Functional improvement of hemostatic dressing by addition of recombinant batroxobin

Sono-responsive smart nanoliposomes for precise and rapid hemostasis application

Massive hemorrhage caused by injuries and surgical procedures is a major challenge in emergency medical scenarios. Conventional means of hemostasis often fail to rapidly and efficiently control bleeding, especially in inaccessible locations. Herein, a type of smart nanoliposome with ultrasonic responsiveness, loaded with thrombin (thrombin@liposome, named TNL) was developed to serve as an efficient and rapid hemostatic agent. Firstly, the hydrophilic cavities of the liposomes were loaded onto the sono-sensitive agent protoporphyrin. Secondly, a singlet oxygen-sensitive chemical bond was connected with the hydrophobic and hydrophilic ends of liposomes in a chemical bond manner. Finally, based on the host guest effect between ultrasound and the sono-sensitizer, singlet oxygen is continuously generated, which breaks the hydrophobic and hydrophilic ends of liposome fragments, causing spatial collapse of the TNL structure, swiftly releases thrombin loaded in the hydrophilic capsule cavity, thereby achieving accurate and rapid local hemostasis (resulted in a reduction of approximately 67% in bleeding in the rat hemorrhage model). More importantly, after thorough assessments of biocompatibility and biodegradability, it has been confirmed that TNL possesses excellent biosafety, providing a new avenue for efficient and precise hemostasis.

Improved hydration property of tissue adhesive/hemostatic microparticle based on hydrophobically-modified Alaska pollock gelatin

The management of bleeding is an important aspect of endoscopic surgery to avoid excessive blood loss and minimize pain. In clinical settings, sprayable hemostatic particles are used for their easy delivery, adaptability to irregular shapes, and rapid hydration. However, conventional hemostatic particles present challenges associated with tissue adhesion. In a previous study, we reported tissue adhesive microparticles (C10-sa-MPs) derived from Alaska pollock gelatin modified with decyl groups (C10-sa-ApGltn) using secondary amines as linkages. The C10-sa-MPs adhere to soft tissues through a hydration mechanism. However, their application as a hemostatic agent was limited by their long hydration times, attributed to their high hydrophobicity. In this study, we present a new type microparticle, C10-am-MPs, synthesized by incorporating decanoyl group modifications into ApGltn (C10-am-ApGltn), using amide bonds as linkages. C10-am-MPs exhibited enhanced hydration characteristics compared to C10-sa-MPs, attributed to superior water absorption facilitated by amide bonds rather than secondary amines. Furthermore, C10-am-MPs demonstrated comparable tissue adhesion properties and underwater adhesion stability to C10-sa-MPs. Notably, C10-am-MPs exhibited accelerated blood coagulation in vitro compared to C10-sa-MPs. The application of C10-am-MPs in an in vivo rat liver hemorrhage model resulted in a hemostatic effect comparable to a commercially available hemostatic particle. These findings highlight the potential utility of C10-am-MPs as an effective hemostatic agent for endoscopic procedures and surgical interventions.

Incidence, clinical features, and risk factors of hemocoagulase-induced hypofibrinogenemia: A retrospective real-world study

The objective of this study was to explore the real-world incidence, severity, clinical features, and potential risk factors associated with hypofibrinogenemia induced by hemocoagulase. Based on Chinese Hospital Pharmacovigilance System, a retrospective case-control study was conducted, enrolling hospitalized patients who received hemocoagulase for the treatment or prevention of hemorrhage in Weifang People's Hospital in China from January 2021 to May 2022. Univariate and multivariate logistic regression was performed to analyze the potential risk factors. Out of 10,397 hospitalized patients who received hemocoagulase, 341 patients showed positive triggers, with 235 patients ultimately conformed as hemocoagulase-associated hypofibrinogenemia. The system positive alarm rate was 68.91%, and the overall incidence of hemocoagulase-induced hypofibrinogenemia was 2.26%, predominantly characterized by mild to moderate severity levels. The incidence varied among the 4 types of hemocoagulase, with the highest incidence observed in hemocoagulase Agkistrodon Halys Pallas at 4.59%. The incidence of hemocoagulase from Deinagkistrodon acutus, Bothrops Atrox and Adder were 0.97%, 0.44% and 0.12%, respectively. Multivariate logistic regression analysis revealed that age (odds ratios [OR] = 177.328, P < .001), source of snake venom (OR = 5.641, P < .05), albumin (OR = 2.487, P < .001), and cumulative dosage (OR = 1.106, P < .001) were independent risk factors. Increased risk of hemocoagulase-related hypofibrinogenemia may be associated with children, elderly patients, low albumin levels, high cumulative doses and hemocoagulase from Agkistrodon Halys Pallas. Early recognition and close drug monitoring for these high-risk patients are vital in clinical practice.

Enhancement of hemostatic properties of Cyclotella cryptica frustule through genetic manipulation

BACKGROUND

The silicified cell wall of diatoms, also known as frustule, shows huge potential as an outstanding bio-nanomaterial for hemostatic applications due to its high hemostatic efficiency, good biocompatibility, and ready availability. As the architectural features of the frustule determine its hemostatic performance, it is of great interest to develop an effective method to modify the frustule morphology into desired patterns to further improve hemostatic efficiency.

RESULTS

In this study, the gene encoding Silicalemma Associated Protein 2 (a silicalemma-spanning protein) of Cyclotella cryptica (CcSAP2) was identified as a key gene in frustule morphogenesis. Thus, it was overexpressed and knocked down, respectively. The frustule of the overexpress lines showed no obvious alteration in morphology compared to the wild type (WT), while the size, specific surface area (BET), pore volume, and pore diameter of the knockdown strains changed greatly. Particularly, the knockdown frustules achieved a more pronounced coagulation effect and in vivo hemostatic performance than the WT strains. Such observations suggested that silicalemma proteins are ideal genetic encoding targets for manipulating frustule morphology associated hemostatic properties. Furthermore, the Mantel test was adopted to identify the key morphologies associated with C. cryptica bleeding control. Finally, based on our results and recent advances, the mechanism of frustule morphogenesis was discussed.

CONCLUSION

This study explores a new strategy for enhancing the hemostatic efficiency of the frustule based on genetic morphology modification and may provide insights into a better understanding of the frustule morphogenesis mechanism.

Hemoadhican, a Tissue Adhesion Hemostatic Material Independent of Blood Coagulation

Uncontrolled hemorrhage is a leading cause of death, emphasizing the need for novel hemostatic agents. Here, a novel hemostatic polysaccharide hemoadhican (HD) is screened out by analyzing the rheological properties of screened material mixed blood sludges, which is prepared by mixing polysaccharide granules and whole blood to mimic the coagulation in vitro. HD is produced by a bacterial isolate Paenibacillus sp.1229, and the repeating units of HD are →)-α-L-Rhap-(1→3)-β-D-Glcp-(1→4)[4,6-ethylidene-α-D-Galp-(1→4)-α-D-Glcp-(1→3)]-α-D-Manp-(1→. Compared to chitosan and celox, HD achieves more effective hemostasis in animal models with mouse and rat femoral arteries, rat carotid arteries, and rabbit femoral arteries. Especially, HD maintains an excellent hemostatic capability in animals with heparin-induced hemorrhage diathesis. In vitro experiments show HD granules can quickly absorb a small amount of blood component to create a hemophobic blood sludge resistant to high pressure. The blood sludge firmly adheres to damaged tissue and efficiently repels blood. In vitro experiments show that HD does not actively trigger blood coagulation cascade and is independent of blood conditions including heparin treatment. In addition, HD moisturizes wounds and accelerates wound healing, exhibiting excellent biodegradability, and hemocompatibility. The results indicate that HD is a promising hemostatic material for treating traumatic hemorrhages and uncontrollable surgical bleeding.

High-efficiency secretory expression and characterization of the recombinant type III human-like collagen in Pichia pastoris

Collagen, the highest content protein in the body, has irreplaceable biological functions, and it is widespread concerned in food, beauty, and medicine with great market demand. The gene encoding the recombinant type III human-like collagen α1 chain fragment was integrated into P. pastoris genome after partial amino acids were substituted. Combined with promoter engineering and high-density fermentation technology, soluble secretory expression with the highest yield of 1.05 g L-1 was achieved using two-stage feeding method, and the purity could reach 96% after affinity purification. The determination of N/C-terminal protein sequence were consistent with the theoretical expectation and showed the characteristics of Gly-X-Y repeated short peptide sequence. In amino acid analysis, glycine shared 27.02% and proline 23.92%, which were in accordance with the characteristics of collagen. Ultraviolet spectrum combined with Fourier transform infrared spectroscopy as well as mass spectrometry demonstrated that the target product conformed to the characteristics of collagen spectrums and existed as homologous dimer and trimer in the broth. This work provided a sustainable and economically viable source of the recombinant type III human-like collagen.

Calcium alginate/silk fibroin peptide/Bletilla striata polysaccharide blended microspheres loaded with tannic acid for rapid wound healing

Biodegradable natural polymers are receiving increasing attention as potential candidates for wound dressing. In the present study, composite microspheres (mCSB) based on calcium alginate (CA), silk fibroin peptide (SP), and Bletilla striata polysaccharide (BSP) were prepared by the reverse emulsion method. The excellent swelling properties of microspheres enable them to rapidly promote thrombosis. Microspheres can increase the platelet aggregation index to 1.5 and the aggregation rate of red blood cells to as high as 80 %. Furthermore, tannic acid (TA)-loaded microspheres demonstrate a slow-release effect on TA; this allows the microspheres to exhibit good long-lasting antibacterial properties. Due to the synergistic effects of SP and TA, the cell senescence was delayed, with a 126.69 % survival rate of fibroblasts after 3 days of incubation. In addition, TA led to a rapid reduction in inflammation levels, with a wound closure rate of >92.80 % within 7 days. The multifunctional TA-loaded mCSB has great application potential for rapid wound healing and the treatment of wound hemostasis.

Preparation of methacrylated hyaluronate/methacrylated collagen sponges with rapid shape recovery and orderly channel for fast blood absorption as hemostatic dressing

Uncontrolled hemorrhage of deep, narrow, and non-compressible perforating wounds is responsible for many trauma deaths. In this study, a rapid hemostatic sponge with an orderly channel based on methacrylated collagen (ColMA) was prepared via directional freeze-drying technology. The methacrylated hyaluronate (HAMA) was added to further enhance the mechanical properties of the sponge. The sponge presents excellent mechanical strength, rapid shape recovery, and absorption speed, which was faster than those of many reported natural polymer hemostatic sponges. Moreover, ColMA/HAMA sponge showed much better blood-clotting capacity and superior hemostasis performance than commercially available collagen sponges in vitro and in the rat-liver injury model. This study demonstrated a feasible strategy to construct the rapid hemostatic sponge with an orderly channel for the deep and non-compressible perforating wound.

Biocompatible Hemostatic Sponge Exhibiting Broad-Spectrum Antibacterial Activity

Hemorrhage during accidents or surgery is a significant challenge that can contribute to mortality. This is further aggravated due to bacterial infections at the injured site. Therefore, rapid application of a hemostatic and antibacterial material is highly necessary as a pretreatment for patients' survival. Herein, we have developed a hemostatic sponge (Hemobac) through amide crosslinking of gelatin and an N-(2-hydroxy) propyl-3-trimethylammonium chitosan (HTCC)-silver chloride nanocomposite (QAm₁-Ag_0.1) to mitigate bacterial infections, while aiding hemostasis. This Hemobac sponge completely eradicated (∼4-5 log) a wide range of Gram-positive and Gram-negative bacteria encompassing various clinical isolates within 6 h. The antihemorrhagic ability of Hemobac was ascertained through SEM images, which exhibited the presence of agglomerated blood cells onto the sponge with a significantly low blood-clotting index value (∼23 ± 1). Notably, Hemobac reduced the blood loss by ∼70-80% in the liver puncture model and femoral vein injury model in mice, displaying its improved hemostatic ability over a marketed gelatin-based sponge. Negligible hemolytic activity (∼6%) and retained healthy morphology of mammalian cells were observed upon exposure to the Hemobac sponge. Minimal immune response was noticed at the Hemobac-treated wound in mice through histopathology analysis. Collectively, these findings indicate that this biocompatible Hemobac sponge can stop the bleeding instantaneously and combat bacterial infections.

Expandable, biodegradable, bioactive quaternized gelatin sponges for rapidly controlling incompressible hemorrhage and promoting wound healing

Designing expandable sponges with biodegradability and effective antibacterial properties are the urgent challenge for incompressible hemorrhage and wound healing. In the present investigation, based on quaternized gelatin (QG) and oxidized dextran (OD), a series of expandable sponges (ODQG) with high-water absorption capacity and robust mechanical properties were prepared. ODQG had good biodegradability in vitro and in vivo, and had inherent antibacterial activity (90% for E. coli and 99.74% for S. aureus). Due to the synergy effect of electrostatic interaction and blood concentration, ODQG could effectively attract and activate red blood cells/platelets and accelerate the coagulation process. Therefore, ODQG showed better hemostatic performance than Kuaikang® gelatin sponges and gauzes in incompressible hemorrhage model. Furthermore, ODQG could regulate inflammatory factor (TNF-α) and cytokines (TGF-β, VEGF), and greatly promote wound healing process. The biodegradable sponges with excellent antibacterial properties might have potential application prospect for incompressible hemostasis and wound healing in the future.

Efficacy and Safety of Novel Beta-Chitin Patches as Haemostat in Rat Vascular and Neurosurgical Model

Background

Intraoperative hemorrhage is a major cause of poor post-operative outcome. Beta-chitin patch has previously been found to be an effective haemostat, but whether modifying the patch can improve its efficacy and safety, remains unknown. In this study, beta-chitin patches were modified using polyethylene oxide, Pluronic-F127 (Chi/F127), calcium (Chi/20%Ca), increased thickness (Chi/Thick) or polyphosphate (Chi/PP).

Objective

Using rat (Wistar Albino; 8–10 weeks old) vascular and neurosurgical models, this project investigated and compared the efficacy and safety of beta-chitin patches with gauze, Surgicel and FloSeal.

Methods

Ninety rats underwent a standardized femoral artery injury and were randomized to receive either beta-chitin patches, gauze, Surgicel or FloSeal. The bleeding time and total blood loss was measured. For the neurosurgical model, forty-four rats underwent a standardized cortical injury and randomization to a treatment group. Following a 48 h recovery period, their brains were collected for histopathological examination.

Results

The mean bleeding time with Chitin (120.8 s) and Chi/PP (117.3 s) was ~60 s lower than Chi/F127, Chi/20%Ca and Chi/Thick (p &lt; 0.05). Chitin and Chi/PP had a significantly lower bleeding time than FloSeal (174.2 s) (p &lt; 0.05), but not Surgicel (172.7 s). Gauze (400 s) had a significantly higher bleeding time compared to all other groups (p &lt; 0.05). There were no significant differences in the total blood loss between the groups. Histopathological examination of brains found no adverse inflammatory reaction to any of the haemostatic compounds.

Conclusion

Chi/PP had superior haemostatic efficacy compared to Surgicel and FloSeal, but not compared to non-modified beta-chitin patch. All of the haemostats were equally safe.

Use of Batroxobin in Central and Peripheral Ischemic Vascular Diseases: A Systematic Review

Background and Purpose: The mechanism of action of Batroxobin included the decomposition of the fibrinogen to fibrin degradation products (FDPs) and D-dimer and mobilization of endothelial cells to release endogenous nt-PA and to promote thrombolysis. This review aims to summarize current study findings about batroxobin on correcting cerebral arterial, venous, and peripheral vascular diseases, to explore the mechanism of batroxobin on anti-thrombosis process.

Methods: A thorough literature search was conducted utilizing the PubMed Central (PMC) and EMBASE databases to identify studies up to June 2021. Data from clinical studies and animal experiments about batroxobin were extracted, integrated and analyzed based on Cochrane handbook for systematic reviews of interventions approach and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P), including the condition of subjects, the usage and dosage, research observation index and main findings.

Results: A total of 62 studies were enrolled in this systematic review, including 26 clinical studies and 36 animal experiments. The 26 clinical studies involved 873 patients with arterial ischemic events, 92 cases with cerebral venous thrombosis, 13 cases with cerebral cortical vein thrombosis, and 1,049 cases with peripheral vascular diseases. These patients included 452 males and 392 females aged 65.6 ± 5.53 years. The results revealed that batroxobin had broad effects, including improving clinical prognosis (n = 12), preventing thrombosis (n = 7), promoting thrombolysis (n = 6), and improving vascular cognitive dysfunction (n = 1). The effects of batroxobin on reducing neuronal apoptosis (n = 8),relieving cellular edema (n = 4), improving spatial memory (n = 3), and promoting thrombolysis (n = 13) were concluded in animal experiments. The predominant mechanisms explored in animal experiments involved promoting depolymerization of fibrinogen polymers (n = 6), regulating the expression of related molecules (n = 9); such as intercellular adhesion molecule, heat shock proteins, tumor necrosis factor), reducing oxidative stress (n = 5), and reducing inflammation response (n = 4).

Conclusion: Batroxobin can correct both arterial and venous ischemic diseases by promoting depolymerization of fibrinogen polymers, regulating the expression of related molecules, reducing oxidative stress, and reducing the inflammation response.

Recent advances in materials for hemostatic management

Traumatic hemorrhage can be a fatal event, particularly when large quantities of blood are lost in a short period of time. Therefore, hemostasis has become a crucial part of emergency treatment. For small wounds, hemostasis can be achieved intrinsically depending on the body's own blood coagulation mechanism; however, for large-area wounds, particularly battlefield and complex wounds, materials delivering rapid and effective hemostasis are required. In parallel with the constant progress in science, technology, and society, advances in hemostatic materials have also undergone various iterations by integrating new ideas with old concepts. There are various natural and synthetic hemostatic materials, including hemostatic powders, adhesives, hydrogels, and tourniquets, for the treatment of severe external trauma. This review covers the differences among the currently available hemostatic materials and comprehensively describes the hemostatic effects of different materials based on the underlying mechanisms. Finally, solutions for current issues related to trauma bleeding are discussed, and the prospects of hemostatic materials are proposed.

Polymer Composite Sponges with Inherent Antibacterial, Hemostatic, Inflammation-Modulating and Proregenerative Performances for Methicillin-Resistant Staphylococcus aureus-Infected Wound Healing

Clinical wound management remains a major challenge due to massive bleeding, bacterial infection, and difficult wound healing after tissue trauma. To simultaneously address these issues, composite polymer sponges for accelerating drug-resistant bacterial infected wound healing are fabricated by facilely mixing sodium polyacrylate (PAAS), double quaternary ammonium salts-conjugated chitosan (QAS-CS), and collagen (COL) in aqueous solution, followed by lyophilization. Composite sponges (PAAS/QAS-CS/COL, PQC) show highly porous microstructures (porosity ≈90%) with moderate compress modulus (≈0.3 MPa), tensile strength (0.004 MPa), and high swelling ratio (≈3500%). Importantly, PQC sponge demonstrates superior hemostasis ability over commercially available CS sponge by inducing rapid hemagglutination, and exhibits significantly better antibacterial activity against both methicillin-resistant Staphylococcus aureus (MRSA) and Escherichia coli by destroying cell membrane and causing the leakage of bioactive components such as potassium ion and β-galactosidase from treated bacterial. Furthermore, PQC sponge can efficiently promote cell proliferation. Significantly, the sponge greatly expedites the regeneration of MRSA-infected full-thickness skin wound in rabbit by successfully eradicating bacterial infection, and reducing inflammation. PQC sponge also improves both early angiogenesis and blood vessel maturation at the wound site. Overall, this multifunctional sponge is a promising wound dressing for clinical use and holds great potential for rapid clinical translation.

Thrombin immobilized polydopamine-diatom biosilica for effective hemorrhage control

In this study, an efficient composite hemostatic material (DA-diatom-T) was prepared, using a polydopamine layer as a linker to immobilize thrombin on the surface of diatom biosilica. DA-diatom-T retained the porous structure of the diatom with high water absorption capacity, which can absorb 31 times its own weight of water. The thrombin activity of DA-diatom-T was as high as 5.81 U mg-1 that could be maintained at 67% after 30 days at room temperature. DA-diatom-T exhibited non-toxicity to mouse fibroblast cell lines, favorable hemocompatibility and fast procoagulant ability. DA-diatom-T could promote the initiation of the coagulation process and increase platelet activity and blood clot strength to form a physical barrier at the wound. In an in vivo study, DA-diatom-T could significantly reduce the clotting time and reduce the bleeding volume. The above results showed that DA-diatom-T had potential as a new hemostatic material.

Nanofibers reinforced injectable hydrogel with self-healing, antibacterial, and hemostatic properties for chronic wound healing

The chronic wounds often hinder wound healing resulting from infection; thus, an ideal wound dressing should be able to maintain a healthy wound microenvironment. Herein, peptide modified nanofibers reinforced hydrogel has been designed by Schiff base dynamic crosslinking. The incorporation of the nanofibers into the hydrogel extremely enhances the stability and mechanical strength of the hydrogel. Taking advantage of the feature, the reinforced hydrogel can restore its original shape while suffering the various external forces on the hydrogel-covered irregular shape wounds. The peptide modified nanofibers reinforced hydrogel (NFRH) not only possesses injectable and self-healing properties, but also inherent antibacterial and hemostatic properties, which can eradicate the bacterial biofilms and induce blood cells and platelets aggregation and finally accelerate the chronic wound healing process. The peptide modified nanofibers reinforced hydrogel has enormous potential to be novel dressing for chronic wounds healing clinically.

Neuroprotective effects of Hemocoagulase Agkistrodon on experimental traumatic brain injury

Traumatic brain injury (TBI) is the major cause of disability and mortality among young people and is associated with neurodegenerative diseases. However, the available clinical options have limited effectiveness. Here, we investigated the neuroprotective effect of Hemocoagulase Agkistrodon (HCA), a thrombin-like enzyme (TLE) isolated and purified from snake venom. Rats subjected to experimental TBI were administered a single dose of HCA or vehicle 10 min after injury. Neurological function was assessed with modified neurological severity score (mNSS). Brain edema were evaluated by measuring brain water content. Levels of hemoglobin and inflammatory cytokines were detected by Enzyme-linked immunosorbent assay (ELISA). In addition, assays including Evans blue extravasation, Western blot analysis and immunofluorescence staining were utilized to determined blood-brain barrier (BBB) integrity. Our results showed that HCA treatment ameliorated neurological deficits (p < 0.01), alleviated brain edema (p < 0.01) and hemorrhage (p < 0.01), decreased the production of the proinflammatory cytokines IL-1β (p < 0.01), TNF-α (p < 0.01) and IL-6 (p < 0.05), and increased the anti-inflammatory cytokine IL-10 at the contusion site (p < 0.01). Moreover, HCA administration reduced BBB disruption by regulating expression of tight junction proteins, including ZO-1, occludin and claudin-5 (ps < 0.01). Together, our results demonstrate that HCA might have therapeutic efficacy in acute TBI, suggesting a potential clinical application for mitigating the neuropathological damage associated with TBI.

Tentative identification of key factors determining the hemostatic efficiency of diatom frustule

It is increasingly essential to develop excellent materials for rapid hemorrhage control. Our previous study showed that centric diatoms such as frustules were superior to QuikClot® in hemostasis, however, related studies in pennate diatoms are still scarce. The morphological and physicochemical properties of pennate diatoms are quite different from those of centric diatoms, meaning that significant differences may also be observed from their hemostatic effects. Thus, the hemostasis effects of four pennate diatom frustules (Cocconeiopsis orthoneoides, Navicula avium, Navicula sp., and Pleurosigma indicum) were investigated in this study. Herein, all diatom frustules demonstrated outstanding hemostasis performance. For example, the in vitro coagulation time of C. orthoneoides (100.33 ± 9.5 s) was 32.4% lower than that of QuikClot®. Meanwhile, the hemostatic times of C. orthoneoides in the rat tail amputation and femoral artery models were 82 s and 180 s, respectively, only around one-half and one-third of the QuikClot® values. Moreover, the blood loss amounts of C. orthoneoides in the rat tail amputation and femoral artery model were 73.4% and 61% less than that of QuikClot®. Besides that, diatom frustules also exhibited favorable biocompatibility (hemolysis ratio <5%, MEFs cell viabilities >80%, and no inflammation). To find out the key factors underlying the hemostatic effect of frustules, Pearson correlation analysis was further performed in this study. The results demonstrated that the coagulation reaction time (R) was negatively correlated with the specific surface area and liquid absorbability but positively with the diatom pore diameter. The angle α, indicating the clot formation rate, was negative to the diatom size and pore diameter. Additionally, MA also showed a negative correlation with the BET value. This study can enrich our knowledge about the application potential of diatoms in the field of bleeding control and is helpful in deepening our understanding about the hemostatic mechanism of frustules.

Epidural hemostasis by autologous fat graft in minimally invasive surgery for lumbar spinal stenosis: In vivo experimental study

BACKGROUND

Epidural hemostasis needs to use small, adapted material in minimally invasive surgery, including bilateral decompression via a unilateral approach for lumbar spinal stenosis. Most surgeons avoid external material for hemostasis because of possible neural tissue damage or complications. We compared epidural hemostasis in minimally invasive surgery by fat graft versus gelatin sponge.

METHODS

The design was a prospective randomized controlled in-vivo human experimental study. The 24 levels operated on for lumbar spinal stenosis were evaluated in two groups: Group A (control group: gelatin sponge) and Group B (experimental group: fat graft). International Normalized Ratio and Prothrombin Time were assessed preoperatively. Number of cotton hemostats and systolic and diastolic blood pressure were assessed intraoperatively. Epidural hemorrhage area, spinal cord size and ratio of epidural hemorrhage area to spinal cord size were evaluated on early postoperative lumbar MRI.

RESULTS

Mean epidural hemorrhage area in groups A and B was respectively 1.3±0.5 and 1.2±0.6cm², and mean spinal cord size 1.2±0.6 and 1.8±0.6cm² on early postoperative axial lumbar MRI. The two groups did not significantly differ in ratio of epidural hemorrhage/spinal cord size or number of intraoperative hemostats (P=0.36, and P=0.71).

CONCLUSIONS

The autologous fat graft ensured sufficient and safe epidural hemostasis without serious adverse events in minimally invasive spinal surgery, and is preferable as autologous tissue is easily and quickly harvested. The surgeon feels safe with this technique and does not need external hemostatic agents.

From Animal Poisons and Venoms to Medicines: Achievements, Challenges and Perspectives in Drug Discovery

Animal poisons and venoms are comprised of different classes of molecules displaying wide-ranging pharmacological activities. This review aims to provide an in-depth view of toxin-based compounds from terrestrial and marine organisms used as diagnostic tools, experimental molecules to validate postulated therapeutic targets, drug libraries, prototypes for the design of drugs, cosmeceuticals, and therapeutic agents. However, making these molecules applicable requires extensive preclinical trials, with some applications also demanding clinical trials, in order to validate their molecular target, mechanism of action, effective dose, potential adverse effects, as well as other fundamental parameters. Here we go through the pitfalls for a toxin-based potential therapeutic drug to become eligible for clinical trials and marketing. The manuscript also presents an overview of the current picture for several molecules from different animal venoms and poisons (such as those from amphibians, cone snails, hymenopterans, scorpions, sea anemones, snakes, spiders, tetraodontiformes, bats, and shrews) that have been used in clinical trials. Advances and perspectives on the therapeutic potential of molecules from other underexploited animals, such as caterpillars and ticks, are also reported. The challenges faced during the lengthy and costly preclinical and clinical studies and how to overcome these hindrances are also discussed for that drug candidates going to the bedside. It covers most of the drugs developed using toxins, the molecules that have failed and those that are currently in clinical trials. The article presents a detailed overview of toxins that have been used as therapeutic agents, including their discovery, formulation, dosage, indications, main adverse effects, and pregnancy and breastfeeding prescription warnings. Toxins in diagnosis, as well as cosmeceuticals and atypical therapies (bee venom and leech therapies) are also reported. The level of cumulative and detailed information provided in this review may help pharmacists, physicians, biotechnologists, pharmacologists, and scientists interested in toxinology, drug discovery, and development of toxin-based products.

Composite Hemostatic Nonwoven Textiles Based on Hyaluronic Acid, Cellulose, and Etamsylate

The achievement of rapid hemostasis represents a long-term trend in hemostatic research. Specifically, composite materials are now the focus of attention, based on the given issues and required properties. In urology, different materials are used to achieve fast and effective hemostasis. Additionally, it is desirable to exert a positive influence on local tissue reaction. In this study, three nonwoven textiles prepared by a wet spinning method and based on a combination of hyaluronic acid with either oxidized cellulose or carboxymethyl cellulose, along with the addition of etamsylate, were introduced and assessed in vivo using the rat partial nephrectomy model. A significantly shorter time to hemostasis in seconds (p < 0.05), was attributed to the effect of the carboxymethyl cellulose material. The addition of etamsylate did not noticeably contribute to further hemostasis, but its application strengthened the structure and therefore significantly improved the effect on local changes, while also facilitating any manipulation by the surgeons. Specifically, the hyaluronic acid supported the tissue healing and regeneration, and ensured the favorable results of the histological analysis. Moreover, the prepared textiles proved their bioresorbability after a three-day period. In brief, the fabrics yielded favorable hemostatic activity, bioresorbability, non-irritability, and had a beneficial effect on the tissue repair.

A Biodegradable Antibacterial Nanocomposite Based on Oxidized Bacterial Nanocellulose for Rapid Hemostasis and Wound Healing

The development of biodegradable and antibacterial hemostatic materials with high blood absorption to halt the internal hemorrhage of deep noncompressible wounds remains a challenge. In this study, a novel hemostatic nanocomposite (OBC/COL/CS) was fabricated by coupling oxidized bacterial cellulose (OBC) and chitosan (CS) with collagen (COL), that is, during the electrostatic self-assembly of OBC with CS (OBC/CS), COL was ingeniously attached as a functional component by the electrostatic attraction of cationic CS and anionic OBC. The introduction of collagen was anticipated to provide functional properties such as enhanced hemostasis and promotion of wound healing so as to achieve a new functional composite. This study is the first to evaluate the performance of OBC, OBC/CS, and the OBC/COL/CS composite for rapid internal hemostasis using a rat liver injury model. To our knowledge, this is also the first study to report that OBC has a faster biodegradability in vivo than commercial hemostatic oxidized regenerated plant cellulose (ORC). The OBC/COL/CS nanocomposite exhibited appropriate mechanical strength, broad spectrum antimicrobial properties, and excellent biodegradation in vivo. Furthermore, excellent hemostatic efficacy of the composite was confirmed in vivo. OBC/COL/CS exhibited greater procoagulant properties and blood-clotting capability, higher adhesion of erythrocytes and platelets with concomitant lower blood loss, in addition to ultrafast cessation of bleeding, superior to the commercial hemostatic ORC product Surgicel gauze. The results suggest that the OBC/COL/CS is a fast and efficient procoagulant agent with good antibacterial properties and great potential for use as an absorbable hemostat for control of internal bleeding.

Research status and development potential of composite hemostatic materials

Through the discussion of the coagulation mechanism of compositehemostatic materials, the future development potential of hemostatic materials is proposed.

Comprehensive assessment of Nile tilapia skin collagen sponges as hemostatic dressings

Nile tilapia skin collagen sponge was fabricated by lyophilization and cross-linked with 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide in the presence of N-hydroxysuccinimide (EDC/NHS). The physicochemical properties were examined. The EDC/NHS cross-linked collagen sponge presented an enhanced water absorption capacity. In addition, biocompatibility and hemostatic efficiency were evaluated by acute systemic toxicity assay, dermal irritation test, intradermal reaction test, sensitization test, cytotoxicity, blood clotting assay in vitro, and liver and femoral artery hemorrhage models in vivo. Results showed that the produced collagen sponges before and after EDC/NHS cross-linking had excellent biocompatibility. Furthermore, EDC/NHS cross-linking promoted fibroblast cells viability and proliferation reflected by the MTT reduction assay. Meanwhile, EDC/NHS cross-linked collagen sponge exhibited the best blood clotting ability and hemostatic efficiency in rat femoral artery hemorrhage model in comparison with non-crosslinked and commercial collagen sponges. Our results demonstrated that the fabricated collagen sponges could be used as perfect hemostatic dressings.

Peptide-immobilized starch/PEG sponge with rapid shape recovery and dual-function for both uncontrolled and noncompressible hemorrhage

It is challenging for traditional hemostatic sponges to meet the clinic demand for both uncontrolled and noncompressible hemorrhage. With the aim to develop a rapid shape recovery material with both active and passive hemostatic performance, a dual-functional hemostatic sponge (TRAP-Sp) with a macroporous structure and good mechanical properties for controlling massive and noncompressible hemorrhage was prepared by chemically immobilizing thrombin-receptor-agonist-peptide (TRAP) onto a starch/polyethylene glycol (PEG) sponge. The TRAP2-Sp1 showed the best hemostatic performance among all samples in both rat artery uncontrollable hemorrhage and liver defect noncompressible hemorrhage models. When analyzing the hemostatic mechanism of TRAP-Sp, the high water absorption capacity of the sponge contributed to absorbing plasma, concentrating blood cells, and enhancing blood coagulation. After absorbing water, the shape-fixed TRAP-Sp with sufficient mechanical strength and high resilience can rapidly expand and apply pressure to the wound. TRAP immobilized on the sponge could activate the adhered platelets in an active pathway. Additionally, evaluation of cytotoxicity, hemolysis, and histology further highlighted the adequate biocompatibility of TRAP-Sp. With excellent hemostatic performance and biosafety, this sponge could be a potential candidate as a topical hemostatic agent for uncontrolled and noncompressible hemorrhage. STATEMENT OF SIGNIFICANCE: There is a need for innovative hemostatic materials for both uncontrolled and noncompressible hemorrhage. This manuscript describes a rapid shape recovery hemostatic sponge with both active and passive hemostatic performances synthesized by foaming technique, cross-linking reaction, and chemical immobilization of thrombin-receptor-agonist-peptide (TRAP). On contact with blood, the shape-fixed sponge can not only rapidly recover its original shape and concentrate platelets and RBCs but also activate the adhered platelets efficiently. The dual-functional sponge has excellent hemostatic efficacy in rat femoral artery hemorrhage and can control noncompressible hemorrhage in penetrating liver wound. Thus, we believe that this sponge could be a potential candidate as a topical hemostatic agent for uncontrolled and noncompressible hemorrhage.

Enhancement of hemostatic property of plant derived oxidized nanocellulose-silk fibroin based scaffolds by thrombin loading

To combat post-surgical and traumatic bleeding conditions effective hemostasis is of great importance. The study was designed to investigate the effect of thrombin (Th) loading on hemostatic performance of TEMPO-oxidized cellulose nanofiber (TOCN)-silk fibroin (SF) scaffolds. Addition of SF with TOCN significantly (***P < 0.001) increased blood absorption capacity and improved biocompatibility of TOCN. Thrombin loading potentiated platelet activation and hemostatic property of scaffolds (TOCN-SF-Th) compared to samples without thrombin (TOCN-SF). The hemostatic time of TOCN-SF5-Th in rabbit ear artery bleeding model was reduced (*** P < 0.001) to 114 s from 220 s of TOCN-SF5. Reduction in bleeding time and blood loss of TOCN-SF5-Th in rat tail amputation and liver avulsion model was comparable to commercial hemostat (Floseal). Surface morphology (SEM) of samples applied on bleeding site showed that RBCs and fibrin fiber could strongly interact with TOCN-SF and TOCN-SF-Th scaffolds. The result suggests that TOCN-SF-Th can be a promising candidate for designing hemostatic agents.

Comparison the efficacy of hemorrhage control of Surgiflo Haemostatic Matrix and absorbable gelatin sponge in posterior lumbar surgery: A randomized controlled study

OBJECTIVE

To compare the hemostatic effect of hematostatic agent Surgiflo and absorbable gelatin sponge (AGS) in posterior lumbar surgery.

METHODS

A total of 60 cases were recruited during August 2016 and June 2017 according to the inclusion and exclusion criteria. Patients were randomly allocated to the Surgiflo Haemostatic Matrix (SHM) group or the AGS group (AGS) by computer-generated randomization codes. The success rates of hemostasis for 3 minutes and 5 minutes, the time of operation, the amount of intraoperative bleeding, the volume of autogenously blood transfusion, the amount of blood during hemostasis, the amount of blood transfusion, and BP, RBC, HCT, HB of preoperative, 2 to 3 days, and 5 to 7 days following operation were recorded to compare. Daily drainage and all adverse events after operation were also compared.

RESULTS

All the patients were followed up for at least 1 month. The RBC and HCT of the AGS group before operation were lower than those in the control group (P = .039, P = .029), but there was no difference after operation (P >.05). In the control group, 19 cases were successfully hemostatic in 3 minutes, 4 cases were successful in 5 minutes, and 7 cases were combined with hemostasis. In the SHM group, it was 22, 3, and 5 cases respectively. There was significant difference in blood loss during hemostatic process between the 2 groups (P <.001). There was no difference in the amount of blood loss and autologous blood transfusion between the 2 groups, and there was no difference in the operation time between the 2 groups. In the AGS group, allogeneic blood was infused in 1 case during operation, and no allogeneic blood was infused in the other patients. The drainage volume on the 1st day and the 2nd to 4th day after operation in the AGS group was less than that in the control group (P = .015, P = .010).

CONCLUSION

Compared with AGS, SHM could decrease the blood loss during hemostatic process and the postoperative drainage volume in posterior operation of lumbar degenerative disease. SHM is a safe and effective hemostatic agent in lumbar posterior surgery.

Collagen/Polyethylene Oxide Nanofibrous Membranes with Improved Hemostasis and Cytocompatibility for Wound Dressing

As a promising agent for biomedical application, collagen has been used as a nanofiber to architecturally mimic its fibrillar structure in Extracellular Matrix (ECM); however, it has to be modified by techniques, such as crosslinking, to overcome its limitations in structural stability along with potential toxicity. Here, we prepared collagen/polyethylene oxide (PEO) nanofibrous membranes with varying crosslinking degrees and their properties, such as water stability, mechanical properties, blood clotting capacity and cytocompatibility, were studied systematically. By investigating the relationship between crosslinking degree and their properties, nanofibrous membranes with improved morphology retention, blood clotting capacity and cytocompatibility have been achieved. The result of circular dichroism measurement demonstrated that a triple helical fraction around 60.5% was retained. Moreover, the electrospun collagen/PEO at crosslinking degrees above 60.6% could maintain more than 72% of its original weight and its nanofibrous morphology under physiological conditions could be well preserved for up to 7 days. Furthermore, the crosslinked collagen/PEO membrane could provide a more friendly and suitable environment to promote cell proliferation, and about 70% of the clot can be formed in 5 min. With its superior performance in water stability, hemostasis and cytocompatibility, we anticipate that this nanofibrous membrane has great potential for wound dressing.

Hyaluronic Acid and Polyethylene Glycol Hybrid Hydrogel Encapsulating Nanogel with Hemostasis and Sustainable Antibacterial Property for Wound Healing

Immediate hemorrhage control and anti-infection play important roles in the wound management. Besides, a moist environment is also beneficial for wound healing. Hydrogels are promising materials in urgent hemostasis and drug release. However, hydrogels have the disadvantage of rapid release profiles, leading to the exposure to high drug concentrations. In this study, we constructed hybrid hydrogels with rapid hemostasis and sustainable antibacterial property combining aminoethyl methacrylate hyaluronic acid (HA-AEMA) and methacrylated methoxy polyethylene glycol (mPEG-MA) hybrid hydrogels and chlorhexidine diacetate (CHX)-loaded nanogels. The CHX-loaded nanogels (CLNs) were prepared by the enzyme degradation of CHX-loaded lysine-based hydrogels. The HA-AEMA and mPEG-MA hybrid hydrogel loaded with CLNs (labeled as Gel@CLN) displayed a three-dimensional microporous structure and exhibited excellent swelling, mechanical property, and low cytotoxicity. The Gel@CLN hydrogel showed a prolonged release period of CHX over 240 h and the antibacterial property over 10 days. The hemostasis and wound-healing properties were evaluated in vivo using a mouse model. The results showed that hydrogel had the rapid hemostasis capacity and accelerated wound healing. In summary, CLN-loaded hydrogels may be excellent candidates as hemostasis and anti-infection materials for the wound dressing application.

Recombinant batroxobin-coated nonwoven chitosan as hemostatic dressing for initial hemorrhage control

The choice of hemostat is determined by the situation and the degree of hemorrhage. One common hemostat, the nonwoven dressing, is easy to handled and controls severe bleeding on wider wounds. In this study, chitosan-based nonwoven dressings with recombinant batroxobin (rBat) were used as efficacious hemostatic dressing agents. Hemostatic agents need to absorb blood quickly in the early stages of blood coagulation cascade to rapidly and effectively control of excessive hemorrhages. To date, most studies of hemostatic agents focused on a single material and hemostats composed of multiple materials have not been studied sufficiently. Thus, we made a chitosan dressing coated with rBat and investigated the microstructure, mechanical properties, hemostatic efficacy, and clotting properties of the coated dressing. Our results showed that the rBat had a synergetic effect on chitosan that improved blood coagulation. Furthermore, the dressing had excellent bleeding control in an Sprague-Dawley (SD) rat femoral artery hemorrhage model. In conclusion, hemostasis can be improved by combining a chitosan-based nonwoven dressing with other agents, and rBat-coated chitosan-based nonwoven dressings have enormous potential to improve blood coagulation.

Facile preparation of polysaccharide-based sponges and their potential application in wound dressing

A cellulose–chitosan hybrid sponge incorporating sustainability, desired functionality and stability was used as a wound dressing.

Hemocoagulase might not control but worsen gastrointestinal bleeding in an elderly patient with type II respiratory failure

Hemocoagulase has been successfully used for the management of bleeding in patients undergoing surgery. Local spray of hemocoagulase during endoscopic therapy may be effective for the management of gastrointestinal bleeding. In China, intravenous infusion of hemocoagulase is given by some physicians for the treatment of gastrointestinal bleeding. However, the potential adverse events secondary to hemocoagulase, such as hypofibrinogenemia, are poorly recognized. In this paper, we reported an elderly patient with type II respiratory failure in whom hemocoagulase might induce hypofibrinogenemia and further worsen gastrointestinal bleeding. We highlighted that fibrinogen levels should be cautiously monitored in patients receiving hemocoagulase.