Impaired wound healing: facts and hypotheses for multi-professional considerations in predictive, preventive and personalised medicine

Targeting the MAPK signaling pathway: implications and prospects of flavonoids in 3P medicine as modulators of cancer cell plasticity and therapeutic resistance in breast cancer patients

Cancer drug resistance poses a significant challenge in oncology, primarily driven by cancer cell plasticity, which promotes tumor initiation, progression, metastasis, and therapeutic evasion in many different cancers. Breast cancers (BCs) are a prominent example of that, with an estimated 2.3 million new cases and 670,000 BC-related deaths registered worldwide annually. Triple-negative BC is especially challenging for treatments demonstrating particularly aggressive disease course, an early manifestation of metastatic disease, frequent drug-resistant cancer types, and poor individual outcomes. Although chemosensitizing agents have been developed, their clinical utility in oncology remains unproven. The mitogen-activated protein kinase (MAPK) pathway is considered a critical regulator of intracellular and extracellular signaling highly relevant for both — genetic and epigenetic modifications. Dysregulation of the MAPK signaling pathways plays a significant role in conferring chemoresistance in BC. Contextually, targeting the MAPK pathway represents a promising strategy for overcoming drug resistance and enhancing the therapeutic efficacy of anticancer agents in BC treatment. On the other hand, flavonoids, a prominent class of phytochemicals, are key modulators of MAPK signaling. Flavonoids interact with the ERK, JNK, p38, and ERK5 pathways of the MAPK signaling cascade and present a promising avenue for developing novel anti-cancer therapies and re-sensitizing agents for the treatment of BC. Compounds such as quercetin, kaempferol, genistein, luteolin, myricetin, EGCG, baicalein, baicalin, nobiletin, morin, delphinidin, acacetin, isorhamnetin, apigenin, silymarin, among others, have been identified as specific modulators of MAPK signaling, exerting complex downstream effects in BC cells increasing therewith drug efficacy and suppressing tumor growth and aggressivity. These properties reflect mechanisms of great clinical relevance to overcome therapeutic resistance in overall BC management. This article highlights corresponding mechanisms and provides clinically relevant illustrations in the framework of 3P medicine for primary (protection of individuals at high risk against health-to-disease transition) and secondary care (protection against metastatic BC progression). 3PM novelty makes good use of patient phenotyping and stratification, predictive multi-level diagnostics, and application of Artificial Intelligence (AI) tools to the individualized interpretation of big data — all proposed for cost-effective treatments tailored to individualized patient profiles with clear benefits to patients and advanced BC management.

Skin and Wound Healing: Conventional Dosage versus Nanobased Emulsions Forms

The skin plays a crucial role in the body's homeostasis through its thermoregulation functions, metabolic activity, and, mainly, its barrier function. Once this system has its homeostasis disturbed, through the promotion of tissue discontinuity, an injury happens and a restoration process starts. Different products can be used to promote, accelerate, or stimulate the healing process, such as hydrogels, emulsions, and ointments (main conventional formulations). Despite the historical use and wide market and consumer acceptance, new systems emerged for wound management with the main challenge to overcome conventional form limitations, in which nanosystems are found, mainly nanobased emulsion forms (nano- and microemulsions, NE and ME). Here, we discuss the skin function and wound healing process, highlighting the cellular and molecular processes, the different wound classifications, and factors that affect physiological healing. We also investigated the recent patents (2012-2023) filed at the United States Patent and Trademark Office, where we found few patents for conventional forms (hydrogels = 5; emulsions = 4; ointments = 6) but a larger number of patents for nanobased emulsions filed in this time (NE = 638; ME = 4,072). Furthermore, we address the use of nanobased emulsions (NE and ME) and their particularities, differences, and application in wound treatment. This work also discusses the challenges, bottlenecks, and regulatory framework for nanosystems, industrial, academic, and government interest in nanotechnology, and future perspectives about this key factor for the nanosystems market and consumer acceptance.

Phosphocreatine-mediated enhancement of mitochondrial function for accelerated healing of diabetic foot ulcers through the PGC-1α-NRF-1 signaling pathway

Diabetic foot ulcers (DFUs) pose a significant clinical challenge due to their slow healing and high risk of complications, which severely affect patient quality of life. Central to the delayed healing observed in DFUs is mitochondrial dysfunction, a critical factor impairing cellular repair processes. Phosphocreatine (PCr), a vital molecule involved in cellular energy buffering and ATP regeneration, has recently emerged as a promising therapeutic candidate for ameliorating mitochondrial dysfunction and enhancing tissue repair. This study explores the novel therapeutic potential of PCr in restoring mitochondrial function and accelerating wound healing in DFUs through both in vitro and in vivo models. Using hyperglycemic human umbilical vein endothelial cells (HUVECs) as an in vitro model and a streptozotocin (STZ)-induced diabetic rat model as an in vivo, we evaluated the impact of PCr treatment on mitochondrial activity and wound repair. PCr treatment notably upregulated key mitochondrial biogenesis markers, including peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) and nuclear respiratory factor 1 (NRF-1), indicating a restoration of mitochondrial function. In vivo, PCr-treated diabetic rats demonstrated significantly accelerated wound closure, enhanced granulation tissue formation, and reduced inflammatory cell infiltration. These findings underscore PCr's potential to address mitochondrial dysfunction and expedite wound healing in DFUs. This study offers promising new insights into PCr as a targeted therapeutic intervention, paving the way for improved patient outcomes in managing diabetic foot ulcers.

Hydrogel-based dressing for wound healing: A systematic review of clinical trials

BACKGROUND

Chronic wounds pose significant healthcare challenges. Hydrogel-based wound dressings have garnered significant attention in the field of wound care. Furthermore, no severe adverse effect was reported for treatment with hydrogel in wound healing. However, a comprehensive review of their clinical application for enhancing chronic wound healing is lacking.

OBJECTIVES

This systematic review evaluates their clinical effectiveness of hydrogel-based dressing in managing chronic wounds and assesses the evidence supporting their use.

SEARCH METHODS

We searched the following databases PubMed, the Cochrane Library; Web of Science; and ClinicalTrials.gov. from January 2010 to January 2023.

SELECTION CRITERIA

Published clinical trial studies that evaluate the effect of hydrogel-based dressing on chronic wounds.

RESULT

We included 39 studies with 1786 participants (1818 wounds), 1024 of whom (1100 wounds) received hydrogel dressings while 679 patients (725 wounds) used non-hydrogel dressings. This systematic review of clinical research indicates that utilizing hydrogel dressings could potentially reduce the required time (31.17 ± 21.74 days) for wound healing and enhance the percentage of wound closure (63.76 ± 28.97 %).

CONCLUSIONS

This systematic review revealed that hydrogel dressings are effective in treatment of chronic wounds. Nonetheless, there is a necessity for additional long-term trials tailored to specific wound types and patient characteristics.

The impact of semaglutide on wound healing in diabetes related foot ulcer patients: A TriNetX database study

IntroductionDiabetes related foot ulcers (DFUs) are common complications of type 2 diabetes mellitus (T2DM), affecting 15-25% of individuals living with diabetes and significantly contributing to healthcare costs ($9-13 billion annually in the U.S.). Without effective management, these wounds often lead to severe outcomes like amputations. This study aims to examine the association of semaglutide on DFU management.MethodsThis retrospective cohort study utilized TriNetX US Research Network data to assess the impact of semaglutide, a GLP-1 receptor agonist, on DFU outcomes between 2013 and 2023. The study compared outcomes between semaglutide users with DFU (Cohort A, N = 6329) and non-users with DFU (Cohort B, N = 118,821) across 64 healthcare organizations. We matched participants by age, gender, race, and ethnicity; however, we excluded patients with certain co-morbidities. Statistical analysis, such as chi-square analysis and risk ratio, using TriNetX software evaluated different complication outcomes.ResultsSemaglutide users with DFU demonstrated lower relative risks for complications compared to non-users. Within 1 year, semaglutide users were associated with lower relative risks for wound healing complications (0.19% vs 0.38%), chronic non-healing wounds (0.75% vs 1.23%), chronic pain (4.44% vs 8.06%), wound care (2.42% vs 4.86%), wound dehiscence (0.26% vs 0.56%), and amputation (2.34% vs 5.21%) (p < .05). Similar trends persisted over 5 years. While these findings highlight potential benefits of semaglutide with patients with DFU, causation cannot be inferred due to the study's observational design.ConclusionSemaglutide use was associated with favorable outcomes in patients with diabetes-related foot ulcers, including reductions in wound-related complications. While these findings suggest potential benefits of semaglutide as an adjunct in DFU management, further research is needed to confirm these associations and to better understand the mechanisms involved.

The Prevalence, Aetiology and Healing Trajectories of Hard-To-Heal Wounds in South Africa

The incidence of hard-to-heal wounds is rising globally with adverse effects on quality of life. Yet, there is no reliable data available on hard-to-heal wound prevalence, aetiology, and outcomes in a low-to-middle income country without improper care being a confounding factor. In this retrospective study of 460 individuals (876 wounds) that received appropriate standard of care at a specialised wound care clinic in the Kwazulu-Natal province of South Africa, acute/traumatic wounds were most prevalent (230/460, 50%) followed by ulcers (173/460, 38%) (DFUs 13%, VLUs 12%, PIs 11%, MLUs < 1%, ALUs < 1%) and atypical wounds (55/460, 12%) (atypical wounds 8%, vectors 4%). Definitions for wound aetiologies are provided. Delayed referral for specialised wound care was evident for individuals with ulcers. 103/460 (22%) individuals did not respond to the standard of care and were classified as hard-to-heal (< 40% wound closure after 4 weeks and/or > 12 weeks of the standard of care). Diabetes mellitus (45/103, 44%) and wound infection (44/103, 43%) accounted for poor healing trajectories in the hard-to-heal cohort, whereas 14/103 (13%) individuals had other comorbidities. High prevalence rates of hard-to-heal wounds in the heterogenous South African population necessitate recognition of wound management as a specialty in South Africa.

Mitochondria in cutaneous health, disease, ageing and rejuvenation-the 3PM-guided mitochondria-centric dermatology

Association of both intrinsic and extrinsic risk factors leading to accelerated skin ageing is reflected in excessive ROS production and ir/reversible mitochondrial injury and burnout, as abundantly demonstrated by accumulating research data. Due to the critical role of mitochondrial stress in the pathophysiology of skin ageing and disorders, maintained (primary care) and restored (secondary care) mitochondrial health, rejuvenation and homoeostasis are considered the most effective holistic approach to advance dermatological treatments based on systemic health-supportive and stimulating measures. Per evidence, an effective skin anti-ageing protection, wound healing and scarring quality - all strongly depend on the sustainable mitochondrial functionality and well-balanced homoeostasis. The latter can be objectively measured and, if necessary, restored in a systemic manner by pre- and rehabilitation algorithms tailored to individualised patient profiles. The entire spectrum of corresponding innovations in the area includes natural and systemic skin rejuvenation, aesthetic and reconstructive medicine, sustainable skin protection and targeted treatments of skin disorders. Contextually, mitochondria-centric dermatology is instrumental for advanced 3PM-guided approach which makes a good use of predictive multi-level diagnostics and targeted protection of skin against both - the health-to-disease transition and progression of relevant disorders. Cost-effective targeted protection and new treatment avenues focused on sustainable mitochondrial health and physiologic homoeostasis are proposed in the article including in-depth analysis of patient cases and exemplified 3PM-guided care with detailed mechanisms and corresponding expert recommendations presented.

Polyphenols in wound healing: unlocking prospects with clinical applications

Wound healing is a multifaceted, complex process that factors like aging, metabolic diseases, and infections may influence. The potentiality of polyphenols, natural compounds, has shown anti-inflammatory and antimicrobial properties in promoting wound healing and their potential applications in wound management. The studies reviewed indicate that polyphenols have multiple mechanisms that promote wound healing. This involves enhancing antioxidant defenses, reducing oxidative stress, modulating inflammatory responses, improving healing times, reducing infection rates, and enhancing tissue regeneration in clinical trials and in vivo and in vitro studies. Polyphenols have been proven to be effective in managing hard-to-heal wounds, especially in diabetic and elderly populations. Polyphenols have shown significant benefits in promoting angiogenesis and stimulating collagen synthesis. Polyphenol treatment has been demonstrated to have therapeutic effects in wound healing and chronic wound management. Their ability to regulate key healing processes makes them suitable for new wound care products and treatments. Future research should enhance formulations and delivery methods to optimize polyphenols' bioavailability and therapeutic efficacy in wound management approaches.

Psychological, behavioural and relevant factors affecting wound healing, and the buffering role of interventions

Wound healing is a complex process accompanying numerous health conditions, and millions of people across the world experience deleterious impacts caused by wounds. There are many non-biological factors that can directly or indirectly affect the health outcomes of patients with wounds. The purpose of this review was to investigate the effects of psychological, behavioural and other relevant factors on wound healing. In addition, as the possible associations among these factors have, in the authors' view, not been addressed appropriately, we also aimed to examine if there were specific relationships among these factors and between these factors and health outcomes. Finally, we reviewed the role of various interventions in buffering negative impacts during health procedures.

Application of novel strategies in chronic wound management with focusing on pressure ulcers: new perspective

Invading blood cells, extracellular tissue, and soluble mediators all play important roles in the wound-healing process. There is a substantial global burden of disease and mortality attributable to skin defects that do not heal. About 1% to 2% of the population in industrialized nations suffers from chronic wounds that don't heal, despite healthcare breakthroughs; this condition is very costly, costing about $25 billion each year in the US alone. Amputation, infection (affecting as many as 25% of chronic wounds), sepsis, and dermal replacements are all consequences of conventional therapeutic approaches like growth factor therapy and diabetic foot ulcers account for 85% of lower limb amputations. Despite these obstacles, scientists are constantly looking for new ways to speed healing and close wounds. The unique immunomodulatory capabilities and multipotency of mesenchymal stem cells (MSCs) have made them a potential therapeutic choice in tissue engineering and regenerative medicine. Animal models of wound healing have shown that MSCs can speed up the process by as much as 40% through enhancing angiogenesis, modulating inflammation, and promoting fibroblast migration. Clinical trials provide more evidence of their effectiveness; for instance, one RCT found that, after 12 weeks, patients treated with MSCs had a 72% smaller wound size than those in the control group. This review offers a thorough examination of MSCs by combining the latest research with preclinical evidence. Highlighting their potential to transform treatment paradigms, it delves into their biological properties, how they work during regeneration and healing, and therapeutic usefulness in controlling chronic wounds.

Lovastatin and Resveratrol Synergistically Improve Wound Healing and Inhibit Bacterial Growth

Wound healing is a complex physiological process, with scarring and infection caused by Staphylococcus aureus and Pseudomonas aeruginosa being the most common complications. The reutilization of known medications has received increased attention for their role in cell function as small molecules. Examples of these include lovastatin, a cholesterol-lowering agent, and resveratrol, which have multiple biological properties. Both molecules have been reported to improve wound healing and possess antibacterial properties, with conflicting results. The wound-healing capabilities of human mesenchymal stem cells were evaluated after exposure to lovastatin, resveratrol, and their combination through scratch test, migrations assay, and qPCR. Protein docking was performed to assess the lovastatin/resveratrol combination as potential wound-healing targets. AlamarBlue assay was used to determine cell viability. Additionally, the impact of lovastatin and resveratrol combination to inhibit the growth of S. aureus and P. aeruginosa was tested using broth microdilution test and checkerboard assay to determine synergism. The combination of lovastatin 0.1 μM and resveratrol 0.1 μM synergistically improved wound healing and demonstrated an additive effect against S. aureus and P. aeruginosa, presenting potential antibacterial applications.

An injectable hydrogel of porcine cholecyst extracellular matrix for accelerated wound healing

Hydrogel formulations of xenogeneic extracellular matrices have been widely used for topical wound care because of their exceptional tunability over other formulations like lyophilized sheets, powders, non-injectable gels, pastes, and ointments. This is important in the treatment of wounds with irregular shapes and depth. This study identified an injectable hydrogel formulation of porcine cholecyst extracellular matrix (60%) in medical-grade carboxymethyl cellulose (40%) as vehicle and evaluated its biomaterial properties. Further, an in-depth evaluation of in vivo wound healing efficacy was conducted in a rat full-thickness skin excision wound healing model, which revealed that the hydrogel formulation accelerated wound healing process compared to wounds treated with a commercial formulation and untreated wounds. The hydrogel appeared to have promoted a desirable pro-regenerative tissue reaction predominated by Th2 helper lymphocytes and M2 macrophages as well as an effective collagen remodeling indicative of diminished scarring. In conclusion, the porcine cholecyst extracellular matrix injectable hydrogel formulation appeared to be a promising candidate formulation as an advanced wound care biomaterial for faster healing of skin wounds with minimal scarring.

Novel microfluidic development of pH-responsive hybrid liposomes: In vitro and in vivo assessment for enhanced wound Healing

Wound healing is a complex biological process crucial for tissue repair, especially in chronic wounds where healing is impaired. Liposomes have emerged as promising vehicles for delivering therapeutics to facilitate wound repair. Liposomes have been explored as effective carriers for therapeutic agents. However, traditional methods of liposome preparation face significant challenges, particularly in achieving consistent stability and precise control over drug encapsulation and release. This study addresses these challenges by pioneering the development of Hybrid Liposomes (HLPs) using microfluidic technology, which provides more controlled characteristics through precisely managed formulation parameters. Notably, the formation of Polydopamine (PDA) polymer within HLPs facilitates pH-responsive drug release, making them well-suited for acidic wound environments. Furthermore, surface modification with Folic Acid (FA) enhances cellular interaction with the HLPs. In vitro and in vivo studies demonstrate the efficacy of HLPs loaded with Hyaluronic Acid (HA) or Phenytoin (PHT) in promoting wound healing. Microfluidics optimizes the stability of HLPs over 90 days, underscoring their potential as a potent, antibiotic-free drug delivery system. In conclusion, this research advances the understanding of microfluidic optimization for HLPs, offering cutting-edge drug delivery systems. The transformative potential of targeted HLPs through microfluidics holds promise for revolutionizing wound healing and inspires optimism for effective therapeutic interventions.

Audit of co-morbidity patterns and 5-year survival among patients presenting to a rapid access leg ulcer service

Background: While leg ulceration is common, data regarding long-term is limited. Historical data indicate that approximately 50% of leg ulcer patients die within 5 years of presentation. However, little is known regarding survival outcomes in contemporary patient populations. This retrospective study aimed to assess 5-year survival in patients attending a vascular leg ulcer clinic. Objectives: To evaluate 5-year survival among patients with leg ulcers and to analyse the effect of ulcer aetiology and patient co-morbidities on survival. Methods: Over 30 months (2016 to 2018), 119 new patients were assessed at the leg ulcer clinic and followed over 5 years. Baseline co-morbidities, ulcer type, interventions performed, and 5-year survival were recorded. Survival was calculated using Kaplan-Meier curves. Co-morbid burden and survival were compared between venous and arterial/mixed patients. Results: Overall 5-year survival was 74%. Venous patients fared better than arterial/mixed patients (5-year mortality 16/88 vs 15/31; p < .01 log-rank test). Arterial/mixed patients had a greater burden of co-morbidities. In multivariate regression modelling, the presence of three or more co-morbidities at presentation was the only significant predictor of mortality. Conclusions: Overall, 5-year survival for leg ulcer patients has improved compared to historical data but remains static for arterial/mixed patients.

Curcumin-loaded gold nanoparticles with enhanced antibacterial efficacy and wound healing properties in diabetic rats

Diabetic wounds pose a significant global health challenge. Although curcumin exhibits promising wound healing and antibacterial properties, its clinical potential is limited by low aqueous solubility, and poor tissue penetration. This study aimed to address these challenges and enhance the wound healing efficacy of curcumin by loading it onto gold nanoparticles (AuNPs). The properties of the AuNPs, including particle size, polydispersity index (PDI), zeta potential, percent drug entrapment efficiency (%EE) and UV-Vis spectra were significantly influenced by the curcumin/gold chloride molar ratio used in the synthesis of AuNPs. The optimal formulation (F2) exhibited the smallest particle size (41.77 ± 6.8 nm), reasonable PDI (0.59 ± 0.17), high %EE (94.43 ± 0.25 %), a moderate zeta potential (-8.44 ± 1.69 mV), and a well-defined surface Plasmon resonance peak at 526 nm. Formulation F2 was incorporated into Pluronic® F127 gel to facilitate its application to the skin. Both curcumin AuNPs solution and gel showed sustained drug release and higher skin permeation parameters compared with the free drug solution. AuNPs significantly enhanced curcumin's antibacterial efficacy by lowering the minimum inhibitory concentrations and enhancing antibacterial biofilm activity against various Gram-positive and Gram-negative bacterial strains. In a diabetic wound rat model, AuNPs-loaded curcumin exhibited superior wound healing attributes compared to the free drug. Specifically, it demonstrated improved wound healing percentage, reduced wound oxidative stress, increased wound collagen deposition, heightened anti-inflammatory effects, and enhanced angiogenesis. These findings underscore the potential of AuNPs as efficacious delivery systems of curcumin for improved wound healing applications.

Pain chronification risk assessment: advanced phenotyping and scoring for prediction and treatments tailored to individualized patient profile

Acute pain is a physiologic, protective life-important warning neurological signal indicating multi-level tissue modulations caused by a broad spectrum of health adverse events such as stress overload, mechanical trauma, ischemia-reperfusion, sterile and infection-triggered inflammation, single- and multi-organ damage, acute and chronic wounds, tissue remodeling and degeneration, amongst others. On the other hand, pain chronification results in a pathologic transformation from the protective pain signaling into persistent debilitative medical condition with severe consequences including but not restricted to phenotype-specific behavioral patterns, reduced quality of life, and cognitive and mood disorders. Who is predisposed to an increased vs. decreased pain sensitivity and to the pain chronification? The motivation of personalized medicine that "same size does not fit all" is getting obvious also for an advanced approach in algesiology. Consequently, an in-depth patient stratification is essential for the paradigm change in overall pain management from currently applied reactive medical services to the cost-effective predictive, preventive, and personalized medicine (PPPM/3PM) in primary (reversible damage to health and targeted protection against health-to-disease transition) and secondary (personalized protection against disease progression) care. To this end, specifically innovative concepts of phenotyping elaborated in this study play a crucial role in patient stratification for predicting pain-associated outcomes, evidence-based targeted prevention of the pain chronification, and creation of treatment algorithms tailored to individualized patient profiles.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-024-00383-3.

Safety of Thread-Embedding Acupuncture: A Multicenter, Prospective, Observational Pilot Study

Background/Objectives: Thread-embedding acupuncture (TEA) is widely used for cosmetic and therapeutic purposes; however, its safety profile, particularly in real-world clinical settings, remains under-researched. This study aimed to evaluate the safety profile of TEA through a prospective, observational analysis and confirm the feasibility of the study design for future studies involving larger patient populations. Methods: A multicenter, prospective observational study was conducted involving 100 patients who received TEA. Adverse events (AEs) were tracked, including incidence, severity, and duration during the 6-month post-treatment period. Bivariate analysis was used to assess factors influencing AE occurrence, including treatment site, depth, and patient-specific variables. Results: A total of 100 patients received 136 treatments during the study period. A total of 12 AEs were reported, most of which were mild and transient local reactions, including pain and bruising. More than half of the AEs occurred on the day of the procedure, with an average duration of 7 days. No serious AEs were observed, and all events resolved without any lasting effects. Patients undergoing multiple treatments showed no significantly higher AE rates than those receiving a single session. Conclusions: This study suggested that TEA generally has a favorable safety profile, with most AEs being mild and resolving without long-term effects. Further studies that evaluate the safety of TEA treatment across larger populations are recommended.

Implications of pH and Ionic Environment in Chronic Diabetic Wounds: An Overlooked Perspective

The high incidence of disability and fatality rates associated with chronic diabetic wounds are difficult problems in the medical field. The steady-state and regular changes of the microenvironment in and around the wound provide good conditions for wound healing and achieve a dynamic and complex process of wound healing.The pH value and ionic environment composed of a variety of ions in wound are important factors affecting the wound microenvironment, and there are direct or indirect connections between them. Abnormalities in pH, ion concentrations, and channels in skin tissue may be one of the reasons for the high incidence and difficulty in chronic diabetic wounds healing. Currently, different wound-dressing applications have been developed based on the efficacy of ions. Here, the effect of pH in wounds, concentrations of calcium (Ca2+), sodium (Na+), potassium (K+) and the metal ions silver (Ag+), copper (Cu2+), iron (Fe2+/Fe3+), zinc (Zn2+), and magnesium (Mg2+) in skin tissue, their roles in wound healing, and the application of related dressings are reviewed. This manuscript provides new ideas and approaches for future clinical and basic research examining the treatment of chronic diabetic wounds by adjusting ion concentrations and channels.

A comprehensive review of the application of 3D-bioprinting in chronic wound management

INTRODUCTION

Chronic wounds require more sophisticated care than standard wound care because they are becoming more severe as a result of diseases like diabetes. By resolving shortcomings in existing methods, 3D-bioprinting offers a viable path toward personalized, mechanically strong, and cell-stimulating wound dressings.

AREAS COVERED

This review highlights the drawbacks of traditional approaches while navigating the difficulties of managing chronic wounds. The conversation revolves around employing natural biomaterials for customized dressings, with a particular emphasis on 3D-bioprinting. A thorough understanding of the uses of 3D-printed dressings in a range of chronic wound scenarios is provided by insights into recent research and patents.

EXPERT OPINION

The expert view recognizes wounds as a historical human ailment and emphasizes the growing difficulties and expenses related to wound treatment. The expert acknowledges that 3D printing is revolutionary, but also points out that it is still in its infancy and has the potential to enhance mass production rather than replace it. The review highlights the benefits of 3D printing for wound dressings by providing instances of smart materials that improve treatment results by stimulating angiogenesis, reducing pain, and targeting particular enzymes. The expert advises taking action to convert the technology's prospective advantages into real benefits for patients, even in the face of resistance to change in the healthcare industry. It is believed that the increasing evidence from in-vivo studies is promising and represents a positive change in the treatment of chronic wounds toward sophisticated 3D-printed dressings.

Systemic Factors Affecting Healing in Dentistry

Healing process in the oral cavity is influenced by a range of systemic factors. More specifically, patient health status, medications, habits, and nutritional state play crucial roles in dental healing. Additionally, the body's immune response, inflammation, and overall well-being are key determinants in wound repair. Understanding these systemic factors is essential for dental professionals to optimize patient care, minimize complications, and achieve successful healing.

Flap-Based Reconstruction in Patients with Autoimmune Disease: An Institutional Experience with the Deep Inferior Epigastric Perforator Flap and Review of the Literature

BACKGROUND

 Autoimmune diseases are associated with characteristic chronic inflammation, aberrations in tissue perfusion, and hypercoagulability, and thus have considerable implications for local and free-flap reconstruction. We seek to summarize the current evidence on outcomes of flap-based reconstruction in patients with pre-existing autoimmune disease and present our experience with autologous breast reconstruction in this population.

METHODS

 PubMed, Embase, Scopus, Cochrane, and Web of Science were searched for relevant articles, and pertinent data were presented qualitatively. Institutional data were queried for patients who underwent autologous breast reconstruction with deep inferior epigastric perforator (DIEP) flaps between 2015 and 2024. A retrospective review was conducted to identify DIEP patients with a history of autoimmune disease. Data on patient demographics, medication history, flap outcomes, and perioperative complications were collected.

RESULTS

 The majority of existing studies found no increased independent risk of flap complications. However, other complications, predominantly wound dehiscence, were independently associated with autoimmune disease. Regarding immunosuppressant therapy, the literature demonstrated that perioperative glucocorticoid use was consistently associated with all complications, including seroma, infection, wound disruption, and partial flap loss.Our 13-patient institutional experience identified no cases of total flap loss or microvascular thrombotic complications. There was one case of partial flap necrosis further complicated by abdominal site cellulitis, and one case of recipient-site dehiscence managed with local wound care. No patients required re-operation for flap or donor-site complications.

CONCLUSION

 The literature suggests that flap reconstruction can be performed safely in patients with autoimmune conditions, which was also supported by our institutional experience. While there is likely minimal risk of microsurgical complications in the context of free tissue transfer, donor-site morbidity and wound dehiscence remain major concerns for patients with a history of autoimmune disease. Limiting the use of immunosuppressive agents, especially corticosteroids, may potentially improve outcomes of flap reconstruction.

Effect of 3-hydrazinylquinoxaline-2-thiol hydrogel on skin wound healing process in diabetic rats

Impaired wound healing in diabetic individuals creates huge social and financial burdens for both diabetic patients and the health system. Unfortunately, the current treatment has not resulted in consistently lower amputation rates. Quinoxalines are heterocyclic compounds with multiple important pharmacological properties. Their effect on wound healing have not been closely studied. In the current work, the wound healing effect of 3-hydrazinylquinoxaline-2-thiol hydrogel is tested topically in a full-thickness excision wound in streptozotocin-induced type 1 diabetic rats. We examined the wound closure rate, expression of inflammatory factors, growth factors in addition to the histological analysis. The results revealed a significant acceleration in wound closure in the treated group compared with the control experimental animals. Histological data demonstrated enhanced re-epithelialization and collagen disposition. The healing effect was additionally evaluated by the inhibition of the inflammatory response of interleukin (IL)-1β interleukin (IL)-6, tumor necrosis factor (TNF-α) and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) with a marked improvement of the transforming growth factor beta (TGFβ-1), antioxidant markers and collagen-1. In silico study indicated a favorable drug-like properties and toxicity profile. The present work showed that 3-hydrazinylquinoxaline-2-thiol holds great potential for the treatment of diabetic wounds.

Cannabinoids in Integumentary Wound Care: A Systematic Review of Emerging Preclinical and Clinical Evidence

This systematic review critically evaluates preclinical and clinical data on the antibacterial and wound healing properties of cannabinoids in integument wounds. Comprehensive searches were conducted across multiple databases, including CINAHL, Cochrane library, Medline, Embase, PubMed, Web of Science, and LILACS, encompassing records up to May 22, 2024. Eighteen studies met the inclusion criteria. Eleven were animal studies, predominantly utilizing murine models (n = 10) and one equine model, involving 437 animals. The seven human studies ranged from case reports to randomized controlled trials, encompassing 92 participants aged six months to ninety years, with sample sizes varying from 1 to 69 patients. The studies examined the effects of various cannabinoid formulations, including combinations with other plant extracts, crude extracts, and purified and synthetic cannabis-based medications administered topically, intraperitoneally, orally, or sublingually. Four animal and three human studies reported complete wound closure. Hemp fruit oil extract, cannabidiol (CBD), and GP1a resulted in complete wound closure in twenty-three (range: 5-84) days with a healing rate of 66-86% within ten days in animal studies. One human study documented a wound healing rate of 3.3 cm2 over 30 days, while three studies on chronic, non-healing wounds reported an average healing time of 54 (21-150) days for 17 patients by oral oils with tetrahydrocannabinol (THC) and CBD and topical gels with THC, CBD, and terpenes. CBD and tetrahydrocannabidiol demonstrated significant potential in reducing bacterial loads in murine models. However, further high-quality research is imperative to fully elucidate the therapeutic potential of cannabinoids in the treatment of bacterial skin infections and wounds. Additionally, it is crucial to delineate the impact of medicinal cannabis on the various phases of wound healing. This study was registered in PROSPERO (CRD42021255413).

Effects of Nursing Program in Preventing Incontinence-Associated Dermatitis by Applying Zinc Oxide and Petroleum Jelly Skin Protection Products Among Older Patients in Semi-Intensive Medical Care Units: A Pilot Study

Aim

Incontinence-associated dermatitis is a common health problem among older clinical patients, causing related severe skin damage such as pressure ulcers, secondary infection, and long length of hospital stay. This pilot study aimed to develop and examine the effects of nursing programs in preventing incontinence-associated dermatitis (IAD) among older patients. Ten older patients at high risk of incontinence-associated dermatitis were included in this study: five patients received a nursing program combined with mixed products, and another five received a nursing program combined with separate use of products. The program was evaluated using a perianal assessment tool (PAT-T) for risk assessment, the incontinence-associated dermatitis invention tool (IADIT-T) for severity assessment, the skin surface pH, and skin surface moisture. The results revealed that the nursing program and skin products are usable and acceptable, provide step-by-step details, and are simple and easy to follow. The nursing program combined with using zinc oxide products followed by petroleum jelly can prevent and decrease the severity of incontinence-associated dermatitis in older patients. Moreover, it can also improve the skin surface pH to a mild acidity appropriate for the skin condition and increase the skin's moisture better the nursing program with mixed skin products. This pilot study confirmed that the developed program can be applied in practice. Moreover, the program could be used to decrease the incidence of IAD and skin surface pH but increase skin moisture. However, future study with a larger sample size and applying a more substantial research design for more accuracy and generalization is needed.

Clinical Trial Registration Number

OSF https://osf.io/8gj3d.

Hepatocyte Growth Factor DNA Aptamer for Prevention of Postoperative Peritoneal Adhesion via Enhancement of Fibrinolysis and Inhibition of Mesothelial Mesenchymal Transition

Postoperative peritoneal adhesion (PPA) is a prevalent complication of abdominal surgery, posing a significant hindrance to postsurgical recovery. Although several strategies have been developed to alleviate and prevent adhesions, their efficacy remains unsatisfactory. For the first time, we studied the therapeutic effect and mechanism of our recently developed thermally stable oligonucleotide-based mimetics of hepatocyte growth factor (HGF DNA aptamer) to prevent PPA. The HGF DNA aptamer effectively inhibited canonical TGF-β1 signaling transduction, partially suppressing mesothelial mesenchymal transition. Additionally, the aptamer, respectively, upregulated and downregulated the expression of tissue plasminogen activator and plasminogen activator inhibitor 1, thereby enhancing fibrinolytic activity. As a pleiotropic factor, the HGF DNA aptamer also enhanced the migratory and proliferative capacities of mesothelial cells. Finally, the aptamer demonstrated a higher level of effectiveness in preventing PPAs than the commercially available antiperitoneal adhesion barrier, Seprafilm. Due to its therapeutic benefits, excellent stability, biosafety, cost-effectiveness, and versatility, the HGF DNA aptamer demonstrates promise for preventing PPA in future clinical settings.

Prediction of wound healing status following dental extraction using Adapted-University of Connecticut osteonecrosis numerical scale: A retrospective study

Background and Aims

There is a scarcity of evidence concerning the use of a prognostic instrument for predicting normal healing, delayed healing, and medication-related osteonecrosis of the jaw (MRONJ) occurrence following tooth extraction in medically compromised patients. The present study aimed to predict healing outcomes following tooth extraction in medically compromised patients using an Adapted-University of Connecticut osteonecrosis numerical scale (A-UCONNS).

Methods

The digital medical records of medically compromised patients were reviewed, who underwent tooth extraction. The A-UCONNS parameters included the initial pathological condition, dental procedures, comorbidities (smoking habits, type and duration of medication, and type of intervention), and administered antiresorptive (AR) medications. Each parameter was assigned a different weight, and the scores were then accumulated and classified into three categories: minimal risk (less than 10), moderate risk (10-15), and significant risk (16 or more). The patient's healing status was categorized as normal healing, delayed healing, or MRONJ.

Results

A total of 353 male patients (mean age: 67.4 years) were recruited from a pool of 3977 patients, where 12.46% of patients had delayed wound healing, and 18.69% developed MRONJ. The median A-UCONNS scores for MRONJ were higher based on initial pathology, comorbidity, and AR drugs compared to normal or delayed healing. In addition, a significant relationship existed between A-UCONNS and healing outcomes (p < 0.05), with a unit increase in A-UCONNS associated with 1.347 times higher odds of experiencing MRONJ compared to normal healing. In contrast, a low score was linked to an increased likelihood of normal wound healing.

Conclusion

The A-UCONNS could act as a promising tool for predicting wound healing outcomes. It can provide clinicians the ability to pinpoint patients at high risk and allow tailoring of patient-specific strategies for improving healing outcomes following tooth extraction.

In vitro effects of wound-dressings on key wound healing properties of dermal fibroblasts

Healing of complex wounds requires dressings that must, at least, not hinder and should ideally promote the activity of key healing cells, in particular fibroblasts. This in vitro study assessed the effects of three wound-dressings (a pure Ca2+ alginate: Algostéril®, a Ca2+ alginate + carboxymethylcellulose: Biatain alginate® and a polyacrylate impregnated with lipido-colloid matrix: UrgoClean®) on dermal fibroblast activity. The results showed the pure calcium alginate to be non-cytotoxic, whereas the other wound-dressings showed moderate to strong cytotoxicity. The two alginates stimulated fibroblast migration and proliferation, whereas the polyacrylate altered migration and had no effect on proliferation. The pure Ca2+ alginate significantly increased the TGF-β-induced fibroblast activation, which is essential to healing. This activation was confirmed by a significant increase in Vascular endothelial growth factor (VEGF) secretion and a higher collagen production. The other dressings reduced these fibroblast activities. The pure Ca2+ alginate was also able to counteract the inhibitory effect of NK cell supernatants on fibroblast migration. These in vitro results demonstrate that tested wound-dressings are not equivalent for fibroblast activation. Only Algostéril was found to promote all the fibroblast activities tested, which could contribute to its healing efficacy demonstrated in the clinic.

Experience of diagnosis and treatment of hard-to-heal wounds infected with Acinetobacter baumannii: a case study

OBJECTIVE

To explore the efficacy of 0.01% hypochlorous acid (HOCl) in the treatment of hard-to-heal wounds infected by multidrug-resistant Acinetobacter baumannii.

METHOD

We report a case of hard-to-heal wounds on a patient's forearms that were infected by Acinetobacter baumannii. The wounds were treated with 0.01% HOCl. We reviewed the relevant literature and discussed the definition, epidemiology and pathogenesis of hard-to-heal wounds infected by Acinetobacter baumannii. We also explored the safety and efficacy of 0.01% HOCl for the treatment of hard-to-heal wounds infected with Acinetobacter baumannii.

RESULTS

After 3-4 weeks of treatment with 0.01% HOCl, the pain and pruritus of the wounds was gradually alleviated, the infection was controlled and the granulation tissue was fresh. The ulcers also shrank and the nutritional condition of the patient improved. In the fifth week, the skin of the patient's right thigh was grafted to repair the wounds, which then healed within 18 days. During the three years of follow-up, the patient had no relapse.

CONCLUSION

In our case, the 0.01% HOCl seemed to effectively inactivate the bacterial biological biofilm. This helped to promote wound healing, and was non-toxic to the tissues. We consider low-concentration HOCl to be safe and effective for the treatment of hard-to-heal wounds infected with Acinetobacter baumannii.

Development of a Sprayable Hydrogel-Based Wound Dressing: An In Vitro Model

Hydrogel-based dressings can effectively heal wounds by providing multiple functions, such as antibacterial, anti-inflammatory, and preangiogenic bioactivities. The ability to spray the dressing is important for the rapid and effective coverage of the wound surface. In this study, we developed a sprayable hydrogel-based wound dressing using naturally derived materials: hyaluronic acid and gelatin. We introduced methacrylate groups (HAMA and GelMA) to these materials to enable controllable photocrosslinking and form a stable hydrogel on the wound surface. To achieve sprayability, we evaluated the concentration of GelMA within a range of 5-15% (w/v) and then incorporated 1% (w/v) HAMA. Additionally, we incorporated calcium peroxide into the hydrogel at concentrations ranging from 0 to 12 mg/mL to provide self-oxygenation and antibacterial properties. The results showed that the composite hydrogels were sprayable and could provide oxygen for up to two weeks. The released oxygen relieved metabolic stress in fibroblasts and reduced cell death under hypoxia in in vitro culture. Furthermore, calcium peroxide added antibacterial properties to the wound dressing. In conclusion, the developed sprayable hydrogel dressing has the potential to be advantageous for wound healing due to its practical and conformable application, as well as its self-oxygenating and antibacterial functions.

Predictive, preventive and personalised approach as a conceptual and technological innovation in primary and secondary care of inflammatory bowel disease benefiting affected individuals and populations

Inflammatory bowel disease (IBD) is a global health burden which carries lifelong morbidity affecting all age groups in populations with the disease-specific peak of the age groups ranging between 15 and 35 years, which are of great economic importance for the society. An accelerating incidence of IBD is reported for newly industrialised countries, whereas stabilising incidence but increasing prevalence is typical for countries with a Westernised lifestyle, such as the European area and the USA. Although the aetiology of IBD is largely unknown, the interplay between the genetic, environmental, immunological, and microbial components is decisive for the disease manifestation, course, severity and individual outcomes. Contextually, the creation of an individualised patient profile is crucial for the cost-effective disease management in primary and secondary care of IBD. The proposed pathomechanisms include intestinal pathoflora and dysbiosis, chronic inflammation and mitochondrial impairments, amongst others, which collectively may reveal individual molecular signatures defining IBD subtypes and leading to clinical phenotypes, patient stratification and cost-effective protection against health-to-disease transition and treatments tailored to individualised patient profiles-all the pillars of an advanced 3PM approach. The paradigm change from reactive medical services to predictive diagnostics, cost-effective targeted prevention and treatments tailored to individualised patient profiles in overall IBD management holds a promise to meet patient needs in primary and secondary care, to increase the life-quality of affected individuals and to improve health economy in the area of IBD management. This article analyses current achievements and provides the roadmap for future developments in the area in the context of 3P medicine benefiting society at large.

Molecular targeted therapies for cutaneous squamous cell carcinoma: recent developments and clinical implications

Cutaneous Squamous Cell Carcinoma (cSCC) is a common and potentially fatal type of skin cancer that poses a significant threat to public health and has a high prevalence rate. Exposure to ultraviolet radiation on the skin surface increases the risk of cSCC, especially in those with genetic syndromes like xerodermapigmentosum and epidermolysis bullosa. Therefore, understanding the molecular pathogenesis of cSCC is critical for developing personalized treatment approaches that are effective in cSCC. This article provides a comprehensive overview of current knowledge of cSCC pathogenesis, emphasizing dysregulated signaling pathways and the significance of molecular profiling. Several limitations and challenges associated with conventional therapies, however, are identified, stressing the need for novel therapeutic strategies. The article further discusses molecular targets and therapeutic approaches, i.e., epidermal growth factor receptor inhibitors, hedgehog pathway inhibitors, and PI3K/AKT/mTOR pathway inhibitors, as well as emerging molecular targets and therapeutic agents. The manuscript explores resistance mechanisms to molecularly targeted therapies and proposes methods to overcome them, including combination strategies, rational design, and optimization. The clinical implications and patient outcomes of molecular-targeted treatments are assessed, including response rates and survival outcomes. The management of adverse events and toxicities in molecular-targeted therapies is crucial and requires careful monitoring and control. The paper further discusses future directions for therapeutic advancement and research in this area, as well as the difficulties and constraints associated with conventional therapies.

Insights into the mechanisms of diabetic wounds: pathophysiology, molecular targets, and treatment strategies through conventional and alternative therapies

Diabetes mellitus is a prevalent cause of mortality worldwide and can lead to several secondary issues, including DWs, which are caused by hyperglycemia, diabetic neuropathy, anemia, and ischemia. Roughly 15% of diabetic patient's experience complications related to DWs, with 25% at risk of lower limb amputations. A conventional management protocol is currently used for treating diabetic foot syndrome, which involves therapy using various substances, such as bFGF, pDGF, VEGF, EGF, IGF-I, TGF-β, skin substitutes, cytokine stimulators, cytokine inhibitors, MMPs inhibitors, gene and stem cell therapies, ECM, and angiogenesis stimulators. The protocol also includes wound cleaning, laser therapy, antibiotics, skin substitutes, HOTC therapy, and removing dead tissue. It has been observed that treatment with numerous plants and their active constituents, including Globularia Arabica, Rhus coriaria L., Neolamarckia cadamba, Olea europaea, Salvia kronenburgii, Moringa oleifera, Syzygium aromaticum, Combretum molle, and Myrtus communis, has been found to promote wound healing, reduce inflammation, stimulate angiogenesis, and cytokines production, increase growth factors production, promote keratinocyte production, and encourage fibroblast proliferation. These therapies may also reduce the need for amputations. However, there is still limited information on how to prevent and manage DWs, and further research is needed to fully understand the role of alternative treatments in managing complications of DWs. The conventional management protocol for treating diabetic foot syndrome can be expensive and may cause adverse side effects. Alternative therapies, such as medicinal plants and green synthesis of nano-formulations, may provide efficient and affordable treatments for DWs.

A biologically functional bioink based on extracellular matrix derived collagen for 3D printing of skin

Over the past few years, several advancements have been made to develop artificial skin that mimics human skin. Artificial skin manufactured using 3D printing technology that includes all epidermal and dermal components, such as collagen, may offer a viable solution. The skin-specific bioink was derived from digested chicken skin and incorporated into PVA (polyvinyl alcohol) and gelatin. The prepared bioink was further analyzed for its structure, stability, biocompatibility, and wound healing potential in in vitro, in ovo, and in vivo models. The 3D-printed skin showed excellent mechanical properties. In vitro scratch assays showed the proliferation and migration of cells within 24 h. In an in ovo assay, the 3D-printed skin facilitated the attachment of cells to the scaffolds. In the animal study, the quick cellular recruitment at the injury site accelerated wound healing. Further, hydroxyproline content was estimated to be 0.9-1.2 mg/ml, and collagen content was 7.5 %, which confirmed the epithelization. The relative expressions of MMP-9, COMP, TNF-α, and IL-6 genes were found to be increased compared to the control. These results demonstrate that 3D bioprinting represents a suitable technology to generate bioengineered skin for therapeutic and industrial applications in an automated manner.

An Insight into Biodegradable Polymers and their Biomedical Applications for Wound Healing

Biodegradable polymers, encompassing both natural and synthetic polymers, have demonstrated efficacy as carriers for synthetic drugs, natural bioactive molecules, and inorganic metals. This is due to their ability to control the release of these substances. As a result, various advanced materials, such as nanoparticle- loaded hydrogels, nanofibrous scaffolds, and nanocomposites, have been developed. These materials have shown promise in enhancing processes, such as cell proliferation, vascular angiogenesis, hair growth, and wound healing management. Natural polymers, including hyaluronic acid, collagen, chitosan, gelatin, and alginate, as well as synthetic polymers like polylactic acid, polyglycolic acid, polylactic co-glycolic acid, and PCA, have significant potential for promoting wound healing. This study examines the advancements in biodegradable polymers for wound healing, specifically focusing on each polymer and its distinctive formulations. It also discusses the in vitro experiments conducted using different cell lines, as well as the in vivo studies that explore the numerous uses of these polymers in wound healing. The discussion also included the exploration of modifications or combinations of several polymers, as well as surface changes, in order to produce synergistic effects and address the limitations of individual polymers. The goal was to expedite the healing process of different chronic wounds. Due to this, there have been notable advancements in the technological use of polymeric mixes, including biodegradable polymer-based scaffolds, which have accelerated the process of wound healing.

Integrating factors associated with complex wound healing into a mobile application: Findings from a cohort study

Complex, chronic or hard-to-heal wounds are a prevalent health problem worldwide, with significant physical, psychological and social consequences. This study aims to identify factors associated with the healing process of these wounds and develop a mobile application for wound care that incorporates these factors. A prospective multicentre cohort study was conducted in nine health units in Portugal, involving data collection through a mobile application by nurses from April to October 2022. The study followed 46 patients with 57 wounds for up to 5 weeks, conducting six evaluations. Healing time was the main outcome measure, analysed using the Mann-Whitney test and three Cox regression models to calculate risk ratios. The study sample comprised various wound types, with pressure ulcers being the most common (61.4%), followed by venous leg ulcers (17.5%) and diabetic foot ulcers (8.8%). Factors that were found to impair the wound healing process included chronic kidney disease (U = 13.50; p = 0.046), obesity (U = 18.0; p = 0.021), non-adherence to treatment (U = 1.0; p = 0.029) and interference of the wound with daily routines (U = 11.0; p = 0.028). Risk factors for delayed healing over time were identified as bone involvement (RR 3.91; p < 0.001), presence of odour (RR 3.36; p = 0.007), presence of neuropathy (RR 2.49; p = 0.002), use of anti-inflammatory drugs (RR 2.45; p = 0.011), stalled wound (RR 2.26; p = 0.022), greater width (RR 2.03; p = 0.002), greater depth (RR 1.72; p = 0.036) and a high score on the healing scale (RR 1.21; p = 0.001). Integrating the identified risk factors for delayed healing into the assessment of patients and incorporating them into a mobile application can enhance decision-making in wound care.

Medical Management to Treat Chronic Non-healing Ulcers: A Case Series

INTRODUCTION

Chronic non-healing leg ulcers are skin defects below the knee that resist healing for more than six weeks. They cause physical, emotional, and economic burdens to patients and society.

OBJECTIVES

To introduce an innovative medical strategy that targets the chronic inflammation component in non-healing ulcers (NHUs) with rheumatic features and to evaluate its potential effectiveness in achieving complete healing.

METHODS

We employed an empirical medical therapy regimen, which combined medications like deflazacort, colchicine, dapsone, hydroxychloroquine, and azathioprine. We retrospectively selected 25 patients with chronic pedal ulcers who underwent our therapy.

RESULTS

The mean duration of ulcers was 7.84 years, and the time to heal was 5.97 months. Among 25 patients, 19 had atypical ulcers, four had venous ulcers, and two had diabetic neuropathy ulcers. Four patients with venous ulcers additionally underwent endovenous laser ablation.

CONCLUSION

Our medical strategy showed promising results in healing chronic NHUs with rheumatic features without significant steroid-induced adverse effects.

Oral administration of Bifidobacterium breve improves anti-angiogenic drugs-derived oral mucosal wound healing impairment via upregulation of interleukin-10

Recent studies have suggested that long-term application of anti-angiogenic drugs may impair oral mucosal wound healing. This study investigated the effect of sunitinib on oral mucosal healing impairment in mice and the therapeutic potential of Bifidobacterium breve (B. breve). A mouse hard palate mucosal defect model was used to investigate the influence of sunitinib and/or zoledronate on wound healing. The volume and density of the bone under the mucosal defect were assessed by micro-computed tomography (micro-CT). Inflammatory factors were detected by protein microarray analysis and enzyme-linked immunosorbent assay (ELISA). The senescence and biological functions were tested in oral mucosal stem cells (OMSCs) treated with sunitinib. Ligated loop experiments were used to investigate the effect of oral B. breve. Neutralizing antibody for interleukin-10 (IL-10) was used to prove the critical role of IL-10 in the pro-healing process derived from B. breve. Results showed that sunitinib caused oral mucosal wound healing impairment in mice. In vitro, sunitinib induced cellular senescence in OMSCs and affected biological functions such as proliferation, migration, and differentiation. Oral administration of B. breve reduced oral mucosal inflammation and promoted wound healing via intestinal dendritic cells (DCs)-derived IL-10. IL-10 reversed cellular senescence caused by sunitinib in OMSCs, and IL-10 neutralizing antibody blocked the ameliorative effect of B. breve on oral mucosal wound healing under sunitinib treatment conditions. In conclusion, sunitinib induces cellular senescence in OMSCs and causes oral mucosal wound healing impairment and oral administration of B. breve could improve wound healing impairment via intestinal DCs-derived IL-10.

A magnetic resonance imaging-based decision-making tool for predicting complex anal fistulas healing in the early postoperative period

BACKGROUND

Magnetic resonance imaging (MRI) has excellent accuracy in diagnosing preoperative lesions before anal fistula surgery. However, MRI is not good in identifying early recurrent lesions and effective methods for quantitative assessment of fistula healing are still warranted. This retrospective study aimed to develop and validate a specific MRI-based nomogram model to predict fistula healing during the early postoperative period.

METHODS

Patients with complex cryptoglandular anal fistulas who underwent surgery between January 2017 and October 2020 were included in this study. MRI features and clinical parameters were analyzed using univariate and multivariate logistic regression analysis. A nomogram for predicting fistula healing was constructed and validated.

RESULTS

In total, 200 patients were included, of whom 186 (93%) were male, with a median age of 36 (18-65) years. Of the fistulas, 58.5% were classified as transsphincteric and 19.5% as suprasphincteric. The data were randomly divided into the training cohort and testing cohort at a ratio of 7:3. Logistic analysis revealed that CNR, ADC, alcohol intake history, and suprasphincteric fistula were significantly correlated with fistula healing. These four predictors were used to construct a predictive nomogram model in the training cohort. AUC was 0.880 and 0.847 for the training and testing cohorts, respectively. Moreover, the decision and calibration curves showed high coherence between the predicted and actual probabilities of fistula healing.

CONCLUSIONS

We developed a predictive model and constructed a nomogram to predict fistula healing during the early postoperative period. This model showed good performance and may be clinically utilized for the management of anal fistulas.

Regulatory T cells in skin regeneration and wound healing

As the body's integumentary system, the skin is vulnerable to injuries. The subsequent wound healing processes aim to restore dermal and epidermal integrity and functionality. To this end, multiple tissue-resident cells and recruited immune cells cooperate to efficiently repair the injured tissue. Such temporally- and spatially-coordinated interplay necessitates tight regulation to prevent collateral damage such as overshooting immune responses and excessive inflammation. In this context, regulatory T cells (Tregs) hold a key role in balancing immune homeostasis and mediating cutaneous wound healing. A comprehensive understanding of Tregs' multifaceted field of activity may help decipher wound pathologies and, ultimately, establish new treatment modalities. Herein, we review the role of Tregs in orchestrating the regeneration of skin adnexa and catalyzing healthy wound repair. Further, we discuss how Tregs operate during fibrosis, keloidosis, and scarring.

The Preparation and Clinical Efficacy of Amnion-Derived Membranes: A Review

Biological tissues from various anatomical sources have been utilized for tissue transplantation and have developed into an important source of extracellular scaffolding material for regenerative medicine applications. Tissue scaffolds ideally integrate with host tissue and provide a homeostatic environment for cellular infiltration, growth, differentiation, and tissue resolution. The human amniotic membrane is considered an important source of scaffolding material due to its 3D structural architecture and function and as a source of growth factors and cytokines. This tissue source has been widely studied and used in various areas of tissue repair including intraoral reconstruction, corneal repair, tendon repair, microvascular reconstruction, nerve procedures, burns, and chronic wound treatment. The production of amniotic membrane allografts has not been standardized, resulting in a wide array of amniotic membrane products, including single, dual, and tri-layered products, such as amnion, chorion, amnion-chorion, amnion-amnion, and amnion-chorion-amnion allografts. Since these allografts are not processed using the same methods, they do not necessarily produce the same clinical responses. The aim of this review is to highlight the properties of different human allograft membranes, present the different processing and preservation methods, and discuss their use in tissue engineering and regenerative applications.

Outcomes of Immediate Multistaged Abdominal Wall Reconstruction of Infected Mesh: Predictors of Surgical Site Complications and Hernia Recurrence

BACKGROUND

Mesh infection is one of the most devastating complications after ventral hernia repair. To date, no clear consensus exists on the optimal timing of definitive abdominal wall reconstruction (AWR) after excision of infected mesh. We evaluated outcomes of immediate multistaged AWR in patients with mesh infection.

METHODS

We performed a retrospective review of patients with mesh infection who underwent immediate, multistaged AWR, which consisted of exploratory laparotomy with debridement and mesh explantation, followed by definitive AWR during the same admission. Primary outcomes included hernia recurrence and surgical site occurrences, defined as wound dehiscence, surgical site infection, hematoma, and seroma.

RESULTS

Forty-seven patients with infected mesh were identified. At mean follow-up of 9.5 months, 5 patients (10.6%) experienced hernia recurrence. Higher body mass index (P = 0.006), bridge repair (P = 0.035), and postoperative surgical site infection (P = 0.005) were associated with hernia recurrence.

CONCLUSION

Immediate multistaged AWR is an effective surgical approach in patients with infected mesh.

Alpha-ketoglutaric acid based polymeric particles for cutaneous wound healing

Metabolites are not only involved in energy pathways but can also act as signaling molecules. Herein, we demonstrate that polyesters of alpha-ketoglutararte (paKG) can be generated by reacting aKG with aliphatic diols of different lengths, which release aKG in a sustained manner. paKG polymer-based microparticles generated via emulsion-evaporation technique lead to faster keratinocyte wound closures in a scratch assay test. Moreover, paKG microparticles also led to faster wound healing responses in an excisional wound model in live mice. Overall, this study shows that paKG MPs that release aKG in a sustained manner can be used to develop regenerative therapeutic responses.

Therapeutic Applications of Garlic and Turmeric for the Diabetic Wound Healing in Mice

Diabetes is involved in delayed wound healing that can be cured by natural products such as garlic, turmeric, and fibroin extracts. Alloxan monohydrate is used for inducing diabetes in mice. The percent wound contraction of garlic (150 mg/ml), turmeric (100 mg/ml), and fibroin (50 mg/ml), individually and in combinations garlic (150 mg/ml) + fibroin (50 mg/ml), turmeric (100 mg/ml) + fibroin (50 mg/ml), garlic (150 mg/ml) + turmeric (100 mg/ml), and garlic (150 mg/ml) + turmeric (100 mg/ml) + fibroin (50 mg/ml) was checked by evaluating the healing time, % wound contraction and histological analysis. The serum level of MMPs (MMP 2, MMP7, MMP 9), pro-inflammatory cytokines (TNF-α, IL-6, IL-8), and TIMPs were evaluated. With the combination of three extracts (Ga+Tu+Fi) garlic (150 mg/ml), turmeric (100 mg/ml) and fibroin (50 mg/ml), wounds healed in 12 days and had 97.3 ± 2.2% wound contraction. While the positive control (polyfax) and diabetic control (saline) wounds healed in 17- and 19-days with wound contraction of 96.7 ± 1.4% and 96.3 ± 1.1%, respectively. Histological analysis showed that the combination of Ga+Tu+Fi exhibited an increase in the growth of collagen fibers, fibroblasts number, and keratinocytes, and lessened inflammation of blood vessels. The combination of Ga+Tu+Fi significantly alleviated the serum concentration of TNF-α (14.2 ± 0.7 pg/ml), IL-6 (10.0 ± 1.0 pg/ml), IL-8 (16.0 ± 1.5 pg/ml), MMP2 (228.0 ± 18.1 pg/ml), MMP7 (271.0 ± 9.9 pg/ml), and MMP9 (141.0 ± 5.3 pg/ml) to diabetic control. The level of TIMPs (193.0 ± 9.1 pg/ml) was increased significantly with respect to diabetic control. We conclude that the combination of these biomaterials possessed high regenerative and healing capabilities and can be an effective remedy in the healing of chronic wounds in diabetic patients.

Individualized Risk Prediction for Improved Chronic Wound Management

Significance: Chronic wounds are associated with significant morbidity, marked loss of quality of life, and considerable economic burden. Evidence-based risk prediction to guide improved wound prevention and treatment is limited by the complexity in their etiology, clinical underreporting, and a lack of studies using large high-quality datasets. Recent Advancements: The objective of this review is to summarize key components and challenges in the development of personalized risk prediction tools for both prevention and management of chronic wounds, while highlighting several innovations in the development of better risk stratification. Critical Issues: Regression-based risk prediction approaches remain important for assessment of prognosis and risk stratification in chronic wound management. Advances in statistical computing have boosted the development of several promising machine learning (ML) and other semiautomated classification tools. These methods may be better placed to handle large number of wound healing risk factors from large datasets, potentially resulting in better risk prediction when combined with conventional methods and clinical experience and expertise. Future Directions: Where the number of predictors is large and heterogenous, the correlations between various risk factors complex, and very large data sets are available, ML may prove a powerful adjuvant for risk stratifying patients predisposed to chronic wounds. Conventional regression-based approaches remain important, particularly where the number of predictors is relatively small. Translating estimated risk derived from ML algorithms into practical prediction tools for use in clinical practice remains challenging.

The effect of chronic kidney disease on tissue formation of in situ tissue-engineered vascular grafts

Vascular in situ tissue engineering encompasses a single-step approach with a wide adaptive potential and true off-the-shelf availability for vascular grafts. However, a synchronized balance between breakdown of the scaffold material and neo-tissue formation is essential. Chronic kidney disease (CKD) may influence this balance, lowering the usability of these grafts for vascular access in end-stage CKD patients on dialysis. We aimed to investigate the effects of CKD on in vivo scaffold breakdown and tissue formation in grafts made of electrospun, modular, supramolecular polycarbonate with ureido-pyrimidinone moieties (PC-UPy). We implanted PC-UPy aortic interposition grafts (n = 40) in a rat 5/6th nephrectomy model that mimics systemic conditions in human CKD patients. We studied patency, mechanical stability, extracellular matrix (ECM) components, total cellularity, vascular tissue formation, and vascular calcification in CKD and healthy rats at 2, 4, 8, and 12 weeks post-implantation. Our study shows successful in vivo application of a slow-degrading small-diameter vascular graft that supports adequate in situ vascular tissue formation. Despite systemic inflammation associated with CKD, no influence of CKD on patency (Sham: 95% vs CKD: 100%), mechanical stability, ECM formation (Sirius red⁺, Sham 16.5% vs CKD 25.0%-p:0.83), tissue composition, and immune cell infiltration was found. We did find a limited increase in vascular calcification at 12 weeks (Sham 0.08% vs CKD 0.80%-p:0.02) in grafts implanted in CKD animals. However, this was not associated with increased stiffness in the explants. Our findings suggest that disease-specific graft design may not be necessary for use in CKD patients on dialysis.

Modulation of NK cell activation by exogenous calcium from alginate dressings in vitro

Natural Killer (NK) cells participate in the defense against infection by killing pathogens and infected cells and secreting immuno-modulatory cytokines. Defects in NK cell activity have been reported in obese, diabetic, and elderly patients that are at high risk of developing infected chronic wounds. Calcium alginate dressings are indicated for the debridement during the inflammatory phase of healing. Since calcium ions are major activators of NK cells, we hypothesized that these dressings could enhance NK functions, as investigated in vitro herein. Primary human blood NK cells were freshly-isolated from healthy volunteers and exposed to conditioned media (CM) from two alginate dressings, Algosteril® (ALG, pure Ca2+ alginate) and Biatain® Alginate (BIA, Ca2+ alginate with CMC), in comparison with an exogenous 3mM calcium solution. Our results demonstrated that exogenous calcium and ALG-CM, but not BIA-CM, induced NK cell activation and enhanced their capacity to kill their targets as a result of increased degranulation. NK cell stimulation by ALG depended on the influx of extracellular Ca2+via the SOCE Ca2+ permeable plasma membrane channels. ALG-CM also activated NK cell cytokine production of IFN-γ and TNF-α through a partly Ca2+-independent mechanism. This work highlights the non-equivalence between alginate dressings for NK cell stimulation and shows that the pure calcium alginate dressing Algosteril® enhances NK cell cytotoxic and immuno-modulatory activities. Altogether, these results underline a specific property of this medical device in innate defense that is key for the cutaneous wound healing process.

Short communication: unique metabolic signature of proliferative retinopathy in the tear fluid of diabetic patients with comorbidities - preliminary data for PPPM validation

Type 2 diabetes (T2DM) defined as the adult-onset type that is primarily not insulin-dependent, comprises over 95% of all diabetes mellitus (DM) cases. According to global records, 537 million adults aged 20-79 years are affected by DM that means at least 1 out of 15 persons. This number is projected to grow by 51% by the year 2045. One of the most common complications of T2DM is diabetic retinopathy (DR) with an overall prevalence over 30%. The total number of the DR-related visual impairments is on the rise, due to the growing T2DM population. Proliferative diabetic retinopathy (PDR) is the progressing DR and leading cause of preventable blindness in working-age adults. Moreover, PDR with characteristic systemic attributes including mitochondrial impairment, increased cell death and chronic inflammation, is an independent predictor of the cascading DM-complications such as ischemic stroke. Therefore, early DR is a reliable predictor appearing upstream of this "domino effect". Global screening, leading to timely identification of DM-related complications, is insufficiently implemented by currently applied reactive medicine. A personalised predictive approach and cost-effective targeted prevention shortly - predictive, preventive and personalised medicine (PPPM / 3PM) could make a good use of the accumulated knowledge, preventing blindness and other severe DM complications. In order to reach this goal, reliable stage- and disease-specific biomarker panels are needed characterised by an easy way of the sample collection, high sensitivity and specificity of analyses. In the current study, we tested the hypothesis that non-invasively collected tear fluid is a robust source for the analysis of ocular and systemic (DM-related complications) biomarker patterns suitable for differential diagnosis of stable DR versus PDR. Here, we report the first results of the comprehensive ongoing study, in which we correlate individualised patient profiles (healthy controls versus patients with stable D as well as patients with PDR with and without co-morbidities) with their metabolic profiles in the tear fluid. Comparative mass spectrometric analysis performed has identified following metabolic clusters which are differentially expressed in the groups of comparison: acylcarnitines, amino acid & related compounds, bile acids, ceramides, lysophosphatidyl-choline, nucleobases & related compounds, phosphatidyl-cholines, triglycerides, cholesterol esters, and fatty acids. Our preliminary data strongly support potential clinical utility of metabolic patterns in the tear fluid indicating a unique metabolic signature characteristic for the DR stages and PDR progression. This pilot study creates a platform for validating the tear fluid biomarker patterns to stratify T2DM-patients predisposed to the PDR. Moreover, since PDR is an independent predictor of severe T2DM-related complications such as ischemic stroke, our international project aims to create an analytical prototype for the "diagnostic tree" (yes/no) applicable to healthrisk assessment in diabetes care.

Acidic sophorolipid and antimicrobial peptide based formulation as antimicrobial and antibiofilm agents

Antimicrobial peptides (AMPs) are considered promising candidates to treat various infections in soft tissues and skin. However, no effective treatment based on AMPs has been reached to clinics due to their instability in serum and wounds. Biosurfactants such as acidic sophorolipids (ASLs) of very high concentrations (equal or above 5 mg/mL) have been demonstrated to be antimicrobial agents, however these concentrations might induce cytotoxic effects to human cells. Here, we have demonstrated the synergistic antimicrobial effect of ASL nanoparticles (NPs) and LL37 peptides (below their minimum inhibitory concentrations; MICs) to eradicate Gram-positive and Gram-negative bacteria in human serum (HS) and in the presence of trypsin. The formulations containing ASL NPs (500 μg/mL) and LL37 peptides (15-25 μg/mL) effectively kill wide strains of bacteria in 5 % HS and the presence of trypsin. Moreover, the combination of ASL NPs (500 μg/mL) and LL37 peptides (15 μg/mL) prevents the formation of S. aureus biofilm and eradicates the one-day old biofilm. Importantly, the combination of ASL NPs and LL37 peptides severely damages the cell membrane of Escherichia coli (E. coli) as shown by atomic force microscopy (AFM). The combination of ASL NPs and LL37 peptides rapidly damages the outer (OM) and inner membrane (IM) of E. coli, while ASL NPs (1000 μg/mL) alone slowly compromise the integrity of the bacterial membrane. Importantly, the combination of ASL NPs and LL37 peptides is biocompatible to human keratinocyte cells (HaCaTs) and human umbilical vein endothelial cells (HUVECs), and induces the expression of anti-inflammatory cytokine in macrophages. Overall, ASL NPs in combination with LL37 peptides might be developed as an effective topical formulation to prevent bacterial infections in the skin.