Aging influences wound healing in patients with chronic lower extremity wounds treated in a specialized wound care center

The role of split-thickness skin grafting in the treatment of vasculitic and pyoderma gangrenosum ulcers in a multidisciplinary wound centre

Vasculitic and pyoderma gangrenosum ulcers are traditionally treated with immunosuppressants, and the role of surgery in the treatment of these atypical ulcers remains unclear. This study aimed to investigate the need for surgical intervention as well as the outcome and safety of skin grafting in the treatment of 46 patients with vasculitic ulcers and 34 with pyoderma gangrenosum ulcers using data recorded in the validated Wound Registry. Of the 80 patients with atypical ulcers, 14% (n = 11) were treated surgically; these patients were older (p = 0.039), had lower mobility status (p = 0.002), and more often pulmonary diseases, rheumatoid arthritis, and previous arterial procedures (p = 0.007; p = 0.031; p = 0.031, respectively) than those treated conservatively. Of 181 ulcers, 15% (n = 27) were surgically treated, 78% once and 22% multiple times. During follow-up, 92.3% of both surgically and conservatively treated ulcers with available data healed. Of the surgically treated ulcers, median healing time after first surgical procedure was 96 days, and post-surgical complications were considered mild or unrelated to surgery. Our results suggest that if surgery is indicated, skin grafting is a safe and efficient treatment method provided that multidisciplinary approach is applied.

Collagen-Based Scaffolds for Chronic Skin Wound Treatment

Chronic wounds, commonly known as ulcers, represent a significant challenge to public health, impacting millions of individuals every year and imposing a significant financial burden on the global health system. Chronic wounds result from the interruption of the natural wound-healing process due to internal and/or external factors, resulting in slow or nonexistent recovery. Conventional medical approaches are often inadequate to deal with chronic wounds, necessitating the exploration of new methods to facilitate rapid and effective healing. In recent years, regenerative medicine and tissue engineering have emerged as promising avenues to encourage tissue regeneration. These approaches aim to achieve anatomical and functional restoration of the affected area through polymeric components, such as scaffolds or hydrogels. This review explores collagen-based biomaterials as potential therapeutic interventions for skin chronic wounds, specifically focusing on infective and diabetic ulcers. Hence, the different approaches described are classified on an action-mechanism basis. Understanding the issues preventing chronic wound healing and identifying effective therapeutic alternatives could indicate the best way to optimize therapeutic units and to promote more direct and efficient healing.

Managing Complex Wounds in Skilled Nursing Facilities (SNFs)

Wounds, especially chronic wounds, can be clinically challenging to manage. The presence of a chronic wound in a patient can not only cause nociceptive pain but also psychological and emotional pain. In extreme cases, they can be life-threatening if they present with infection and sepsis from poor wound care. This paper highlights the care of a patient in a skilled nursing facility who presented with a very complicated post-surgical abdominal wound, secondary to an infected post-surgical incision. The skilled nursing facility was very concerned about the size, depth, and nature of the wound, and talks were underway to transfer the patient to a different long-term acute care facility or to the hospital for more specialized care. Thanks to the weekly rounds of a specialized wound care physician to the facility, and a dedicated wound care nurse to execute the physician's orders, the wound was adequately cared for and close to resolution at the time of the patient's discharge to home.

Effectiveness of Secretome from Human Umbilical Cord Mesenchymal Stem Cells in Gel (10% SM-hUCMSC Gel) for Chronic Wounds (Diabetic and Trophic Ulcer) - Phase 2 Clinical Trial

Background

Chronic wounds carry financial burdens and increase morbidity and mortality, especially in diabetic ulcers and Hansen's Morbus. More than 50% of chronic ulcers are difficult to heal with regular treatment and require new types of therapy such as the use of secretome of human umbilical cord mesenchymal stem cells (SM-hUCMSC).

Methods

This experimental study was carried out to see the effectiveness of using SM-hUCMSC in diabetic ulcers and Hansen's Morbus in four medical facilities (multicentre). The level of active secretion has been measured by default in 10% SM-hUCMSC gel, used as a treatment intervention. The primary outcome is wound healing in terms of the length, width, and extent of the wound. The secondary is the side effects of treatment 2 weeks after administration. Follow-up visits will be scheduled at 1 and 2 weeks post-treatment.

Results

Forty-one chronic ulcers successfully followed the study until the end. In patients with chronic ulcers, the mean ulcer length, width, and area were 1.60 (0,50-13,0), 1.3 (0,5-6,0), and 2.21 (0,25-78) cm square, respectively, before interventions and 1 (0-12), 0,8 (0-6,0), and 1 (0-72) square cm after interventions at the second follow-up. The change between the beginning and end of the intervention was significant (p-value <0.05).

Conclusion

The use of 10% SM-hUCMSC gel topically has been proven effective in accelerating the process of wound healing, especially chronic ulcers with side effects that are not present in this study.

Hyperbaric Oxygen Therapy for Nonhealing Wounds-A Long-term Retrospective Cohort Study

OBJECTIVE

To analyze wound healing results of hyperbaric oxygen therapy (HBOT) for a variety of different wound types.

METHODS

This retrospective cohort study included all patients treated with HBOT and wound care at a single hyperbaric center between January 2017 and December 2020. The primary outcome was wound healing. Secondary outcome measures were quality of life (QoL), number of sessions, adverse effects, and treatment cost. Investigators also examined possible influencing factors, including age, sex, type and duration of wound, socioeconomic status, smoking status, and presence of peripheral vascular disease.

RESULTS

A total of 774 treatment series were recorded, with a median of 39 sessions per patient (interquartile range, 23-51 sessions). In total, 472 wounds (61.0%) healed, 177 (22.9%) partially healed, 41 (5.3%) deteriorated, and 39 (5.0%) minor and 45 (5.8%) major amputations were performed. Following HBOT, median wound surface area decreased from 4.4 cm 2 to 0.2 cm 2 ( P < .01), and patient QoL improved from 60 to 75 on a 100-point scale ( P < .01). The median cost of therapy was €9,188 (interquartile range, €5,947-€12,557). Frequently recorded adverse effects were fatigue, hyperoxic myopia, and middle ear barotrauma. Attending fewer than 30 sessions and having severe arterial disease were both associated with a negative outcome.

CONCLUSIONS

Adding HBOT to standard wound care increases wound healing and QoL in selected wounds. Patients with severe arterial disease should be screened for potential benefits. Most reported adverse effects are mild and transient.

The Skin Microbiome: Current Techniques, Challenges, and Future Directions

Skin acts as a barrier that promotes the colonization of bacteria, fungi, archaea, and viruses whose membership and function may differ depending on the various specialized niches or micro-environments of the skin. The group of microorganisms inhabiting the skin, also known as the skin microbiome, offers protection against pathogens while actively interacting with the host's immune system. Some members of the skin microbiome can also act as opportunistic pathogens. The skin microbiome is influenced by factors such as skin site, birth mode, genetics, environment, skin products, and skin conditions. The association(s) of the skin microbiome with health and disease has (have) been identified and characterized via culture-dependent and culture-independent methods. Culture-independent methods (such as high-throughput sequencing), in particular, have expanded our understanding of the skin microbiome's role in maintaining health or promoting disease. However, the intrinsic challenges associated with the low microbial biomass and high host content of skin microbiome samples have hindered advancements in the field. In addition, the limitations of current collection and extraction methods and biases derived from sample preparation and analysis have significantly influenced the results and conclusions of many skin microbiome studies. Therefore, the present review discusses the technical challenges associated with the collection and processing of skin microbiome samples, the advantages and disadvantages of current sequencing approaches, and potential future areas of focus for the field.

Ketoprofen-Based Polymer-Drug Nanoparticles Provide Anti-Inflammatory Properties to HA/Collagen Hydrogels

Current limitations of wound dressings for treating chronic wounds require the development of novel approaches. One of these is the immune-centered approach, which aims to restore the pro-regenerative and anti-inflammatory properties of macrophages. Under inflammatory conditions, ketoprofen nanoparticles (KT NPs) can reduce pro-inflammatory markers of macrophages and increase anti-inflammatory cytokines. To assess their suitability as part of wound dressings, these NPs were combined with hyaluronan (HA)/collagen-based hydro- (HGs) and cryogels (CGs). Different HA and NP concentrations and loading techniques for NP incorporation were used. The NP release, gel morphology, and mechanical properties were studied. Generally, colonialization of the gels with macrophages resulted in high cell viability and proliferation. Furthermore, direct contact of the NPs to the cells reduced the level of nitric oxide (NO). The formation of multinucleated cells on the gels was low and further decreased by the NPs. For the HGs that produced the highest reduction in NO, extended ELISA studies showed reduced levels of the pro-inflammatory markers PGE2, IL-12 p40, TNF-α, and IL-6. Thus, HA/collagen-based gels containing KT NPs may represent a novel therapeutic approach for treating chronic wounds. Whether effects observed in vitro translate into a favorable profile on skin regeneration in vivo will require rigorous testing.

The Skin Microbiome: Current Landscape and Future Opportunities

Our skin is the largest organ of the body, serving as an important barrier against the harsh extrinsic environment. Alongside preventing desiccation, chemical damage and hypothermia, this barrier protects the body from invading pathogens through a sophisticated innate immune response and co-adapted consortium of commensal microorganisms, collectively termed the microbiota. These microorganisms inhabit distinct biogeographical regions dictated by skin physiology. Thus, it follows that perturbations to normal skin homeostasis, as occurs with ageing, diabetes and skin disease, can cause microbial dysbiosis and increase infection risk. In this review, we discuss emerging concepts in skin microbiome research, highlighting pertinent links between skin ageing, the microbiome and cutaneous repair. Moreover, we address gaps in current knowledge and highlight key areas requiring further exploration. Future advances in this field could revolutionise the way we treat microbial dysbiosis associated with skin ageing and other pathologies.

Larval Therapy and Larval Excretions/Secretions: A Potential Treatment for Biofilm in Chronic Wounds? A Systematic Review

Chronic wounds present a global healthcare challenge and are increasing in prevalence, with bacterial biofilms being the primary roadblock to healing in most cases. A systematic review of the to-date knowledge on larval therapy's interaction with chronic-wound biofilm is presented here. The findings detail how larval therapy-the controlled application of necrophagous blowfly larvae-acts on biofilms produced by chronic-wound-relevant bacteria through their principle pharmacological mode of action: the secretion and excretion of biologically active substances into the wound bed. A total of 12 inclusion-criteria-meeting publications were identified following the application of a PRISMA-guided methodology for a systematic review. The findings of these publications were qualitatively analyzed to provide a summary of the prevailing understanding of larval therapy's effects on bacterial biofilm. A further review assessed the quality of the existing evidence to identify knowledge gaps and suggest ways these may be bridged. In summary, larval therapy has a seemingly unarguable ability to inhibit and degrade bacterial biofilms associated with impaired wound healing. However, further research is needed to clarify and standardize the methodological approach in this area of investigation. Such research may lead to the clinical application of larval therapy or derivative treatments for the management of chronic-wound biofilms and improve patient healing outcomes at a time when alternative therapies are desperately needed.

Is the Increase in Record of Skin Wounds in Hospitalized Patients in Internal Medicine Units a Side Effect of the COVID-19 Pandemic?

Wound care is an important public health challenge that is present in all areas of the healthcare system, whether in hospitals, long term care institutions or in the community. We aimed to quantify the number of skin wounds reported after and during the COVID-19 pandemic. This descriptive longitudinal retrospective study compared of wound records in patients hospitalized in the internal medicine service during the first year of the COVID-19 pandemic (from 1 March 2020, to 28 February 2021) and previous-year to the outbreak (from 1 January 2019, to 31 December 2019). A sample of 1979 episodes was collected corresponding to 932 inpatients, 434 from the pre-pandemic year and 498 from the first year of COVID-19 pandemic; 147 inpatients were diagnosed with SARS-CoV-2 infection (3.2%). The percentage of wound episodes in the first year of the COVID-19 pandemic was higher than the pre-pandemic year, 17.9% (1092/6090) versus 15% (887/5906), with a significant increase in the months with the highest incidence of COVID cases. This study shows an increase in the burden of wound care during the COVID-19 pandemic, and it could be attributable to the increase in the number of patients hospitalized for SARS-CoV-2 infection in internal medicine units.

Psychometric properties of Persian version of wound-QOL questionnaire among older adults suffering from chronic wounds

Background

Patients with chronic wounds experience various biopsychosocial problems which severely affects their quality of life (QoL). Thus, a Persian instrument to assess the QoL of these patients is required. This study aimed to determine the psychometric properties of the Persian version of the wound-QOL questionnaire.

Methods

This methodological study was performed on Iranian patients during 2021-2022. The translation was carried out via forward-backward method. Face validity was addressed with 10 patients and content validity with 12 wound specialists. Construct validity was also assessed by performing exploratory factor analysis (EFA) (n = 100) and convergent validation with EQ-5D-3L plus Pain VAS Score and known-groups validity. The reliability was assessed by internal consistency using Cronbach's alpha coefficient and test-retest.

Results

A total of 100 patients with chronic wounds were included in the study. Two factors with cumulative variance of 65.39% were extracted during EFA. The results revealed a significant and high correlation between the total scores of wound-QOL questionnaire, the Persian version of EQ-5D-3L (p = 0.000, r = 0.502), and Pain score (0-10; p = 0.000, r = 0.627). The Cronbach's alpha was 0.743 and stability of the questionnaire (α = 0.872) was confirmed. In confirming the known-groups validity, the results showed that this tool can differentiate the QOL of patients with different wounds.

Conclusion

The Persian version of the wound-QOL questionnaire is a valid and reliable questionnaire which can measure the QoL of patients with chronic wounds. This instrument can be used in clinical evaluation as well as research purposes across the Iranian population.

Fabrication and Bioactivity of Peptide-Conjugated Biomaterial Tissue Engineering Constructs

Tissue engineering combines materials engineering, cells and biochemical factors to improve, restore or replace various types of biological tissues. A nearly limitless combination of these strategies can be combined, providing a means to augment the function of a number of biological tissues such as skin tissue, neural tissue, bones, and cartilage. Compounds such as small molecule therapeutics, proteins, and even living cells have been incorporated into tissue engineering constructs to influence biological processes at the site of implantation. Peptides have been conjugated to tissue engineering constructs to circumvent limitations associated with conjugation of proteins or incorporation of cells. This review highlights various contemporary examples in which peptide conjugation is used to overcome the disadvantages associated with the inclusion of other bioactive compounds. This review covers several peptides that are commonly used in the literature as well as those that do not appear as frequently to provide a broad scope of the utility of the peptide conjugation technique for designing constructs capable of influencing the repair and regeneration of various bodily tissues. Additionally, a brief description of the construct fabrication techniques encountered in the covered examples and their advantages in various tissue engineering applications is provided.

Preparation of therapy-grade extracellular vesicles from adipose tissue to promote diabetic wound healing

Background: Treatment of diabetic wounds is a major challenge in clinical practice. Extracellular vesicles (EVs) from adipose-derived stem cells have shown effectiveness in diabetic wound models. However, obtaining ADSC-EVs requires culturing vast numbers of cells, which is hampered by the need for expensive equipment and reagents, extended time cost, and complicated procedures before commercialization. Therefore, methods to extract EVs from discarded tissue need to be developed, for immediate application during surgery. For this reason, mechanical, collagenase-digestive, and constant in-vitro-collective methods were designed and compared for preparing therapy-grade EVs directly from adipose tissue. Methods: Characteristics and quantities of EVs were detected by transmission electron microscopy, nanoparticle tracking analysis, and Western blotting firstly. To investigate the biological effects of EVs on diabetic wound healing, angiogenesis, proliferation, migration, and inflammation-regulation assays were then evaluated in vitro, along with a diabetic wound healing mouse model in vivo. To further explore the potential therapeutic mechanism of EVs, miRNA expression profile of EVs were also identified and analyzed. Results: The adipose tissue derived EVs (AT-EVs) were showed to qualify ISEV identification by nanoparticle tracking analysis and Western blotting and the AT-EVs yield from three methods was equal. EVs also showed promoting effects on biological processes related to diabetic wound healing, which depend on fibroblasts, keratinocytes, endothelial cells, and macrophages both in vitro and in vivo. We also observed enrichment of overlapping or unique miRNAs originate from different types of AT-EVs associated with diabetic wound healing for further investigation. Conclusion: After comparative analyses, a mechanical method was proposed for preparing immediate clinical applicable EVs from adipose tissue that would result in reduced preparation time and lower cost, which could have promising application potential in treating diabetic wounds.

Chelating the valley of death: Deferoxamine's path from bench to wound clinic

There is undisputable benefit in translating basic science research concretely into clinical practice, and yet, the vast majority of therapies and treatments fail to achieve approval. The rift between basic research and approved treatment continues to grow, and in cases where a drug is granted approval, the average time from initiation of human trials to regulatory marketing authorization spans almost a decade. Albeit with these hurdles, recent research with deferoxamine (DFO) bodes significant promise as a potential treatment for chronic, radiation-induced soft tissue injury. DFO was originally approved by the Food and Drug Administration (FDA) in 1968 for the treatment of iron overload. However, investigators more recently have posited that its angiogenic and antioxidant properties could be beneficial in treating the hypovascular and reactive-oxygen species-rich tissues seen in chronic wounds and radiation-induced fibrosis (RIF). Small animal experiments of various chronic wound and RIF models confirmed that treatment with DFO improved blood flow and collagen ultrastructure. With a well-established safety profile, and now a strong foundation of basic scientific research that supports its potential use in chronic wounds and RIF, we believe that the next steps required for DFO to achieve FDA marketing approval will include large animal studies and, if those prove successful, human clinical trials. Though these milestones remain, the extensive research thus far leaves hope for DFO to bridge the gap between bench and wound clinic in the near future.

Prevalence and prognosis of hard-to-heal wounds with comorbidities in China

OBJECTIVE

Regular retrospective analysis is necessary for potential improvement in clinical practice for the treatment of hard-to-heal wounds. Comorbidities and outcomes have demonstrated spatial and temporal diversity, emphasising the importance of updates in epidemiology. The complexity of healing hard-to-heal wounds has long been known, and so we sought evidence-based improvement on the current principles of treatment.

METHOD

Demographic and clinical information of patients from the WoundCareLog database was collected. Patients who met the inclusion criteria and completed follow-up after treatment were included. Comorbidities were diagnosed and classified into eight categories based on ICD-10. We compared the demographic and aetiological characteristics between patients with and without comorbidities by t-test and Chi-squared test. The impact of comorbidities on wound healing were evaluated with a multivariate Cox model.

RESULTS

A total of 2163 patients met the inclusion criteria and were enrolled, of whom 37.0% were aged 61-80 years, 36.0% were aged 41-60 years and 60.8% were male. The lower extremities and buttocks were the most commonly affected areas with hard-to-heal wounds. Non-traumatic wounds accounted for 66.6% of cases, and infection, pressure and diabetes were the most common causes. Paralysis and diabetes were the most important factors which led to a prolonged healing process and inferior clinical outcomes.

CONCLUSION

Comorbidities of hard-to-heal wounds were treated as separate contributors and their weighted effect on outcome was calculated through correlation analysis. Paralysis and diabetes were the most unfavourable comorbidities affecting the treatment of non-traumatic hard-to-heal wounds. Our study highlighted the priority of comorbidity treatment through data-driven approaches. It provides potential value in developing better public health strategies and preventive medicine.

A Biomaterial Model to Assess the Effects of Age in Vascularization

As humans age, there is an increased risk for developing age-associated diseases. Many of these diseases, such as cardiovascular disease, involve dysfunction in the vasculature. Cardiovascular disease stems from endothelial cell dysfunction and reduction in vascularization. Macrophages, prominent innate immune cells involved in orchestrating inflammation and wound healing, have a significant influence on vascularization. While much recent work has investigated the crosstalk between endothelial cells and macrophages, it is still not well defined. The interactions between the cell types are even less understood in specific disease states such as advanced age. Understanding how age influences macrophage/endothelial cell interaction is essential for understanding cardiovascular disease development in the elderly. In the polyethylene glycol (PEG)-based hydrogel system, we model the effects of age on vascularization by encapsulating endothelial cells, pericytes, and human donor macrophages. We created a biomaterial model system in which macrophages, either from young (<35 years old) or old (>65 years old) donors, interact with the modeled vasculature, termed microvessels. Confocal image analysis of vessel density, vessel length, and branch points were used to quantify microvessel growth depending on the age of the macrophage donor. Alongside this, soluble factor secretion and gene expression were evaluated using ELISA and NanoString to showcase biological mechanisms based on the age of each donor. Endothelial cells cultured with macrophages from old donors have reduced microvessel density. There also is reduced soluble factor secretion by the macrophages from old donors, which likely influenced microvessel growth. Altogether, we establish our PEG-based hydrogel vascular model as a system to evaluate patient-specific cell function as well as proposed mechanisms for how age influences microvessels.

Role of copper nanoparticles in wound healing for chronic wounds: literature review

Chronic wounds are defined as wounds that fail to proceed through the normal phases of wound healing in an orderly and timely manner. The most common and inevitable impairment to wound healing is the installation of an infection, usually in the case of chronic wounds. Therefore, the objective of the present review was to identify the importance of copper nanoparticles in dressings for wound healing. Nanoparticles such as silver, gold and copper combat infectious processes through the inhibition of protein synthesis, peroxidation of the cell membrane and destroying the nucleic acids of bacteria and viruses. Among bioactive nanoparticles, copper plays a complex role in various cells, it modulates several cytokines and growth factor mechanisms of action and is essentially involved in all stages of the wound healing process. More importantly, copper plays a key role in skin regeneration and angiogenesis and accelerates the healing process through induction of vascular endothelial growth factor (VEGF) and angiogenesis by hypoxia-induced factor-1-alpha (HIF-1α) action where copper enhances HIF-1α expression and HIF-1α binding to the critical motifs in the promoter and putative enhancer regions of HIF-1-regulated genes.

The Regenerative Potential of Substance P

Wound healing is a highly coordinated process which leads to the repair and regeneration of damaged tissue. Still, numerous diseases such as diabetes, venous insufficiencies or autoimmune diseases could disturb proper wound healing and lead to chronic and non-healing wounds, which are still a great challenge for medicine. For many years, research has been carried out on finding new therapeutics which improve the healing of chronic wounds. One of the most extensively studied active substances that has been widely tested in the treatment of different types of wounds was Substance P (SP). SP is one of the main neuropeptides released by nervous fibers in responses to injury. This review provides a thorough overview of the application of SP in different types of wound models and assesses its efficacy in wound healing.

Use of autologous conditioned serum dressings in hard-to-heal wounds: a randomised prospective clinical trial

OBJECTIVE

In this study, we aimed to assess both the efficacy and tolerability of autologous conditioned serum (ACS) as an innovative wound dressing in the local management of hard-to-heal wounds.

METHOD

In this single-blinded randomised controlled trial, patients with hard-to-heal wounds were randomly assigned to receive either ACS treatment or normal saline (NS) dressings. The treatment was applied once a week for three weeks with a final assessment at three weeks from the first ACS application.

RESULTS

A total of 30 patients took part in the study. Analysis of wound assessment data demonstrated statistically significant differences for wound surface area and Pressure Ulcer Scale for Healing scores (area score, exudate and tissue) from baseline to the end of the study in patients who received the ACS dressing, but not in patients who received the normal saline dressing. There were statistically significant differences in changes in: the wound surface area at week three (-6.4±2.69cm² versus +0.4±2.52cm²); area score at week three (-2.2±1.08 versus +0.2±0.86); exudate at week two (-1.2±0.70 versus +0.0±0.45) and at week 3 (-1.3±0.72 versus -0.1±0.63); tissue at week two (-1.1±0.35 versus +0.0±0.53) and at week three (-1.8±0.65 versus -0.1±0.63); and the PUSH total score at week one (-1.6±0.98 versus +0.4±1.22), week two (-3.2±0.86 versus +0.4±0.98) and week three (-5.3±1.17 versus -0.0±1.33) between the ACS and NS groups, respectively.

CONCLUSION

This trial revealed a significant decrease in wound surface area as well as a considerable improvement in wound healing in the ACS dressing group.

Epithelial arginase-1 is a key mediator of age-associated delayed healing in vaginal injury

Pelvic organ prolapse is a disorder that substantially affects the quality of life of millions of women worldwide. The greatest risk factors for prolapse are increased parity and older age, with the largest group requiring surgical intervention being post-menopausal women over 65. Due to ineffective healing in the elderly, prolapse recurrence rates following surgery remain high. Therefore, there is an urgent need to elucidate the cellular and molecular drivers of poor healing in pelvic floor dysfunction to allow effective management and even prevention. Recent studies have uncovered the importance of Arginase 1 for modulating effective healing in the skin. We thus employed novel in vitro and in vivo vaginal injury models to determine the specific role of Arginase 1 in age-related vaginal repair. Here we show, for the first time, that aged rat vaginal wounds have reduced Arginase 1 expression and delayed healing. Moreover, direct inhibition of Arginase 1 in human vaginal epithelial cells also led to delayed scratch-wound closure. By contrast, activation of Arginase 1 significantly accelerated healing in aged vaginal wounds in vivo, to rates comparable to those in young animals. Collectively, these findings reveal a new and important role for Arginase 1 in mediating effective vaginal repair. Targeting age-related Arginase 1 deficiency is a potential viable therapeutic strategy to promote vaginal healing and reduce recurrence rate after surgical repair of pelvic organ prolapse.

Assessment of frailty in elderly patients attending a multidisciplinary wound care centre: a cohort study

BACKGROUND

The incidence of frailty and non-healing wounds increases with patients' age. Knowledge of the relationship between frailty and wound healing progress is greatly lacking.

METHODS

The aim of this study is to characterize the degree of frailty in elderly patients attending a multidisciplinary wound care centres (MWCC). Additionally, we seek to assess the impact of frailty on the wound healing rate and wound healing time. An open cohort study was conducted on 51 consecutive patients aged > 70 years treated for wounds at an MWCC of an intermediate care hospital. The frailty score was determined according to the Frail-VIG index. Data were collected through patient questionnaires at the beginning of the study, and at 6 months or upon wound healing. Wounds were followed up every 2 weeks. To analyse the relationship between two variables was used the Chi-square test and Student's or the ANOVA model. The t-test for paired data was used to analyse the evolution of the frailty index during follow-up.

RESULTS

A total of 51 consecutive patients were included (aged 81.1 ± 6.1 years). Frailty prevalence was 74.5% according to the Frail-VIG index (47.1% mildly frail, 19.6% moderately frail, and 7.8% severely frail). Wounds healed in 69.6% of cases at 6 months. The frailty index (FI) was higher in patients with non-healing wounds in comparison with patients with healing wounds (IF 0.31 ± 0.15 vs IF 0.24 ± 0.11, p = 0.043). A strong correlation between FI and wound healing results was observed in patients with non-venous ulcers (FI 0.37 ± 0.13 vs FI 0.27 ± 0.10, p = 0.015). However, no correlation was observed in patients with venous ulcers (FI 0.17 ± 0.09 vs FI 0.19 ± 0.09, p = 0.637). Wound healing rate is statically significantly higher in non-frail patients (8.9% wound reduction/day, P25-P75 3.34-18.3%/day;AQ6 p = 0.044) in comparison with frail patients (3.26% wound reduction/day, P25-P75 0.8-8.8%/day).

CONCLUSION

Frailty is prevalent in elderly patients treated at an MWCC. Frailty degree is correlated with wound healing results and wound healing time.

Efficacy and safety of biofilm dispersal by glycoside hydrolases in wounds

Novel anti-biofilm and dispersal agents are currently being investigated in an attempt to combat biofilm-associated wound infections. Glycoside hydrolases (GHs) are enzymes that hydrolyze the glycosidic bonds between sugars, such as those found within the exopolysaccharides of the biofilm matrix. Previous studies have shown that GHs can weaken the matrix, inducing bacterial dispersal, and improving antibiotic clearance. Yet, the number of GH enzymes that have been examined for potential therapeutic effects is limited. In this study, we screened sixteen GHs for their ability to disperse mono-microbial and polymicrobial biofilms grown in different environments. Six GHs, α-amylase (source: A. oryzae), alginate lyase (source: various algae), pectinase (source: Rhizopus sp.), amyloglucosidase (source: A. niger), inulinase (source: A. niger), and xylanase (source: A. oryzae), exhibited the highest dispersal efficacy in vitro. Two GHs, α-amylase (source: Bacillus sp.) and cellulase (source: A. niger), used in conjunction with meropenem demonstrated infection clearing ability in a mouse wound model. GHs were also effective in improving antibiotic clearance in diabetic mice. To examine their safety, we screened the GHs for toxicity in cell culture. Overall, there was an inverse relationship between enzyme exposure time and cellular toxicity, with twelve out of sixteen GHs demonstrating some level of toxicity in cell culture. However, only one GH exhibited harmful effects in mice. These results further support the ability of GHs to improve antibiotic clearance of biofilm-associated infections and help lay a foundation for establishing GHs as therapeutic agents for chronic wound infections.

The Importance of Cutaneous Innervation in Wound Healing: From Animal Studies to Clinical Applications

The skin is a neuroimmunoendocrine organ that regularly undergoes injury and repair. The complex process of wound healing relies heavily on the cutaneous nervous system. Despite the observation that wound healing deficiencies cause significant morbidity and mortality for patients with nervous dysfunction across many disciplinaries, the role of cutaneous innervation in wound repair has not been well elucidated. In a previous article, we learned the basics of cutaneous neuroanatomy and the important neuropeptides involved in the wound healing process. Currently, we aim to synthesize the basics with observations from animal models and human studies for a more comprehensive understanding of nervous system involvement in cutaneous wound healing. We have demonstrated in this review, the importance of the cutaneous nervous system in each phase of wound healing through basic science research, animal experiments, and human studies.

Chemokine-Capturing Wound Contact Layer Rescues Dermal Healing

Excessive inflammation often impedes the healing of chronic wounds. Scavenging of chemokines by multiarmed poly(ethylene glycol)-glycosaminoglycan (starPEG-GAG) hydrogels has recently been shown to support regeneration in a diabetic mouse chronic skin wound model. Herein, a textile-starPEG-GAG composite wound contact layer (WCL) capable of selectively sequestering pro-inflammatory chemokines is reported. Systematic variation of the local and integral charge densities of the starPEG-GAG hydrogel component allows for tailoring its affinity profile for biomolecular signals of the wound milieu. The composite WCL is subsequently tested in a large animal (porcine) model of human wound healing disorders. Dampening excessive inflammatory signals without affecting the levels of pro-regenerative growth factors, the starPEG-GAG hydrogel-based WCL treatment induced healing with increased granulation tissue formation, angiogenesis, and deposition of connective tissue (collagen fibers). Thus, this biomaterials technology expands the scope of a new anti-inflammatory therapy toward clinical use.

Wound Healing in the Golden Agers: What We Know and the Possible Way Ahead

While "population aging" is an accomplishment that deserves acclamation, it is in itself a tremendous challenge. Age-related skin changes, impaired wound healing, and concurrent comorbidities are the deadly triad that contribute most to the development of nonhealing chronic wounds in the elderly. This imposes enormous medical, social, and financial burden. With the rising trend in the aging population, this problem is likely to exacerbate unless multidisciplinary, rapt wound care strategies are developed. The last decade was dedicated to understand the basic biology underlying the wound healing process but most in vitro and animal model studies translated poorly to human conditions. Forthcoming, the focus is on the development of diagnostic and therapeutic strategies to improve healing in this vulnerable age group. Further, understanding the complex pathobiology of cellular senescence and wound healing process is required to develop focused therapy for these "problem wounds" in the elderly.

Hyperbaric Oxygen Therapy for Venous Leg Ulcers: A 6 Year Retrospective Study of Results of a Single Center

Background: Venous leg ulcers (VLUs) are common and have a large impact on healthcare budgets worldwide. Hyperbaric oxygen therapy (HBOT) may improve healing of these ulcers. Methods: Retrospective, single-center cohort study between 2013 and 2019. All patients with a VLU from an outpatient clinic providing HBOT and wound care were included. The primary outcome measure was wound healing, determined at discharge from the center. Other outcome measures were improvement in patient related outcome measures (PROMs), as assessed by the EQ-5D-3L questionnaire and including quality of life (QoL) and pain score. Results: Fifty patients were included, 53% female, with a mean age of 73.4 (±12.2). Most wounds (83%) had existed longer than 3 months before starting treatment. Patients received an average of 43 (±20) sessions of HBOT. After treatment, 37 patients (63%) achieved complete or near-complete wound healing. Wound size decreased from a median of 14 cm² [interquartile range (IQR) 32 cm²] to 0.5 cm² (IQR 5.3 cm²), a median decrease of 7.5 (IQR 16.2 cm²) in cm² (94%). Patients mostly reported improvement for all health aspects on the questionnaire. Pain score decreased from 5.7 (±2.5) to 2.1 (±2.2) (p < 0.0001) and health score increased from 57.2 (±15.6) to 69.9 (±18.9) (p = 0.02). Conclusions: Patients with non-healing VLUs may benefit from HBOT to achieve complete or substantial wound healing. We recommend a well-designed randomized clinical trial with a number of patients allowing enough statistical power, and of a reasonable duration, to establish the potential of additional HBOT on hard-to-heal venous ulcers.

Macrophage regulation of angiogenesis in health and disease

Macrophages are primarily known as phagocytic innate immune cells, but are, in fact, highly dynamic multi-taskers that interact with many different tissue types and have regulatory roles in development, homeostasis, tissue repair, and disease. In all of these scenarios angiogenesis is pivotal and macrophages appear to play a key role in guiding both blood vessel sprouting and remodelling wherever that occurs. Recent studies have explored these processes in a diverse range of models utilising the complementary strengths of rodent, fish and tissue culture studies to unravel the mechanisms underlying these interactions and regulatory functions. Here we discuss how macrophages regulate angiogenesis and its resolution as embryonic tissues grow, as well as their parallel and different functions in repairing wounds and in pathologies, with a focus on chronic wounds and cancer.

External administration of moon jellyfish collagen solution accelerates physiological wound healing and improves delayed wound closure in diabetic model mice

Introduction

Artificial dermis is an effective therapeutic method for full-thickness dermal defects. However, the currently available artificial dermis made of porcine or bovine type I collagen has several limitations such as incomplete epithelialization and delayed migration of fibrogenic and angiogenic cells into the graft. We previously developed a composite dermal graft containing a mixture of moon jellyfish collagen and porcine type I collagen, and reported its stimulatory effect on both the re-epithelialization of the epidermis and the migration of fibrogenic and angiogenic cells into the graft. In the present study, we examined whether the same effect was observed by administering jellyfish collagen solution externally onto an artificial dermal graft made of bovine type I collagen.

Methods

We used a 6 mm full-thickness wound defect model. Moon jellyfish collagen was prepared as a concentrated 0.5% solution and dripped externally onto a transplanted artificial dermal graft made of bovine type I collagen. Wound repair and long-term dermal tissue remodeling were compared between mice administered jellyfish collagen solution on the bovine collagen graft and those transplanted with a composite dermal graft containing the same amounts of jellyfish and bovine collagens. The stimulatory effect of jellyfish collagen solution was also evaluated using diabetic dB/dB mice.

Results

External administration of jellyfish collagen solution onto the bovine collagen graft significantly accelerated wound closure compared to control saline. It also decreased the number of inflammatory cells infiltrating the wound and suppressed absorption of the transplanted graft, as well as reduced subsequent scar formation. Furthermore, external administration of jellyfish collagen solution onto the bovine collagen graft improved the delayed wound healing in diabetic model mice, and this effect was superior to that of the currently used basic fibroblast growth factor.

Conclusions

External administration of moon jellyfish collagen solution onto a bovine collagen graft significantly accelerated physiological wound healing and prevented excessive scar formation. It also improved wound closure in diabetic model mice, confirming its therapeutic application for intractable skin ulcers caused by impaired wound healing.

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Impaired wound healing is frequently observed in elderly and diabetic patients.

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Moon jellyfish collagen accelerates wound closure after full-thickness dermal defect in mice.

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Jellyfish collagen used as an external medicine stimulates the elongation of regenerating epithelial cells.

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Externally applied jellyfish collagen improves wound healing in diabetic model mice.

Bromelain-based enzymatic debridement of chronic wounds: Results of a multicentre randomized controlled trial

Chronic wounds are estimated to affect over 6 million people annually in the United States with an estimated annual cost of $25 billion. Debridement represents a key step in their management and is considered a basic necessity to induce the functional process of tissue repair. However, there is an unmet need for an efficient rapid acting non-surgical debridement agent. Bromelain-based enzymatic debridement has been proven to provide an effective, selective and safe non-surgical debridement in deep burns. EscharEx (MediWound Ltd, Yavne, Israel), is a bromelain-based enzymatic debridement agent currently in development for chronic wounds. The aim of this study was to assess its safety and efficacy in chronic wounds. Seventy-three patients suffering from a lower extremity ulcer of diabetic/venous insufficiency/post-surgical/traumatic aetiology were enrolled in a multicentre, assessor blinded, randomized controlled trial. Patients were randomized to topical treatment by either EscharEx or its gel vehicle for up to 10 daily 4 hour applications, and then continued follow-up for up to 6 months. The EscharEx arm achieved a significantly higher incidence of complete debridement compared to the gel vehicle arm; 55 versus 29% (p = .047), thus meeting the primary endpoint of this study. The EscharEx and gel vehicle arms achieved similar reductions in wound area, non-viable tissue area and wound healing scores during the debridement period. There were no significant differences between the arms in the incidence of complete wound closure (41% in the EsxcharEx arm vs. 53% in the gel vehicle arm) and in the mean time to complete wound closure (70.0 ± 32.8 days in the EsxcharEx arm vs. 65.7 ± 38.4 days in gel vehicle arm). There were no significant safety issues and EscharEx demonstrated a favourable benefit to risk profile.

Social participation of people with chronic wounds: A systematic review

Living with chronic ulcers can be burdensome and restrictive, with regard to not only physical and psychological but also social well-being. This review aims to analyse social participation in patients with chronic wounds and to compare results across different wound types. A search string was applied in several electronic databases. Results were screened according to predefined inclusion and exclusion criteria. Data of eligible articles were extracted and synthesised narratively. The search revealed 42 eligible publications. Only minor differences across different ulcer types could be detected. Overall, family members were the main social contacts for patients; they often provided wound care and emotional support. Patients had few non-family relations, but those existing were often very close. Patients felt guilty as their condition imposed burden on family and friends, as well. A close relationship with nurses was described. Restrictions were caused by direct and indirect consequences of the wound. Overall, social support and social connections were reduced in wound patients. Inconsistent results were found regarding social isolation. In summary, people with chronic wounds experience impairments in all aspects of social participation. Therefore, social participation deserves increased attention in routine care both as a trigger of burden and as an outcome of therapy.

Periwound skin care considerations for older adults

This article discusses the effects of ageing on the skin, particularly the main structural and functional changes that occur in the epidermis and dermis that make the skin more vulnerable to damage. Specific alterations that occur with ageing include slower epidermal turnover, flattening of the epidermal-dermal junction, loss of moisture and hydration as well as reduced immunity placing the skin at increased risk of damage. The discussion will also examine common periwound complications associated with ageing including; maceration, excoriation, dry skin, hyperkeratosis, callus, contact dermatitis and eczema. Strategies to manage these problems and interventions to reduce the risk of these complications include moisturising the skin to make it more resilient, debriding keratinised and callus tissue in the periwound area, appropriate choice of dressings to manage excessive exudate, careful removal of dressings as well as treating inflammatory conditions of the periwound skin.

The development and testing of the C/WoundComp instrument for assessing chronic wound-care competence in student nurses and podiatrists

The purpose of this study was to describe the level of chronic wound-care competence among graduating student nurses and student podiatrists in comparison with that of professionals and to develop and test a new instrument (the C/WoundComp) that assesses both theoretical and practical competence in chronic wound care as well as attitudes towards wound care. The data (N = 135) were collected in 2019 from four groups (1): graduating student nurses (n = 44) (2); graduating student podiatrists (n = 28) (3); registered nurses (n = 54); and (4) podiatrists (n = 9). The data were analysed using statistical analysis. According to the results, the students' total mean competence score was 62%. Their mean score for theoretical competence was 67%, and for practical competence, it was 52%. The students' competence level was statistically significantly lower than that of the professionals (P < .0001), but the students showed a positive attitude towards chronic wound care. The instrument demonstrated preliminary validity and reliability, but this warrants further testing. This study provides new knowledge about student nurses' and student podiatrists' competence in chronic wound care, suggesting that their theoretical and practical competence is limited. In addition, it provides information on different methods of assessing competence and how they can be combined.

Efficacy of Telemedicine for Patients with Chronic Wounds: A Meta-Analysis of Randomized Controlled Trials

Objective: The meta-analysis was performed to summarize the available evidence and assess the efficacy of telemedicine for patients with chronic wounds. Approach: PubMed, Embase, Web of Science, The Cochrane Library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), WanFang, and VIP databases were electronically searched to identify eligible studies updated to February 2020 to collect randomized controlled trials regarding the efficacy of telemedicine for patients with chronic wounds. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of included studies with the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis was performed using RevMan 5.3 and StataSE. Results: Fourteen studies involving 1,926 patients were included in the meta-analysis. Compared with usual care, telemedicine intervention significantly improved wound healing rate (risk ratio [RR] = 1.44, confidence interval [95% CI] = 1.16-1.80, p = 0.001) and reduced adverse events (RR = 0.52, 95% CI = 0.34-0.80, p = 0.003). No significant differences were found between patients allocated to the telemedicine group or usual care group, in terms of the outcomes of healing time, change in wound size, or mortality. Innovations: Telemedicine is an effective approach to promote chronic wound healing and reduce adverse events. Conclusion: The meta-analysis demonstrates that telemedicine may improve the healing rate and reduce adverse events for patients with chronic wounds. Because of the limited quality and quantity of the included studies, rigorous studies with adequate sample sizes are required to conclude with more confidence.

Extracellular vesicle-based therapeutics for the regeneration of chronic wounds: current knowledge and future perspectives

Chronic wounds are still an intractable medical problem for both clinicians and researchers and cause a substantial social and medical burden. Current clinical approaches can only manage wounds but have limited capacity to promote the regeneration of chronic wounds. As a type of natural nanovesicle, extracellular vesicles (EVs) from multiple cell types (e.g., stem cells, immune cells, and skin cells) have been shown to participate in all stages of skin wound healing including inflammation, proliferation, and remodeling, and display beneficial roles in promoting wound repair. Moreover, EVs can be further re-engineered with genetic/chemical or scaffold material-based strategies for enhanced skin regeneration. In this review, we provide an overview of EV biology and discuss the current findings regarding the roles of EVs in chronic wound healing, particularly in immune regulation, cell proliferation and migration, angiogenesis, and extracellular matrix remodeling, as well as the therapeutic effects of EVs on chronic wounds by genetic modification, in combination with functionalized biomaterials, and as drug carriers. We also discuss the challenges and perspectives of translating EV-based therapies into clinical wound care in the future.

Hyperbaric oxygen therapy for nonhealing wounds: Treatment results of a single center

The present article evaluates the results of the treatment with adjuvant hyperbaric oxygen therapy (HBOT) of patients with nonhealing, chronic wounds. In the period 2013 to 2016, 248 patients were referred from various hospitals because of chronic wounds that were recalcitrant in healing despite standard wound care as described in national and international guidelines. After inclusion, all patients were treated with HBOT and subjected to a weekly standard wound care treatment. During each HBOT session, 100% O₂ was administered for 75 minutes under increased pressure of 2.4 ATA. Wounds and quality of life were assessed before and after the total treatment period. A total of 248 patients have been evaluated. Diabetic foot ulcers were present in 134 patients, the remainder (114 patients) showed a variety of wound locations and etiologies. The number of HBOT treatments amounted to an average of 48 (range 20-68) sessions. Before referral to our clinic, 31% of all wounds had existed for at least 18 months (72 patients). After HBOT, 81% of all wounds were near complete healing or completely healed, in 13% of the cases the wound was stable, and in 2% minor or major amputation had to be carried out. The mean treatment time for wounds pre-existing fewer than 6 weeks ("early referrals") was 67 days, and 119 days for wounds pre-existing more than 18 months ("late referrals"). A majority of the patients in our study referred with nonhealing wounds clinically improved when adjuvant HBOT was added to standard wound care protocols. No differences in success rate were seen between diabetic and nondiabetic wounds. It showed that HBOT is a well-tolerated treatment.

Epidemiology and disease burden of complex wounds for inpatients in China: an observational study from Sichuan province

OBJECTIVES

To investigate the period prevalence of complex wounds among the overall inpatients, and the impact of complex wounds on inpatient health expense and length of hospital stay (LOS).

DESIGN

An observational study.

SETTING

6056 healthcare institutions across Sichuan province in China.

PARTICIPANTS

This study included 4 033 763 people admitted to healthcare institutions during 1 September 2018 and 31 December 2018.

RESULTS

The point prevalence of complex wounds was 4.07 per 1000 among inpatients in Sichuan. The most common complex wounds were pressure ulcers (1.47 per 1000 among inpatients). Older, male, Han ethnic groups and retired people were most likely to suffer from complex wounds. The median LOS was longer for those with complex wounds as their main condition of treatment compared with all-cause admissions in Sichuan (12 days compared with 7 days; p<0.001). The median cost of care for people with complex wounds was higher than for admission for any cause (¥6500.18 compared with ¥3337.16; p<0.001). People with pressure ulcers had the longest LOS, while people with ulcers related to diabetes incurred the highest costs.

CONCLUSIONS

Complex wounds, especially pressure ulcers, are common in Sichuan province and their presence is associated with significantly longer lengths of hospital stay and higher medical costs. Additionally, this study only included admitted inpatients during the sampling time period, hence the prevalence of complex wounds may be underestimated. The high prevalence rate and heavy direct and indirect disease burden of complex wounds indicate that health policies for early detection and prevention of complex wounds in elders are urgently needed.

Incidence of chronic wounds in Singapore, a multiethnic Asian country, between 2000 and 2017: a retrospective cohort study using a nationwide claims database

OBJECTIVES

Chronic wounds are common, costly and impair quality of life, yet epidemiological data are scarce. We aimed to estimate the incidence trend of a multiethnic Asian population.

DESIGN

Retrospective cohort study.

SETTING

Singapore's nationwide claims database.

PARTICIPANTS

Singaporeans and permanent residents.

OUTCOMES

Patients were identified by International Classification of Disease, Ninth Revision, Australian Modification (ICD-9-AM) and ICD-10-AM codes from all admissions between 2000 and 2017, and categorised according to aetiology: venous, arterial, diabetic and pressure. Comorbidities were extracted from a national database of Charlson Comorbidity Index scores.

RESULTS

Between 2000 and 2017, 124 023 wound-related claims among 86 631 patients were identified. Age-specific rate (ASR) and age-adjusted incidence rates of all wounds increased over 18 years, with greatest increases among those aged ≥80. In 2017, the median age of patients was 74 (IQR 63-84). Half were male (51%). 70% were ethnic Chinese, 15% Malay and 9% Indian. In 2017, the crude incidence rate (CIR) was 15 per 100 000 persons (95% CI 14 to 16) for venous wounds, 56 (95% CI 53 to 58) for arterial, 168 (95% CI 164 to 173) for diabetic and 183 (95% CI 179 to 188) for pressure wounds. The CIR of any chronic wound was 296 (95% CI 291 to 301). ASRs were greatest in patients aged ≥80: 92 (95% CI 74 to 112) for venous, 478 (95% CI 436 to 522) for arterial, 1791 (95% CI 1710 to 1876) for diabetic, 3647 (95% CI 3530 to 3766) for pressure and 4277 (95% CI 4151 to 4407) for any wound. Compared with the Chinese, Indians had thrice the ASRs of venous and arterial wounds and double the ASR of diabetic wounds. Malays had double the ASRs of arterial and diabetic wounds.

CONCLUSIONS

Chronic wounds are common in the elderly with significant ethnic disparities in this Asian cohort. With the incidence expected to rise with ageing populations, it is crucial to address health disparities and evaluate utilisation and cost to inform clinical practice and health policy.

Maggot Therapy in Wound Healing: A Systematic Review

BACKGROUND

It is estimated that 2% of the population in developing countries suffer from a chronic wound, making it a hidden phenomenon that is increasing as populations age. The ease of access to maggot therapy has made it increasingly attractive for implementation. This study aimed to explore the effectiveness of maggot therapy as compared to hydrogel dressings in the healing of chronic wounds.

METHODS

An electronic literature search until October 2019 was performed using Medline, Embase, and Cumulative Index of Nursing and Allied Health Literature. The eligibility criteria were chronic wound patients with an intervention that involved a comparison of any maggot species with hydrogel dressings.

RESULTS

The full text of five studies, involving 580 patients with chronic wounds, was retrieved. Four studies used the Lucilia sericata species. The maggot therapy facilitated faster and more effective debridement of non-viable tissue. It enabled faster development of granulation tissue and increased reduction in the wound surface area compared to hydrogel dressings. Maggot therapy had no effect on disinfection or complete healing rate for the wound.

CONCLUSION

Maggot therapy should be considered for faster wound debridement, granulation tissue development, and wound surface area reduction as well as in surgical contraindications. This review can be used as a guide to assist clinicians in identifying patients who may benefit from maggot therapy.

Degradable Hydrogels for the Delivery of Immune-modulatory Proteins in the Wound Environment

Chronic wounds represent a growing clinical problem for which limited treatment strategies exist. Defects in immune cell-mediated healing play an important role in chronic wound development, presenting an attractive clinical target in the treatment of chronic wounds. However, efforts to improve healing through the application of growth factors and cytokines have been limited by the rapid degradation and diffusion of these molecules in the wound environment. In this study we sought to overcome the challenge of rapid diffusion through the development of a hydrogel delivery system in which protein cargo can be released into the wound environment at a constant and tunable rate. This system was used to deliver the intercellular adhesion molecule-1 (ICAM-1) in order to target endogenous cells upstream of growth factor and cytokine production and circumvent the issue of their rapid degradation. We demonstrated that our delivery system was able to release cargo at different and highly controllable rates and thereby improved cargo retention in the wound environment. Additionally, treatment with ICAM-1 in the delivery system improved healing in both ICAM-1-deficient mice and an aged mouse model of delayed healing, highlighting a potential clinical benefit for this protein in the treatment of chronic wounds.

A Novel Composite Biomaterial Made of Jellyfish and Porcine Collagens Accelerates Dermal Wound Healing by Enhancing Reepithelization and Granulation Tissue Formation in Mice

Background and Objective: Impaired dermal wound healing represents a major medical issue in today's aging populations. Granulation tissue formation in the dermis and reepithelization of the epidermis are both important and necessary for proper wound healing. Although a number of artificial dermal grafts have been used to treat full-thickness dermal loss in humans, they do not induce reepithelization of the wound, requiring subsequent epithelial transplantation. In the present study, we sought a novel biomaterial that accelerates the wound healing process. Approach: We prepared a composite biomaterial made of jellyfish and porcine collagens and developed a hybrid-type dermal graft that composed of the upper layer film and the lower layer sponge made of this composite biomaterial. Its effect on dermal wound healing was examined using a full-thickness excisional wound model. Structural properties of the dermal graft and histological features of the regenerating skin tissue were characterized by electron microscopic observation and immunohistological examination, respectively. Results: The composite biomaterial film stimulated migration of keratinocytes, leading to prompt reepithelization. The regenerating epithelium consisted of two distinct cell populations: keratin 5-positive basal keratinocytes and more differentiated cells expressing tight junction proteins such as claudin-1 and occludin. At the same time, the sponge made of the composite biomaterial possessed a significantly enlarged intrinsic space and enhanced infiltration of inflammatory cells and fibroblasts, accelerating granulation tissue formation. Innovation: This newly developed composite biomaterial may serve as a dermal graft that accelerates wound healing in various pathological conditions. Conclusion: We have developed a novel dermal graft composed of jellyfish and porcine collagens that remarkably accelerates the wound healing process.

Effectiveness of autologous platelet-rich plasma gel in the treatment of hard-to-heal leg ulcers: a randomised control trial

OBJECTIVE

Regenerative medicine products such as autologous platelet-rich plasma (autologous PRP) gel may speed up the process of healing. Clinical studies show promising results in the treatment of diabetic foot ulcers (DFUs), however there is lack of scientific evidence of autologous PRP effectiveness in treating leg ulcers of other aetiology. This study evaluates the effectiveness of autologous PRP gel in the treatment of hard-to-heal leg ulcers compared with existing conventional treatment.

METHOD

A prospective, randomised controlled, open-labelled clinical trial was carried out between 2014 and 2018. An eight-week study protocol was chosen or until 100% wound re-epithelialisation was observed. Wound size reduction, granulation tissue formation, microbiological wound bed changes and safety were evaluated.

RESULTS

A total of 69 patients (35 in the autologous PRP group and 34 in the control group) were included in the study; 25.71% of the autologous PRP group and 17.64% of control group had ulcers completely re-epithelialised (p>0.05). Wound size reduction in the autologous PRP group was 52.35% and 33.36% in the control group (p=0.003). The autologous PRP group showed superiority over conventional treatment in wound bed coverage with granulation (p=0.001). However, more frequent wound contamination was observed at the end of treatment in the autologous PRP group (p=0.024). No severe adverse events were noted during the study. Both treatment methods were considered equally safe.

CONCLUSION

Topical application of autologous PRP gel in leg ulcers of various aetiology show beneficial results in wound size reduction and induces the granulation tissue formation. However, it is associated with more frequent microbiological wound contamination.

A Novel Nanofiber Hydrogel Loaded with Platelet-Rich Plasma Promotes Wound Healing Through Enhancing the Survival of Fibroblasts

Background

Hydrogels are ideal biological carriers in vivo and have been widely used in the treatment of wound healing through loading with or without bioactive substances. Platelet-rich plasma (PRP) is purified from autologous plasma and has known curative efficacy for wound healing. The combined efficacy of shorten poly-N-acetyl glucosamine (sNAG) hydrogels and PRP in the treatment of wound healing has not been previously assessed.

Material/Methods

The cytotoxic and proliferative effects of PRP on fibroblasts were detected using Cell Counting Kit-8 assays and flow cytometry. The levels of cyclin D1 and cyclin D3 were assessed to evaluate cell proliferation. Protein expression was assessed by western blot analysis. Adenosine levels were assessed by enzyme-linked immunosorbent assay. Cell apoptosis was assessed by flow cytometry and western blot analysis. Rat wound models were performed, and the effects of PRP, single hydrogels, and sNAG hydrogels loaded with PRP were respectively detected through the assessment of wound closure. Hematoxylin eosin staining was used to measure the depth and width of regenerative scars.

Results

Our results demonstrated that PRP promotes fibroblast proliferation and inhibits apoptosis. PRP contains abundant levels of adenosine, which has a positive role on fibroblast function, whilst the inhibition of adenosine A2A receptors impairs the efficacy of PRP. sNAG hydrogels loaded with PRP showed curative efficacy during wound healing in mice. Mice treated with hydrogels loaded with PRP showed high levels of regeneration with scarless healing.

Conclusions

Our results indicate that sNAG hydrogels loaded with PRP promote wound healing. The pro-proliferative, and anti-apoptotic effects of the fibroblasts are mediated by the activating A2A receptor in response to elevated adenosine levels.

Secretome of Adipose Tissue-Derived Stem Cells (ASCs) as a Novel Trend in Chronic Non-Healing Wounds: An Overview of Experimental In Vitro and In Vivo Studies and Methodological Variables

Wound healing is a complex process with a linear development that involves many actors in a multistep timeline commonly divided into four stages: Hemostasis, inflammation, proliferation, and remodeling. Chronic non-healing wounds fail to progress beyond the inflammatory phase, thus precluding the next steps and, ultimately, wound repair. Many intrinsic or extrinsic factors may contribute to such an occurrence, including patient health conditions, age-related diseases, metabolic deficiencies, advanced age, mechanical pressure, and infections. Great interest is being focused on the adipose tissue-derived stem cell’s (ASC) paracrine activity for its potential therapeutic impact on chronic non-healing wounds. In this review, we summarize the results of in vitro and in vivo experimental studies on the pro-wound healing effects of ASC-secretome and/or extracellular vesicles (EVs). To define an overall picture of the available literature data, experimental conditions and applied methodologies are described as well as the in vitro and in vivo models chosen in the reported studies. Even if a comparative analysis of the results obtained by the different groups is challenging due to the large variability of experimental conditions, the available findings are undoubtedly encouraging and fully support the use of cell-free therapies for the treatment of chronic non-healing wounds.

Stratification of chronic and complex wounds according to healing characteristics: a retrospective study

OBJECTIVE

Wound risk-stratified analyses are clinically relevant as they can assist in identifying hard-to-heal wounds. The aim of the study is to develop risk categories for wound healing based on a limited number of reliably recordable clinical data.

METHOD

This retrospective study used observational data. The primary outcome measure was wound healing at the end of treatment and the secondary outcome measure was the time to wound healing. A stratification model using regression analyses was developed to assign the patients to risk categories for wound healing and the time-to-heal.

RESULTS

The study cohort comprised of 540 patients. The most common wound diagnoses were diabetic ulcers, wounds in irradiated areas and wound dehiscence after surgery. Average wound duration before starting treatment at the wound centre was 11.7 months. Healing was achieved in 382 (71%) wounds, after an average treatment time of 4.4 months. A total of four risk categories for wound healing were developed by combining wound diagnosis (favourable versus unfavourable) and duration (<3 months versus >3 months). These risk categories demonstrated healing percentages ranging from 69-97% (p=0.0004) and mean time-to-healing varying from 2.7-5.9 months (p=0.01).

CONCLUSION

Using two clinical wound variables, diagnosis and duration, stratification categories were identified with significant associations with wound healing outcomes. Longer wound duration and unfavourable diagnoses, when combined into unfavourable risk categories, were associated with a lower percentage of wound healing and a longer treatment time until healing.

Skin considerations for older adults with wounds

Ageing leads to a number of skin changes that not only place an older adult at risk of tissue damage, but can present as peri-wound problems for those with existing wounds, for example, incontinence-associated and moisture-associated dermatitis in individuals with pressure ulcers. Older adults with venous disease experience skin changes concomitant with venous hypertension, making the skin more at risk of breakdown, specifically the common complications of lipodermatosclerosis and venous eczema. In individuals with diabetic foot disease, skin changes related to autonomic neuropathy mean patients can experience dry skin that cracks easily, placing them at higher risk of infection. Common to all individuals with wounds requiring some sort of dressing is the risk of medical adhesive-related skin injury, where dressing application and removal need to be of the utmost priority to reduce the risk of injury. This article discusses some of the common peri-wound skin considerations in patients with chronic wounds.

A review of the effects of ageing on skin integrity and wound healing

It is well known that advancing age is a factor that affects the normal course of wound healing. The population over the age of 65 years is increasing globally, and this may be accompanied by an increase in the number of individuals experiencing delayed wound healing. There is a breadth of research to show that age-related changes in the epidermis and dermis change the skin's ability to resist damage and injury. In particular, the dermoepidermal junction becomes flattened, which predisposes the tissue to shear and friction forces. Within the dermis, alterations in the amount and structure of collagen also mean that the tissue is much more rigid. Prompt assessment of the skin to identify existing conditions as well as preventive measures is therefore essential. This article discusses the anatomy of the skin and the effects of ageing on the tissues. It also offers some guidance on skin assessment and the basics of skin care.

A change in the prevalence and the etiological factors of chronic wounds in Helsinki metropolitan area during 2008-2016

The prevalence of chronic wounds in the Helsinki metropolitan area in 2008 was investigated. Thereafter, a specialised wound care team was founded as part of the City of Helsinki Health Services, aiming for early diagnoses of chronic wounds. In the current study, we have repeated the prevalence study to analyse the changes in the prevalence of chronic wounds. A questionnaire on wound patients was sent to all units of social and health care in the Helsinki metropolitan area. We asked about the number of patients with wounds treated during a 24-hour period, as well the aetiology and location of the wounds. A total of 911 patients had, altogether, 1021 wounds. Thus, prevalence was 0.08%. Pressure and multifactorial ulcers were the most common aetiological groups, whereas wound without defined aetiology had diminished greatly (61%) The prevalence of chronic wound decreased when compared with 2008 (0.08% vs 0.1%). The number of elderly people aged over 65 years had increased 35%, and the age-adjusted prevalence had decreased. Wounds are treated mostly in primary care units and as outpatients. Therefore, the following conclusion may be reached: diagnostic process and implementation of treatment paths are strengthened within primary care units, yet prevalence of wounds has decreased.

REAL-WORLD CLINICAL EVALUATION AND COSTS OF TELEMEDICINE FOR CHRONIC WOUND MANAGEMENT

BACKGROUND

Chronic wounds are frequent, affect quality of life, and increase care costs. Telemedicine provides potential for effective wound care management, especially for the monitoring of complex wounds at home.

OBJECTIVES

The objective of the present study was to determine the clinical effects and costs of telemedicine for the follow-up of complex chronic wounds from the perspective of the public health insurance. The study ran over a period of 9 months.

METHODS

We conducted a prospective, pragmatic, open-label, observational study and carried out a cost-effectiveness analysis. A total of 116 patients with chronic wounds were assigned to their choice of two groups: telemedicine (N = 77) and traditional follow-up (control; N = 39). The primary outcome was the time to healing. Secondary outcomes included percentage of wounds reaching target objective, percentage of wounds healed completely, outpatient care costs, travel costs, and hospitalizations.

RESULTS

Time to healing was shorter in the telemedicine group than in the control group (137 versus 174 days; p .05). Outpatient care and hospitalization costs were not significantly different. The main results in terms of economic savings were medical transport costs reimbursed by the French public health insurance, which were significantly lower in the telemedicine group. Telemedicine costs were found to be €4,583 less per patient compared with standard practice over 9 months.

CONCLUSIONS

This trial suggests that telemedicine saves travel costs and results in a shorter healing time than traditional follow-up.