Cell suspensions of autologous keratinocytes or autologous fibroblasts accelerate the healing of full thickness skin wounds in a diabetic porcine wound healing model

Growth factors IGF-1 and KGF and adipose-derived stem cells promote migration and viability of primary human keratinocytes in an in vitro wound model

Introduction

In the field of plastic surgery, epidermal transplantation is a potential treatment for chronic wounds that results in only minor donor site morbidity. Improving the regenerative capacities of epidermal grafts or single-cell suspensions and therefore accelerating healing processes would be of significant interest.

Methods

In the present study, we analyzed the effects of growth factors and adipose-derived stem cells (ADSCs) on keratinocyte properties. For optimum translation into the clinical setting, primary human keratinocytes and patient-matched ADSCs were isolated and used in an in vitro wound model.

Results

The keratinocyte migration and viability increased after treatment with the growth factors insulin-like growth factor 1 (IGF-1) and keratinocyte growth factor (KGF). A similar effect was observed with the use of a concentrated ADSC-conditioned medium (ADSC-CM). It was further possible to isolate the keratinocytes in a xenogen-free medium, which is essential for clinical translation. Importantly, a patient-dependent influence on the effects of the growth factors and ADSC-CM was observed.

Discussion

This study provides potential for the improvement of epidermal transplantation in the treatment of chronic wounds using xenogen-free isolated and cultivated keratinocytes, growth factors, and ADSC. Translating these results into clinical application may help accelerate wound healing and shorten the time until patients can return to everyday life.

Effects of Probiotic Lactobacilli plantarum in Treatment of Experimentally Induced Periodontal Disease in Rabbits

The aim of this study was to evaluate the therapeutic effects of probiotic Lactobacillus plantarum in experimentally induced periodontal disease in rabbits. The incisor teeth of 24 rabbits were scaled under general anesthesia. Two weeks later, silk ligatures were placed at the gingival margin of the incisor teeth to induce periodontal disease. After confirming the presence of periodontal disease by periodontal probing four weeks later, incisor mucogingival flaps were created and gingival pocket lavage and debridement was performed. The rabbits were randomly divided into four groups. Group 1: Control; Group 2: Microencapsulated form of the probiotic; Group 3: Planktonic form of the probiotic; and Group 4: Biofilm form of the probiotic. The rabbits were euthanized eight weeks later, and gingival connective tissue and epithelium were resected for histopathological and histomorphometric evaluation. The results showed that the rate of epithelial regeneration was lower and bone regeneration was significantly higher in the treatment groups compared to the Control group. The highest level of bone regeneration was in Group 2 (Microencapsulated probiotic). There was no significant difference in bone regeneration observed between the biofilm and planktonic probiotic groups. This study showed that applying the probiotic Lactobacillus plantarum in microencapsulated form improved bone regeneration in experimentally induced periodontal disease in rabbits.

Bi-layered living cellular construct resulted in greater healing in an alloxan-induced diabetic porcine model

Tissue-engineered skin constructs, including bi-layered living cellular constructs (BLCC) used in the treatment of chronic wounds, are structurally/functionally complex. While some work has been performed to understand their mechanisms, the totality of how BLCC may function in wound healing remains unknown. To this end, we have developed a delayed wound healing model to test BLCC cellular and molecular mechanisms of action. Diabetes was chemically-induced using alloxan in Yucatan miniature pigs, and full-thickness wounds were generated on their dorsum. These wounds were either allowed to heal by secondary intention alone (control) or treated with a single or multiple treatments of a porcine autologous BLCC. Results indicated a single treatment with porcine BLCC resulted in statistically significant wound healing at day 17, while four treatments resulted in statistically significant healing on days 10, 13, and 17 compared to control. Statistically accelerated wound closure was driven by re-epithelialisation rather than contraction or granulation. This porcine diabetic model and the use of a porcine BLCC allowed evaluation of healing responses in vivo without the complications typically seen with either xenogenic responses of human/animal systems or the use of immune compromised animals, expanding the knowledge base around how BLCC may impact chronic wounds.

Overexpression of VEGF in dermal fibroblast cells accelerates the angiogenesis and wound healing function: in vitro and in vivo studies

Fibroblasts are the main cells of connective tissue and have pivotal roles in the proliferative and maturation phases of wound healing. These cells can secrete various cytokines, growth factors, and collagen. Vascular endothelial growth factor (VEGF) is a unique factor in the migration process of fibroblast cells through induces wound healing cascade components such as angiogenesis, collagen deposition, and epithelialization. This study aimed to create VEGF₁₆₅ overexpressing fibroblast cells to evaluate angiogenesis function in wound healing. In vitro, a novel recombinant expression vector, pcDNA3.1(-)-VEGF, was produced and transfected into the fibroblast cells. Following selecting fibroblast cells with hygromycin, recombinant cells were investigated in terms of VEGF expression by quantifying and qualifying methods. Mechanical, physical, and survival properties of polyurethane-cellulose acetate (PU-CA) scaffold were investigated. Finally, in vivo, the angiogenic potential was evaluated in four groups containing control, PU-CA, PU-CA with fibroblast cells, and VEGF-expressing cells on days 0, 2, 5, 12 and 15. Wound biopsies were harvested and the healing process was histopathologically evaluated on different days. qRT-PCR showed VEGF overexpression (sevenfold) in genetically-manipulated cells compared to fibroblast cells. Recombinant VEGF expression was also confirmed by western blotting. Manipulated fibroblast cells represented more angiogenesis than other groups on the second day after surgery, which was also confirmed by the antiCD31 antibody. The percentage of wound closure area on day 5 in genetically-manipulated Hu02 and Hu02 groups showed a significant reduction of wound area compared to other groups. These findings indicate that overexpression of VEGF₁₆₅ in fibroblast cells results in enhanced angiogenesis and formation of granulated tissue in the early stage of the healing process, which can show its therapeutic potential in patients with impaired wound healing and also provide functional support for gene therapy.

Stem and Somatic Cell Monotherapy for the Treatment of Diabetic Foot Ulcers: Review of Clinical Studies and Mechanisms of Action

Diabetic foot ulcer (DFU) is one of the most severe complications of diabetes mellitus, often resulting in a limb amputation. A cell-based therapy is a highly promising approach for an effective DFU treatment. However, there is no consensus regarding the most effective cell type for DFU treatment. Various cell types contribute to chronic wound healing via different mechanisms. For example, application of keratinocytes can stimulate migration of native keratinocytes from the wound edge, while mesenchymal stem cells can correct limb ischemia. To assess the effectiveness of a certain cell type, it should be administered as a monotherapy without other substances and procedures that have additional therapeutic effects. In the present review, we described therapeutic effects of various cells and provided an overview of clinical studies in which stem and somatic cell-based therapy was administered as a monotherapy. Topical application of somatic cells contributes to DFU healing only, while injection of mesenchymal stem cells and mononuclear cells can break a pathophysiological chain leading from insufficient blood supply to DFU development. At the same time, the systemic use of mesenchymal stem cells carries greater risks. Undoubtedly, cell therapy is a potent tool for the treatment of DFU. However, it is vital to conduct further high-quality clinical research to determine the most effective cell type, dosage and way of administration for DFU treatment. Ischemia, neuropathy and neuro-ischemia are underlying factors of diabetic foot ulcer. Stem and somatic cells monotherapy can improve chronic wound healing via different mechanisms.

Role of Cultured Skin Fibroblasts in Regenerative Dermatology

The skin, as the largest organ, covers the entire outer part of the body, and since this organ is directly exposed to microbial, thermal, mechanical and chemical damage, it may be destroyed by factors such as acute trauma, chronic wounds or even surgical interventions. Cell therapy is one of the most important procedures to treat skin lesions. Fibroblasts are cells that are responsible for the synthesis of collagen, elastin, and the organization of extracellular matrix (ECM) components and have many vital functions in wound healing processes. Today, cultured autologous fibroblasts are used to treat wrinkles, scars, wounds and subcutaneous atrophy. The results of many studies have shown that fibroblasts can be effective and beneficial in the treatment of skin lesions. On the other hand, skin substitutes are used as a regenerative model to improve and regenerate the skin. The use of these alternatives, restorative medicine and therapeutic cells such as fibroblasts has tremendous potential in the treatment of skin diseases and can be a new window for the treatment of diseases with no definitive treatment. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description ofthese Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Allotransplantation of ascorbic acid-treated fibroblasts improves healing of excisional cutaneous wound in diabetic rats

The purpose of this study was to evaluate the effects of ascorbic acid (AA)-treated fibroblasts transplantation on excisional diabetic wound healing. An excisional wound was created between the shoulders of streptozotocin-induced diabetic rats. On day three, 1 ml of PBS, ‎1 × 10⁶ ‎intact homologous fibroblasts, and ‎1 × 10⁶ ‎ fibroblasts treated with 50 μM AA were injected subcutaneously around the wound edges in control, treatment-1 and treatment-2 groups, respectively. In the sham group, the wound was left intact. Wound area was measured by planimetry. On day 15, samples were harvested for histopathological examination and hydroxyproline content. Wound area in treatment-1 and - 2 groups was ‎significantly decreased compared to other groups, on days 11 and 15. The hydroxyproline content was significantly lower in the control group compared to the other groups. Histopathology revealed significant increases in the number of neovessels, macrophages, lymphocytes and fibroblasts in the treatment-2 group compared to the other groups. Trichrome staining showed the highest level of collagen deposition and orientation in the treatment-2 group. In conclusion, allotransplantation of ‎50 μM ‎ AA-treated fibroblasts ‎could result in progressive healing and improved reparative indices of excisional dermal wound in diabetic rats.

Chemokine-Capturing Wound Contact Layer Rescues Dermal Healing

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

Wound Healing Driver Gene and Therapeutic Development: Political and Scientific Hurdles

Significance: Since the last Food and Drug Administration (FDA) approval of a wound healing therapeutic in 1997, no new therapeutic candidate (excluding physical therapies, devices, dressings, and antimicrobial agents) has advanced to clinical applications. During this period, the FDA drug approvals for tumors, which have been referred to as "wounds that do not heal," have reached a total of 284 (by end of 2018). Both political and scientific factors may explain this large discrepancy in drug approvals for the two seemingly related and equally complex pathophysiological conditions. Recent Advances: Using the current research funding ratio of 1:150 for wound healing to cancer and the 5% FDA drug approval rate for oncology, we reach a crude estimate of a 0.03% success rate for wound healing therapeutics. Unless a drastic improvement of the current situation, we express a pessimistic outlook toward new and effective wound healing drugs. Critical Issues: We argue that successful development of wound healing therapeutics will rely on identification of wound healing driver genes (WDGs), and the focus should be on WDGs for the wound closure phase of wound healing. Therefore, WDGs must be both necessary and sufficient for wound closure; the absence of a WDG disrupts wound closure, while its supplementation alone is sufficient to restore full wound closure. Successful translation of a WDG into therapeutics requires availability of well-defined animal models with a high degree of relevance to humans. This review discusses the main hurdles faced by the wound healing research community behind the development of so-called "rescuing drugs" for wound healing. Future Directions: Given the lack of new wound healing drugs for the past 23 years, there is a need for a wide range of fresh, innovative, and thorough debates on wound healing drug development, including an organized movement to raise public support for wound healing research.

Mussel-inspired poly(γ-gl utamic acid)/nanosilicate composite hydrogels with enhanced mechanical properties, tissue adhesive properties, and skin tissue regeneration

It was demonstrated herein that the adhesive property of catechol-functionalized nanocomposite hydrogel can be enhanced by tuning the cohesive strength due to the secondary crosslinking between catechol and synthetic bioactive nanosilicate, viz. Laponite (LP). The nanocomposite hydrogel consists of the natural anionic poly(γ-glutamic acid) (γ-PGA), which was functionalized with catechol moiety, and incorporated with disk-structured LP. The dual-crosslinked hydrogel was fabricated by enzymatic chemical crosslinking of catechol in the presence of horseradish peroxidase (HRP) and H₂O₂, and physical crosslinking between γ-PGA-catechol conjugate and LP. The PGADA/LP nanocomposite hydrogels with catechol moieties showed strong adhesiveness to various tissue layers and demonstrated an excellent hemostatic properties. These PGADA/LP nanocomposite hydrogels are potentially applied for injectable tissue engineering hydrogels, tissue adhesives, and hemostatic materials. STATEMENT OF SIGNIFICANCE: Recently, many attempts have been performed to manufacture high-performance tissue adhesives using synthetic and natural polymer-based materials. In order to apply in various biological substrates, commercially available tissue adhesives should have an improved adhesive property in wet conditions. Here, we designed a mussel-inspired dual crosslinked tissue adhesive that meets most of conditions as an ideal tissue adhesive. The designed tissue adhesive is composed of poly(γ-glutamic acid)-dopamine conjugate (PGADA)-gluing macromer, horseradish peroxidase (HRP)/hydrogen peroxide (H₂O₂)-enzymatic crosslinker, and Laponite (LP)-additional physical crosslinking nanomaterial. The PGADA hydrogel has tunable physicochemical properties by controlling the LP concentration. Furthermore, this dual crosslinked hydrogel shows strong tissue adhesive property, regardless of the tissue types. Specially the PGADA hydrogel has tissue adhesive strength four times higher than commercial bioadhesive. This dual crosslinked PGADA hydrogel with improved tissue adhesion property is a promising biological tissue adhesive for various tissue type in surgical operation.

Protease-Resistant Growth Factor Formulations for the Healing of Chronic Wounds

Objective: Chronic wounds are long-term nonhealing wounds that are refractory to treatment. These wounds can present elevated protease levels, leading to rapid degradation of native and exogenously added growth factors. This work focused on developing a protease-resistant growth factor formulation for treatment of chronic wounds presented with high protease activity. Approach: This study developed protease-resistant growth factor formulations comprising elastin-like peptides (ELPs) fused with a known protease inhibitor peptide or growth factor. The ELP component of the fusion proteins allows assembly of heterogeneous nanoparticles (NPs) putting the inhibitor in close proximity to the growth factor to be protected. Results: We show successful preservation of growth factor activity in high human neutrophil elastase (HNE) environment and in human chronic wound fluid derived from patients. We further show that these NPs result in enhanced collagen remodeling and resolution of inflammation in a full thickness wound supplemented with HNE in genetically diabetic mice. Innovation: Development of heterogeneous NPs that put the protease inhibitor in close proximity of the growth factor. Moreover, the modular nature of the NPs allows for protection of multiple growth factors by the same inhibitor without changing the amino acid sequence of the growth factor. Conclusion: Our results indicate that the developed NPs hold tremendous promise in chronic wound healing therapy and may further help the translation of growth factor therapies to clinic. The customizable template for the NP design allows for multifaceted use across several fields in research and medicine.

Evaluation of epithelial progenitor cells and growth factors in a preclinical model of wound healing induced by mesenchymal stromal cells

Background: Skin wounds continue to be a global health problem. Several cellular therapy protocols have been used to improve and accelerate skin wound healing. Here, we evaluated the effect of transplantation of mesenchymal stromal cells (MSC) on the wound re-epithelialization process and its possible relationship with the presence of epithelial progenitor cells (EPC) and the expression of growth factors. Methods: An experimental wound model was developed in C57BL/6 mice. Human MSCs seeded on collagen membranes (CM) were implanted on wounds. As controls, animals with wounds without treatment or treated with CM were established. Histological and immunohistochemical (IH) studies were performed at day 3 post-treatment to detect early skin wound changes associated with the presence of EPC expressing Lgr6 and CD34 markers and the expression of keratinocyte growth factor (KGF) and basic fibroblast growth factor (bFGF). Results: MSC transplantation enhanced skin wound re-epithelialization, as compared with controls. It was associated with an increase in Lgr6⁺ and CD34⁺ cells and the expression of KGF and bFGF in the wound bed. Conclusion: Our results show that cutaneous wound healing induced by MSC is associated with an increase in EPC and growth factors. These preclinical results support the possible clinical use of MSC to treat cutaneous wounds.

Does survivin overexpression enhance the efficiency of fibroblast cell-based wound therapy?

Cell-based wound therapy is faced with some limiting factors that decrease the therapeutic efficacy of transplanted cells. In this study, we aimed to genetically modify fibroblast cells with anti-apoptotic Survivin gene (Birc5) before cell transplantation. In vitro, pIRES2-eGFP-Survivin plasmid was transfected into the fibroblast cells and the growth curve was evaluated for transfected and normal cells performing MTT assay. In vivo, two 6-diameter cutaneous wounds were created at mice dorsal skin. Fibrin clot was used as a delivery vehicle to transfer cells into the wound bed. The effects of four treatment groups including (a) Cell-SVV-Clot (b) Cell-GFP-Clot, (c) Normal cell-Clot and, (d) Clot alone were evaluated. After 1,2,3,7 and 14 days post-transplantation, the wounds were photographed for evaluating the wound closure rate and wound samples were obtained. Angiogenesis and formation of granulated tissue were assessed via H&E staining for wound samples. The expression levels of Survivin, VEGF, and bFGF genes were also determined using qRT-PCR. The MTT assay showed similar proliferation potential of transfected cells with normal cells verifying that Survivin had no detrimental effect. Compared to the Normal cell-Clot group, the Survivin overexpression was seen for 3 days in the Cell-SVV-Clot group verifying the cell survival during the early stage of wound healing. The Survivin further upregulated VEGF and bFGF expressions resulting in more angiogenesis and formation of granulated tissue by day 3 and 14. The treated wounds with Cell-SVV-Clot were regenerated with a higher wound closure rate by day 7 compared to Normal cell-Clot and Clot groups. Survivin enhanced wound healing through induction of VEGF and bFGF at particular times post-wounding that led to a more structured-epidermis with higher angiogenesis and granulation tissue formation rate.

Ozonated Oils and Cutaneous Wound Healing

Wound tissue repair is a complex and dynamic process of restoring cellular structures and tissue layers. Improvement in this process is necessary to effectively treat several pathologies characterized by a chronic delayed wound closure, such as in diabetes, and the investigation of new approaches aimed to ameliorate the wound healing process is under continuous evolution. Recently, the usage of vegetable matrices in the form of ozonated oils has been proposed, and several researchers have shown positive effects on wound healing, due to the bactericidal, antiviral, and antifungal properties of these ozonated oils. In the present review, we intend to summarize the actual state of the art of the topical usage of ozonated oil in cutaneous wounds with special emphasis to the importance of the ozonated degree of the oil.

Probiotic Bacteria in Wound Healing; An In-Vivo Study

BACKGROUND

Probiotics are food supplements that benefit the host by improving its intestinal microbial balance. Probiotics are used as diet supplements to prevent diarrhoea and improve lactose tolerance.

OBJECTIVES

The present study deals with the isolation of a potent probiotic strain capable of inducing healing properties in rat model.

MATERIALS AND METHODS

Probiotic VITSAMJ1 was isolated from goat milk using MRS media. The antimicrobial assay was carried out against S. aureus (MTCC 3160) and the wound healing properties were assessed on female Wistar rats. A 1.5 cm² subcutaneous wound was induced in the rats, and a probiotic gel formulation was tropically applied onto the wounds. Tissue biopsy was carried out after days 1, 3, 5, 7, 9, and 11. Total leucocyte count and Histopathological analysis were performed after each interval.

RESULTS

VITSAMJ1 can be effectively used for wound healing.

CONCLUSION

VITSAMJ1 can be effectively used for wound healing.

Mechanistic insight into diabetic wounds: Pathogenesis, molecular targets and treatment strategies to pace wound healing

Wound management in diabetic patient is of an extreme clinical and social concern. The delayed and impaired healing makes it more critical for research focus. The research on impaired healing process is proceeding hastily evident by new therapeutic approaches other than conventional such as single growth factor, dual growth factor, skin substitutes, cytokine stimulators, cytokine inhibitors, matrix metalloproteinase inhibitors, gene and stem cell therapy, extracellular matrix and angiogenesis stimulators. Although numerous studies are available that support delayed wound healing in diabetes but detailed mechanistic insight including factors involved and their role still needs to be revealed. This review mainly focuses on the molecular cascades of cytokines (with growth factors) and erstwhile factors responsible for delayed wound healing, molecular targets and recent advancements in complete healing and its cure. Present article briefed recent pioneering information on possible molecular targets and treatment strategies including clinical trials to clinicians and researchers working in similar area.

Acceleration of Diabetic Wound Healing with PHD2- and miR-210-Targeting Oligonucleotides

In diabetes-associated chronic wounds, the normal response to hypoxia is impaired and many cellular processes involved in wound healing are hindered. Central to the hypoxia response is hypoxia-inducible factor-1α (HIF-1α), which activates multiple factors that enhance wound healing by promoting cellular motility and proliferation, new vessel formation, and re-epithelialization. Prolyl hydroxylase domain-containing protein 2 (PHD2) regulates HIF-1α activity by targeting it for degradation under normoxia. HIF-1α also upregulates microRNA miR-210, which in turn regulates proteins involved in cell cycle control, DNA repair, and mitochondrial respiration in ways that are antagonistic to wound repair. We have identified a highly potent short synthetic hairpin RNA (sshRNA) that inhibits expression of PHD2 and an antisense oligonucleotide (antimiR) that inhibits miR-210. Both oligonucleotides were chemically modified for improved biostability and to mitigate potential immunostimulatory effects. Using the sshRNA to silence PHD2 transcripts stabilizes HIF-1α and, in combination with the antimiR targeting miR-210, increases proliferation and migration of keratinocytes in vitro. To assess activity and delivery in an impaired wound healing model in diabetic mice, PHD2-targeting sshRNAs and miR-210 antimiRs both alone and in combination were formulated for local delivery to wounds using layer-by-layer (LbL) technology. LbL nanofabrication was applied to incorporate sshRNA into a thin polymer coating on a Tegaderm mesh. This coating gradually degrades under physiological conditions, releasing sshRNA and antimiR for sustained cellular uptake. Formulated treatments were applied directly to splinted full-thickness excisional wounds in db/db mice. Cellular uptake was confirmed using fluorescent sshRNA. Wounds treated with a single application of PHD2 sshRNA or antimiR-210 closed 4 days faster than untreated wounds, and wounds treated with both oligonucleotides closed on average 4.75 days faster. Markers for neovascularization and cell proliferation (CD31 and Ki67, respectively) were increased in the wound area following treatment, and vascular endothelial growth factor (VEGF) was increased in sshRNA-treated wounds. Our results suggest that silencing of PHD2 and miR-210 either together or separately by localized delivery of sshRNAs and antimiRs is a promising approach for the treatment of chronic wounds, with the potential for rapid clinical translation.

Theoretical and practical aspects of using fetal fibroblasts for skin regeneration

Cutaneous wounding in late-gestational fetal or postnatal humans results in scar formation without any skin appendages. Early or mid- gestational skin healing in humans is characterized by the absence of scaring in a process resembling regeneration. Tremendous cellular and molecular mechanisms contribute to this distinction, and fibroblasts play critical roles in scar or scarless wound healing. This review discussed the different repair mechanisms involved in wound healing of fibroblasts at different developmental stages and further confirmed that fetal fibroblast transplantation resulted in reduced scar healing in vivo. We also discussed the possible problem in fetal fibroblast transplantation for wound repair. We proposed the use of small molecules to improve the regenerative potential of repairing cells in the wound given that remodeling of the wound microenvironment into a regenerative microenvironment in adults might improve skin regeneration.

Current Advancements and Strategies in Tissue Engineering for Wound Healing: A Comprehensive Review

Significance: With an aging population leading to an increase in diabetes and associated cutaneous wounds, there is a pressing clinical need to improve wound-healing therapies. Recent Advances: Tissue engineering approaches for wound healing and skin regeneration have been developed over the past few decades. A review of current literature has identified common themes and strategies that are proving successful within the field: The delivery of cells, mainly mesenchymal stem cells, within scaffolds of the native matrix is one such strategy. We overview these approaches and give insights into mechanisms that aid wound healing in different clinical scenarios. Critical Issues: We discuss the importance of the biomimetic niche, and how recapitulating elements of the native microenvironment of cells can help direct cell behavior and fate. Future Directions: It is crucial that during the continued development of tissue engineering in wound repair, there is close collaboration between tissue engineers and clinicians to maintain the translational efficacy of this approach.

Treatment of standardised wounds with pure epidermal micrografts generated with an automated device

In this study, we analysed the effects of pure epidermal micrografts generated with an automated device in a standardised human wound model. Epidermal micrografts were harvested using an automated device. Micrografts were then transplanted onto split-skin donor sites. The target area was only partially covered with transplants to create an intra-individual control area. Wounds were evaluated by subjective assessment as well as measurements with combined laser and white light spectroscopy and cutometry. The epidermal graft sites remained completely stable, whereas control sites offered partially unstable and blistering areas. Statistically, no measurable difference in the speed of initial reepithelialisation could be shown. However, there was an increased pliability and softness of the treated areas that correlated with the subjective impression of both investigators and patients. There was a significantly higher relative haemoglobin concentration, measurable in treated and untreated areas at 4 weeks and 6 months. Cutometry showed no differences in skin properties between treated and untreated areas. This study shows an effect of epidermal micrografts in a standardised human wound model and supports the positive impact of keratinocytes on early wound healing as described in literature. Long-term effects of epidermal grafting deserve further studies.

Models for the study of skin wound healing. The role of Nrf2 and NF-κB

Nrf2 and NF-κB transcription factors act in wound healing via their anti-inflammatory and anti-oxidant effects or through the immune response. Studying this process is a matter of some importance given the high cost of wound treatment. A major contribution in this regard is being made by models that enable investigation of the involvement of multiple factors in wound healing and testing new curative substances. This literature review was carried out via searches in the PubMed and Web of Science databases up to 2016. It covers skin wound healing, available models for its study (part I), the role of Nrf2 and NF-κB, substances that influence them and whether they can be used as markers (part II). Was found that in vitro assays are used for their availability but a holistic view must be established in vivo. In silico approaches are facilitating assessment of a vast amount of research data. Nfr2 and NF-κB play a crucial and reciprocal role in wound healing. Nrf2 controls repair-associated inflammation and protects against excessive accumulation of ROS while Nf-κB activates the innate immune reaction, proliferation and migration of cells, modulates expression of matrix metalloproteinases, secretion and stability of cytokines and growth factors for wound healing.

Keratinocyte-Secreted Heat Shock Protein-90alpha: Leading Wound Reepithelialization and Closure

Significance: Delayed and nonhealing wounds pose a health, economic, and social problem worldwide. For decades, the conventional wisdom pointed to growth factors as the driving force of wound healing and granted them a center stage for therapeutic development. To date, few have obtained US FDA approvals or shown clinical effectiveness and safety. Critical Issue: Wound closure is the initial and most critical step during wound healing. Closing chronic wounds to shut down continued infection is the primary and likely the only achievable goal at the clinic in the foreseeable future. The critical question here is to identify the factor(s) in wounded tissues that drives the initial wound closure. Recent Advances: We made an unexpected discovery of the secreted form of heat shock protein-90alpha (Hsp90α) for promoting skin cell motility, reepithelialization, and wound closure. Secreted Hsp90α possesses unique properties to remain functional under the hostile wound environment that compromises conventional growth factors' effectiveness. Through the common lipoprotein receptor-related protein-1 cell surface receptor and activation of the Akt signaling pathway, topical application of human recombinant Hsp90α protein greatly accelerates excision, burn, and diabetic skin wound closure in rodent and porcine models. Future Directions: In almost all cells, the 2-3% of their total proteins (∼7,000 per cell) are Hsp90 (α and β), a long unraveled puzzle. Our new finding of Hsp90 secretion in wounded tissues suggests that the stockpile of Hsp90α by all cells is to rapidly supply the need for extracellular Hsp90α to repair damaged tissues. We propose that keratinocytes at the wound edge secrete Hsp90α that leads the reepithelialization process to close the wound.

Substance P combined with epidermal stem cells promotes wound healing and nerve regeneration in diabetes mellitus

Exogenous substance P accelerates wound healing in diabetes, but the mechanism remains poorly understood. Here, we established a rat model by intraperitoneally injecting streptozotocin. Four wounds (1.8 cm diameter) were drilled using a self-made punch onto the back, bilateral to the vertebral column, and then treated using amniotic membrane with epidermal stem cells and/or substance P around and in the middle of the wounds. With the combined treatment the wound-healing rate was 100% at 14 days. With prolonged time, type I collagen content gradually increased, yet type III collagen content gradually diminished. Abundant protein gene product 9.5- and substance P-immunoreactive nerve fibers regenerated. Partial nerve fiber endings extended to the epidermis. The therapeutic effects of combined substance P and epidermal stem cells were better than with amniotic membrane and either factor alone. Our results suggest that the combination of substance P and epidermal stem cells effectively contributes to nerve regeneration and wound healing in diabetic rats.

Autologous epidermal cell suspension: A promising treatment for chronic wounds

BACKGROUND

Chronic wounds have become an increasing medical and economic problem of aging societies because they are difficult to manage. Skin grafting is an important treatment method for chronic wounds, which are refractory to conservative therapy. The technique involving epidermal cell suspensions was invented to enable the possibility of treating larger wounds with only a small piece of donor skin. Both uncultured and cultured autologous epidermal cell suspensions can be prepared and survive permanently on the wound bed.

METHODS

A systematic search was conducted of EMBASE, Cochrane Library, PubMed and web of science by using Boolean search terms, from the establishment of the database until May 31, 2014. The bibliographies of all retrieved articles in English were searched. The search terms were: (epithelial cell suspension OR keratinocyte suspension) and chronic and wound.

RESULTS

From the included, 6 studies are descriptive interventions and discussed the use of autologous keratinocyte suspension to treat 61 patients' chronic wound. The various methods of preparation of epidermal cell suspension are described. The advantages and shortcomings of different carriers for epidermal cell suspensions are also summarised. Both uncultured and cultured autologous epidermal cell suspensions have been used to treat chronic wounds.

CONCLUSION

Although the limitations of these studies include the small number of patient populations with chronic wounds and many important problems that remain to be solved, autologous epidermal cell suspension is a promising treatment for chronic wounds.

Identification of the critical therapeutic entity in secreted Hsp90α that promotes wound healing in newly re-standardized healthy and diabetic pig models

Chronic and non-healing skin wounds represent a significant clinical, economic and social problem worldwide. Currently, there are few effective treatments. Lack of well-defined animal models to investigate wound healing mechanisms and furthermore to identify new and more effective therapeutic agents still remains a major challenge. Pig skin wound healing is close to humans. However, standardized pig wound healing models with demonstrated validity for testing new wound healing candidates are unavailable. Here we report a systematic evaluation and establishment of both acute and diabetic wound healing models in pigs, including wound-creating pattern for drug treatment versus control, measurements of diabetic parameters and the time for detecting delayed wound healing. We find that treatment and control wounds should be on the opposite and corresponding sides of a pig. We demonstrate a strong correlation between duration of diabetic conditions and the length of delay in wound closure. Using these new models, we narrow down the minimum therapeutic entity of secreted Hsp90α to a 27-amino acid peptide, called fragment-8 (F-8). In addition, results of histochemistry and immunohistochemistry analyses reveal more organized epidermis and dermis in Hsp90α-healed wounds than the control. Finally, Hsp90α uses a similar signaling mechanism to promote migration of isolated pig and human keratinocytes and dermal fibroblasts. This is the first report that shows standardized pig models for acute and diabetic wound healing studies and proves its usefulness with both an approved drug and a new therapeutic agent.

Current preventive measures for health-care associated surgical site infections: a review

Healthcare-associated infections (HAIs) continue to be a tremendous issue today. It is estimated 1.7 million HAIs occur per year, and cost the healthcare system up to $45 billion annually. Surgical site infections (SSIs) alone account for 290,000 of total HAIs and approximately 8,000 deaths. In today's rapidly changing world of medicine, it is ever important to remain cognizant of this matter and its impact both globally and on the individual lives of our patients. This review aims to impress upon the reader the unremitting significance of HAIs in the daily practice of medicine. Further, we discuss the etiology of HAIs and review successful preventive measures that have been demonstrated in the literature. In particular, we highlight preoperative, intraoperative, and postoperative interventions to combat SSIs. Finally, we contend that current systems in place are often insufficient, and emphasize the benefits of institution-wide adoption of multiple preventive interventions. We hope this concise update and review can inspire additional dialogue for the continuing progress towards improving patient care and patient lives.

The effects of insulin-like growth factor-1 gene therapy and cell transplantation on rat acute wound model

BACKGROUND

Wound healing is a complex process. Different types of skin cells, extracellular matrix and variety of growth factors are involved in wound healing. The use of recombinant growth factors in researches and production of skin substitutes are still a challenge.

OBJECTIVES

Much research has been done on the effects of gene therapy and cell therapy on wound healing. In this experimental study, the effect of insulin-like growth factor (IGF-1) gene transfer in fibroblast cells was assessed on acute dermal wound healing.

MATERIALS AND METHODS

Fibroblasts were cultured and transfected with IGF-1. Lipofectamine 2000 was used as a reagent of transfection. Transgene expression levels were measured by the enzyme linked immunosorbent assay (ELISA). To study in vivo, rats (weighing 170-200 g) were randomly divided into three groups (five/group) and full-thickness wounds were created on the dorsum region. Suspensions of transfected fibroblast cells were injected into the wound and were compared with wounds treated with native fibroblast cells and normal saline. For the microscopic examination, biopsy was performed on day seven.

RESULTS

In vitro, the maximum expression of IGF1 (96.95 pg/mL) in transfected fibroblast cells was 24 hours after gene transfer. In vivo, it was clear that IGF-1 gene therapy caused an increase in the number of keratinocyte cells during the wound healing process (mean of group A vs. group B with P value = 0.01, mean of group A vs. group C with P value = 0.000). Granulation of tissue formation in the transfected fibroblast group was more organized when compared with the normal saline group and native fibroblast cells.

CONCLUSIONS

This study indicated that the optimization of gene transfer increases the expression of IGF-1. High concentrations of IGF-1, in combination with cell therapy, have a significant effect on wound healing.

Allogenous skin fibroblast transplantation enhances excisional wound healing following alloxan diabetes in sheep, a randomized controlled trial

BACKGROUND

Healing of skin wound is a multi-factorial and complex process. Treatment of diabetic wounds is still a major clinical challenge. Recently, stem cell transplantation to chronic wounds is favored. The objective of this study was to evaluate effects of pre-labeled allogenous skin fibroblasts on healing of ovine diabetic wound model.

METHODS

Eight 4-month-old Iranian Makoui wethers were used in this study. Alloxan monohydrate was used for induction of diabetes. In each wether two excisional wound were created on dorsum of the animal. Wounds of one side were randomly chosen as treatment group (n = 8), and wounds of the other side were considered as control group (n = 8). Pre-labeled skin fibroblasts with bromodeoxyuridine were used in wounds of one side as treatment. Photographs were taken in distinct times for planimetric evaluation. Wound samples were taken for BrdU detection and histopathologic evaluations on day 21 post-wounding.

RESULTS

The planimetric study showed closure of fibroblast treated wounds is significantly faster than control group (P < 0.05). Immunohistochemical staining with anti-bromodeoxyuridine antibody indicated presence of transplanted cells in the wounds. Histopathologic evaluations of H&E stained sections disclosed significantly increasing of re-epithelialization, number of fibroblasts, and number of blood vessels in treatment group in comparison to control group (P < 0.05).

CONCLUSION

[corrected] The results of this study indicated that allogenous skin fibroblast transplantation can positively affect wound healing in diabetic sheep.

Polysaccharides of Aloe vera induce MMP-3 and TIMP-2 gene expression during the skin wound repair of rat

Polysaccharides are the main macromolecules of Aloe vera gel but no data about their effect on extracellular matrix (ECM) elements are available. Here, mannose rich Aloe vera polysaccharides (AVP) with molecular weight between 50 and 250 kDa were isolated and characterized. Open cutaneous wounds on the back of 45 rats (control and treated) were daily treated with 25mg (n=15) and 50 mg (n=15) AVP for 30 days. The levels of MMP-3 and TIMP-2 gene expression were analyzed using real time PCR. The levels of n-acetyl glucosamine (NAGA), n-acetyl galactosamine (NAGLA) and collagen contents were also measured using standard biochemical methods. Faster wound closure was observed at day 15 post wounding in AVP treated animals in comparison with untreated group. At day 10 post wounding, AVP inhibited MMP-3 gene expression, while afterwards MMP-3 gene expression was upregulated. AVP enhanced TIMP-2 gene expression, collagen, NAGLA and NAGA synthesis in relation to untreated wounds. Our results suggest that AVP has positive effects on the regulation of ECM factor synthesis, which open up new perspectives for the wound repair activity of Aloe vera polysaccharide at molecular level.

Enzyme-catalyzed in situ forming gelatin hydrogels as bioactive wound dressings: effects of fibroblast delivery on wound healing efficacy

Wound treatment using injectable or sprayable fibroblast-encapsulated GH-hydrogels.

Continuous electrical current and zinc sulphate administered by transdermal iontophoresis improves skin healing in diabetic rats induced by alloxan: morphological and ultrastructural analysis

PURPOSE

Evaluated the effects of continuous electrical current (CEC) or zinc administrated by transdermal iontophoresis (Zn+TDI).

METHODS

120 male Wistar rats were submitted to an incision surgery at the anterior region of abdomen and distributed into 6 experimental groups with 40 animals: 3 diabetic groups and 3 normal groups, untreated and treated with CEC alone or with Zn + TDI. Each group was further divided into 4 subgroups with 10 rats each to be evaluated on the 4th, 7th, 14th, and 21st day after surgery. In each period, clinical and laboratory parameters from the animals were analyzed.

RESULTS

The analysis by optical and scanning electron microscopy showed a delay in the phases of wound healing in diabetic rats without treatment in all periods of the experiment; breaking strength (BS) was significantly reduced in skin scars of untreated diabetic rats when compared to other groups. In contrast, BS in skin scars of nondiabetic groups and diabetic rats treated with Zn + TDI showed significant increase in those, besides not presenting delayed healing.

CONCLUSION

Electrical stimulation of surgical wounds used alone or in association with zinc by TDI is able to consistently improve the morphological and ultrastructural changes observed in the healing of diabetic animals.

Avocado/soybean unsaponifiables: a novel regulator of cutaneous wound healing, modelling and remodelling

We investigated the effects of avocado/soybean unsaponifiables (ASU) on the healing response of cutaneous wound defect in rats. Sixty male rats were randomly divided into three groups including control, vehicle and treatment (n = 20 in each group). A 2 × 2 cm(2) wound defect was made on the dorsum. The control, vehicle and treatment groups were treated daily with topical application of saline, cream and cream/ASU for 10 days, respectively. The wounds were monitored daily. The animals were euthanised at 10, 20 and 30 days post injury (D). The dry matter, hydroxyproline, collagen, n-acetyl glucosamine (NAGLA) and n-acetyl galactosamine (NAGAA) contents of the skin samples were measured and the histopathological and biomechanical characteristics of the samples were investigated. Statistics of P < 0·05 was considered significant. Treatment significantly increased tissue glycosaminoglycans and collagen contents at various stages of wound healing compared to controls. Treatment modulated inflammation, improved fibroplasia and produced high amounts of scar tissue at short term. At long term, treatment reduced the scar tissue size and increased the quality and rate of wound contraction and reepithelisation compared to controls. The treated lesions were more cosmetically pleasing and had significantly higher biomechanical characteristics than controls. ASU was effective in rat wound healing.

Recombinant human collagen III gel for transplantation of autologous skin cells in porcine full-thickness wounds

Complex skin wounds, such as chronic ulcers and deep burns, require lengthy treatments and cause extensive burdens on healthcare and the economy. Use of biomaterials and cell transplantation may improve traditional treatments and promote the healing of difficult-to-treat wounds. In this study, we investigated the use of recombinant human collagen III (rhCol-III) gel as a delivery vehicle for cultured autologous skin cells (keratinocytes only or keratinocyte-fibroblast mixtures). We examined its effect on the healing of full-thickness wounds in a porcine wound-healing model. Two Landrace pigs were used for the study. Fourteen deep dermal wounds were created on the back of each pig with an 8 mm biopsy punch. Syringes containing acellular rhCol-III gel (n = 8) or rhCol-III gel with autologous keratinocytes (n = 8) or rhCol-III gel with autologous keratinocytes and fibroblasts (n = 8) were applied into wounds. Untreated wounds were used as controls for the treatment groups (n = 4). We used rhCol-III gel to manufacture a cell-delivery syringe containing autologous skin cells. In a full-thickness wound-healing model, we observed that rhCol-III gel enhances early granulation tissue formation. Interestingly, we found cell type-dependent differences in the stability of rhCol-III in vivo. Fibroblast-containing gel was effectively removed from the wound, whereas gels without cells or with keratinocytes only remained intact. Our results demonstrate that the properties of rhCol-III gel for skin cell transplantation can be significantly altered in a cell type-dependent manner.

Development of fibroblast culture in three-dimensional activated carbon fiber-based scaffold for wound healing

This work developed a novel bi-layer wound dressing composed of 3D activated carbon fibers that allows facilitates fibroblast cell growth and migration to a wound site for tissue reconstruction, and the gentamicin is incorporated into a poly(γ-glutamic acid)/gelatin membrane to prevent bacterial infection. In an in vitro, field emission scanning electron microscopy shows that rat skin fibroblasts appeared and spread on the surface of activated carbon fibers, and penetrated the interior and exterior of the 3D activated carbon fiber construct to a depth of roughly 200 μm. An in vivo analysis shows that fibroblast cells containing the proposed 3D scaffold had the potential of a biologically functionalized dressing to accelerate wound closure. Additionally, fibroblasts migrated to the wound site in a bi-layer wound dressing containing fibroblasts, enhancing fibronectin and type I collagen expression, resulting in faster skin regeneration than that achieved with a Tegaderm™ hydrocolloid dressing or gauze.

Regenerative medicine as applied to general surgery

The present review illustrates the state of the art of regenerative medicine (RM) as applied to surgical diseases and demonstrates that this field has the potential to address some of the unmet needs in surgery. RM is a multidisciplinary field whose purpose is to regenerate in vivo or ex vivo human cells, tissues, or organs to restore or establish normal function through exploitation of the potential to regenerate, which is intrinsic to human cells, tissues, and organs. RM uses cells and/or specially designed biomaterials to reach its goals and RM-based therapies are already in use in several clinical trials in most fields of surgery. The main challenges for investigators are threefold: Creation of an appropriate microenvironment ex vivo that is able to sustain cell physiology and function in order to generate the desired cells or body parts; identification and appropriate manipulation of cells that have the potential to generate parenchymal, stromal and vascular components on demand, both in vivo and ex vivo; and production of smart materials that are able to drive cell fate.

Autologous fibroblast culture in the repair of aging skin

BACKGROUND

Human cell cultures are being developed to replace various body tissues.

OBJECTIVE

To assess the safety and efficacy of dermal regeneration with the injection of young autologous fibroblasts obtained from culture containing serum from patients themselves.

MATERIALS AND METHODS

Dermal tissue from the groin of five patients was cultivated in M199 medium supplemented with 10% human serum. Four population doublings were obtained. The fibroblasts were injected intradermally into forehead wrinkles and periorbital and paranasal areas.

RESULT

At the fourth population doubling, a mean of 3.85 × 10(6) cells/mL was obtained; viability was 98%. Sixty days after completing treatment, with four injections given at 15-day intervals, periorbital tonicity had improved significantly, although the quantity of fibroblasts used resulted in little improvement to surface lines and no improvement at all in deeper wrinkles. After 6 months, no further changes were found beyond the initial results obtained.

CONCLUSION

Injection of skin fibroblasts cultivated in medium supplemented with human serum is a viable technique and provokes no side effects. Four injections given at 15-day intervals containing a total of 6.4 × 10(6) fibroblasts/mL resulted in significant improvement in periorbital skin flaccidity. Further studies should be conducted with larger sample sizes.

Self-assembling elastin-like peptides growth factor chimeric nanoparticles for the treatment of chronic wounds

Chronic wounds are associated with poor epidermal and dermal remodeling. Previous work has shown the efficacy of keratinocyte growth factor (KGF) in reepithelialization and elastin in dermal wound healing. Here we demonstrate the fabrication of a fusion protein comprising of elastin-like peptides and KGF. This fusion protein retains the performance characteristics of KGF and elastin as evidenced by its enhancement of keratinocyte and fibroblast proliferation. It also preserved the characteristic elastin-like peptides inverse phase transitioning allowing the recombinant protein to be expressed in bacterial hosts (such as Escherichia coli) and purified rapidly and easily using inverse temperature cycling. The fusion protein self-assembled into nanoparticles at physiological temperatures. When applied to full thickness, wounds in Lepr(db) diabetic mice these particles enhanced reepithelialization and granulation, by 2- and 3-fold respectively, when compared to the controls. The data strongly suggests that these self-assembled nanoparticles may be beneficial in the treatment of chronic wounds resulting from diabetes or other underlying circulatory conditions.