TEX, P less than 0.005). These results show that pre-operative food intake has a greater influence over the wound healing response than absolute losses of protein and fat from body stores and they suggest that the maintenance of a normal food intake up until the time of surgery is of importance in preventing an impairment of the wound healing response.

Role of nutrition in wound healing

Nutritional cofactors play a major role in the wound-healing process. Deficiencies of specific nutrients, especially proteins, vitamins, and minerals, may significantly impair the healing process. The recognition of deficits and understanding of methods of repletion are a critical part of modern surgical practice.

Preoperative total parenteral nutrition and surgical outcome in patients with inflammatory bowel disease

Further trials are needed to identify the preoperative patient who will have a significantly improved postoperative outcome with the use of total parenteral nutrition. Better nutritional markers are needed to evaluate the response to total parenteral nutrition and to help identify the irreducible minimum that should be given. In our series, patients who received preoperative total parenteral nutrition for at least 5 days had significantly fewer postoperative complications (p less than 0.05) than those who did not. All patients with postoperative complications had either a preoperative serum albumin level less than 3.5 g/dl or a serum transferrin level less than 150 mg/dl. Preoperative total parenteral nutrition for at least 5 days is strongly recommended in patients with inflammatory bowel disease who have severe protein depletion.