Efficacy of shellac, a natural product, for the prevention of wet gangrene

Shellac as a multifunctional biopolymer: A review on properties, applications and future potential

Shellac is a physically refined form of lac resin, a natural biopolymer of animal origin obtained from tiny insects feeding on the sap of specific host trees. Shellac, in its basic form, is a polyester macromolecule composed of inter and intra esters of polyhydroxy aliphatic and sesquiterpene acids. It has been used in several industries for ages due to its exceptional properties such as film-forming, adhering, bonding, thermoplasticity, water-resistance and easy solubility in spirit and aqueous alkali solvents. From the beginning of the 21^st century, due to increasing demand for natural products, a paradigm shift in the scope and applications of shellac has been witnessed, especially in green electronics, 3D printing, stealth technology, intelligent sensors, food and pharmaceutical industries. Shellac offers enormous potential for greener technologies as a natural and environmentally friendly material. This review provides an insight into the lac in detail, covering various forms of the lac, structure, properties, different applications of shellac and its future potential. This article would benefit the researchers involved in shellac research and others looking for natural and greener alternatives to synthetic polymers in various applications.

Multiscale Shellac-Based Delivery Systems: From Macro- to Nanoscale

Delivery systems play a crucial role in enhancing the activity of active substances; however, they require complex processing techniques and raw material design to achieve the desired properties. In this regard, raw materials that can be easily processed for different delivery systems are garnering attention. Among these raw materials, shellac, which is the only pharmaceutically used resin of animal origin, has been widely used in the development of various delivery systems owing to its pH responsiveness, biocompatibility, and degradability. Notably, shellac performs better on encapsulating hydrophobic active substances than other natural polymers, such as polysaccharides and proteins. In addition, specially designed shellac-based delivery systems can also be used for the codelivery of hydrophilic and hydrophobic active substances. Shellac is most widely used for oral administration, as shellac-based delivery systems can form a compact structure through hydrophobic interaction, protecting transported active substances from the harsh environment of the stomach to achieve targeted delivery in the small intestine or colon. In this review, the advantages of shellac in delivery systems are discussed in detail. Multiscale shellac-based delivery systems from the macroscale to nanoscale are comprehensively introduced, including matrix tablets, films, enteric coatings, hydrogels, microcapsules, microparticles (beads/spheres), nanoparticles, and nanofibers. Furthermore, the hotspots, deficiencies, and future perspectives of shellac-based delivery system development are also analyzed. We hoped this review will increase the understanding of shellac-based delivery systems and inspire their further development.

Physical Properties of Shellac Material Used for Hot Melt Extrusion with Potential Application in the Pharmaceutical Industry

Hot melt extrusion offers an efficient way of increasing the solubility of a poorly soluble drug. Shellac has potential as a pharmaceutical matrix polymer that can be used in this extrusion process, with further advantages for use in enteric drug delivery systems. The rheological property of a material affects the extrusion process conditions. However, the literature does not refer to any published work that investigates the processability of various shellac materials. This work explores various types of shellac and explores their physicochemical and thermal properties along with their processability in the hot melt extrusion application. Physicochemical characterization of the materials was achieved using differential scanning calorimetry, Fourier transform infrared spectroscopy, scanning electron microscopy and energy-dispersive X-ray spectroscopy. Additional processability characterization was achieved using melt flow index and rheology analysis. The results indicated that there was no chemical difference between the various shellac types compared in this study. However, the extrudable temperature ranges and rheological properties of different shellac types varied; SSB 55 Pharma FL had the lowest processing temperature and glass transition temperatures. Due to the shear-thinning behaviours, shellac can be extruded at lower temperatures. This study provides necessary data to determine the processing conditions in hot melt extrusion applications for the range of shellac materials.

Autoamputation of diabetic toe with dry gangrene: a myth or a fact?

Diabetes is associated with various complications and reduced quality of life. Of the many complications, some are life-threatening. Among these, foot complications remain an important concern. The major foot complications include foot ulceration, cellulitis, abscess, wet gangrene, dry gangrene, and necrotizing fasciitis, with different pathophysiological concepts behind each of them. Gangrene occurs due to reduced blood supply in the body tissues that leads to necrosis. This condition may arise because of an injury, infection, or other health conditions, majorly diabetes. Gangrene is classified as dry, wet, and gas gangrene. In case of wet and gas gangrene, surgical amputation is usually performed to prevent the spread of infection to other tissues. In dry gangrene, due to the presence of clear demarcation, autoamputation is preferred in certain parts of the globe. The present review aims to analyze the mode of dry gangrene management in diabetic patients based on previous evidence and plans to highlight various management strategies available for dry gangrene and the advantages/disadvantages of different treatments with special consideration to autoamputation.

Design and characterization of monolaurin loaded electrospun shellac nanofibers with antimicrobial activity

The aim of this study was to elucidate the optimized fabrication factors influencing the formation and properties of shellac (SHL) nanofibers loaded with an antimicrobial monolaurin (ML). The main and interaction effects of formulation and process parameters including SHL content (35%–40% w/w), ML content (1%–3% w/w), applied voltage (9–27 kV) and flow rate (0.4–1.2 ml/h) on the characteristic of nanofibers were investigated through a total of 19 experiments based on a full factorial design with three replicated center points. As a result, the SHL content was the major parameter affecting fiber diameter. Another response result revealed that the SHL content would be also the most significant negative impact on amount of beads. An increase in the concentration of SHL leaded to a reduction in the amount of beads. From the results of characterization study, it was proved that ML might be entrapped between the chains of SHL during the electrospinning process exhibiting an excellent encapsulation. According to the response surface area, small (~488 nm) and beadless (~0.48) fibers were obtained with the SHL and ML contents of 37.5% and 1.1% w/w respectively, at the applied voltage of 18 kV and the flow rate of 0.8 ml/h. In addition, the results of the kill-kinetic studies showed that SHL nanofibers loaded with ML exhibited an excellent antibacterial activity against Staphylococcus aureus, while Escherichia coli was less affected due to the hydrophilic structure of the its outer membrane. ML also exerted an antifungal activity by reducing the number of Candida albicans colonies. Based on their structural and antimicrobial properties, SHL nanofibers containing ML could be potentially used as a medicated dressing for wound treatment.

Topical antimicrobial agents for treating foot ulcers in people with diabetes

BACKGROUND

People with diabetes are at high risk for developing foot ulcers, which often become infected. These wounds, especially when infected, cause substantial morbidity. Wound treatments should aim to alleviate symptoms, promote healing, and avoid adverse outcomes, especially lower extremity amputation. Topical antimicrobial therapy has been used on diabetic foot ulcers, either as a treatment for clinically infected wounds, or to prevent infection in clinically uninfected wounds.

OBJECTIVES

To evaluate the effects of treatment with topical antimicrobial agents on: the resolution of signs and symptoms of infection; the healing of infected diabetic foot ulcers; and preventing infection and improving healing in clinically uninfected diabetic foot ulcers.

SEARCH METHODS

We searched the Cochrane Wounds Specialised Register, CENTRAL, Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus in August 2016. We also searched clinical trials registries for ongoing and unpublished studies, and checked reference lists to identify additional studies. We used no restrictions with respect to language, date of publication, or study setting.

SELECTION CRITERIA

We included randomised controlled trials conducted in any setting (inpatient or outpatient) that evaluated topical treatment with any type of solid or liquid (e.g., cream, gel, ointment) antimicrobial agent, including antiseptics, antibiotics, and antimicrobial dressings, in people with diabetes mellitus who were diagnosed with an ulcer or open wound of the foot, whether clinically infected or uninfected.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, 'Risk of bias' assessment, and data extraction. Initial disagreements were resolved by discussion, or by including a third review author when necessary.

MAIN RESULTS

We found 22 trials that met our inclusion criteria with a total of over 2310 participants (one study did not report number of participants). The included studies mostly had small numbers of participants (from 4 to 317) and relatively short follow-up periods (4 to 24 weeks). At baseline, six trials included only people with ulcers that were clinically infected; one trial included people with both infected and uninfected ulcers; two trials included people with non-infected ulcers; and the remaining 13 studies did not report infection status.Included studies employed various topical antimicrobial treatments, including antimicrobial dressings (e.g. silver, iodides), super-oxidised aqueous solutions, zinc hyaluronate, silver sulphadiazine, tretinoin, pexiganan cream, and chloramine. We performed the following five comparisons based on the included studies: Antimicrobial dressings compared with non-antimicrobial dressings: Pooled data from five trials with a total of 945 participants suggest (based on the average treatment effect from a random-effects model) that more wounds may heal when treated with an antimicrobial dressing than with a non-antimicrobial dressing: risk ratio (RR) 1.28, 95% confidence interval (CI) 1.12 to 1.45. These results correspond to an additional 119 healing events in the antimicrobial-dressing arm per 1000 participants (95% CI 51 to 191 more). We consider this low-certainty evidence (downgraded twice due to risk of bias). The evidence on adverse events or other outcomes was uncertain (very low-certainty evidence, frequently downgraded due to risk of bias and imprecision). Antimicrobial topical treatments (non dressings) compared with non-antimicrobial topical treatments (non dressings): There were four trials with a total of 132 participants in this comparison that contributed variously to the estimates of outcome data. Evidence was generally of low or very low certainty, and the 95% CIs spanned benefit and harm: proportion of wounds healed RR 2.82 (95% CI 0.56 to 14.23; 112 participants; 3 trials; very low-certainty evidence); achieving resolution of infection RR 1.16 (95% CI 0.54 to 2.51; 40 participants; 1 trial; low-certainty evidence); undergoing surgical resection RR 1.67 (95% CI 0.47 to 5.90; 40 participants; 1 trial; low-certainty evidence); and sustaining an adverse event (no events in either arm; 81 participants; 2 trials; very low-certainty evidence). Comparison of different topical antimicrobial treatments: We included eight studies with a total of 250 participants, but all of the comparisons were different and no data could be appropriately pooled. Reported outcome data were limited and we are uncertain about the relative effects of antimicrobial topical agents for each of our review outcomes for this comparison, that is wound healing, resolution of infection, surgical resection, and adverse events (all very low-certainty evidence). Topical antimicrobials compared with systemic antibiotics : We included four studies with a total of 937 participants. These studies reported no wound-healing data, and the evidence was uncertain for the relative effects on resolution of infection in infected ulcers and surgical resection (very low certainty). On average, there is probably little difference in the risk of adverse events between the compared topical antimicrobial and systemic antibiotics treatments: RR 0.91 (95% CI 0.78 to 1.06; moderate-certainty evidence - downgraded once for inconsistency). Topical antimicrobial agents compared with growth factor: We included one study with 40 participants. The only review-relevant outcome reported was number of ulcers healed, and these data were uncertain (very low-certainty evidence).

AUTHORS' CONCLUSIONS

The randomised controlled trial data on the effectiveness and safety of topical antimicrobial treatments for diabetic foot ulcers is limited by the availability of relatively few, mostly small, and often poorly designed trials. Based on our systematic review and analysis of the literature, we suggest that: 1) use of an antimicrobial dressing instead of a non-antimicrobial dressing may increase the number of diabetic foot ulcers healed over a medium-term follow-up period (low-certainty evidence); and 2) there is probably little difference in the risk of adverse events related to treatment between systemic antibiotics and topical antimicrobial treatments based on the available studies (moderate-certainty evidence). For each of the other outcomes we examined there were either no reported data or the available data left us uncertain as to whether or not there were any differences between the compared treatments. Given the high, and increasing, frequency of diabetic foot wounds, we encourage investigators to undertake properly designed randomised controlled trials in this area to evaluate the effects of topical antimicrobial treatments for both the prevention and the treatment of infection in these wounds and ultimately the effects on wound healing.