Hyperbaric oxygen potentiates diabetic wound healing by promoting fibroblast cell proliferation and endothelial cell angiogenesis

Role of nuclear factor erythroid 2-related factor 2 in negative pressure wound therapy for diabetic foot ulcers

BACKGROUND

Negative pressure wound therapy (NPWT) is a potential treatment for diabetic foot ulcers (DFUs), although the mechanisms underlying its effectiveness remain unclear. This study posits that NPWT may improve wound healing by promoting angiogenesis and activating the nuclear factor erythroid 2-related factor 2 (Nrf2)/Kelch-like epichlorohydrin-associated protein 1 (Keap1) signaling pathway, which is crucial for the body’s defense against oxidative stress. The hypothesis indicates that enhancing antioxidant defenses through NPWT may positively affect the healing process. There are still limited data on the roles of Nrf2, its downstream signaling molecules, and angiogenesis markers in patients undergoing NPWT.

AIM

To study the mechanism of NPWT in DFUs.

METHODS

This study included a total of 40 hospitalized patients with DFUs from Xuzhou Central Hospital, who were divided into Control group (n = 21) and NPWT group (n = 19). The levels of Nrf2 and Keap1 were analyzed in the granulation tissue 7 days after treatment. The wound condition, erythrocyte sedimentation rate (ESR), procalcitonin (PCT), interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-α), vascular endothelial growth factor (VEGF), basic fibroblast growth factor (b-FGF), cluster of differentiation 31 (CD31), and levels of oxidative stress [malondialdehyde (MDA), superoxide dismutase (SOD), catalase (CAT), and total antioxidant capacity (T-AOC)] were analyzed before and 7 days after treatment by the Mann-Whitney U test.

RESULTS

The NPWT group demonstrated significant improvements in wound healing compared to the control group after 7 days of treatment. The levels of ESR, PCT, IL-6, and TNF-α were significantly reduced in the NPWT group compared to the control group (P < 0.05), while the levels of CD31, VEGF, and b-FGF showed significant increases (P < 0.05). The NPWT group exhibited notable elevations in the levels of Nrf2 and its downstream targets (SOD, CAT, and T-AOC), accompanied by decreases in the levels of Keap1 and MDA (P < 0.05).

CONCLUSION

NPWT may contribute to the healing of DFUs by potentially reducing levels of oxidative stress. Its effects could possibly be enhanced through the action of Nrf2.

Immune-Vascular Synergy: A Photodynamic Hydrogel Activating ALDH2 to Combat Inflammation and Enhance Angiogenesis in Diabetic Wound Healing

Infected diabetic wounds present serious therapeutic challenges, primarily due to persistent infections, impaired immune responses, and insufficient vascularization. Excessive secretion of neutrophil extracellular traps (NETs) is increasingly recognized as a key driver of inflammation in diabetic wounds. Single-cell sequencing analysis of clinical specimens reveals a deficiency in aldehyde dehydrogenase 2 (ALDH2) within wound tissues, which plays a critical role in sustaining inflammation and hindering vascular regeneration. Unlike conventional treatments that focus on either infection control or vascular repair, a photodynamic hydrogel with a dual-function strategy is developed, uniquely integrating ALDH2 activation with immune-vascular modulation to address these multifaceted challenges. The hydrogel-mediated activation of ALDH2 effectively reduces NET formation and mitigates chronic inflammation, while promoting macrophage polarization from the pro-inflammatory M1 phenotype to the reparative M2 phenotype. This transition fosters an anti-inflammatory microenvironment that not only facilitates tissue repair but also enhances angiogenesis by stimulating endothelial cell activity, improving vascularization at the wound site. In contrast to existing therapeutics, the approach directly targets the interplay between immune regulation and vascular regeneration, offering a synergistic mechanism to enhance wound healing outcomes. The findings introduce an immune-vascular synergy-based therapeutic strategy, emphasizing the translational potential of this hydrogel technology for chronic wound management.

Pathogenetic characteristics and related risk factors of incisional infection after surgery for acute intestinal obstruction and construction of prediction model

OBJECTIVE

To investigate the causative factors, antimicrobial resistance patterns, and associated risk factors of postoperative incisional infections in patients with acute intestinal obstruction and to develop a predictive model.

METHODS

A retrospective study was conducted on patients with acute intestinal obstruction (n = 329) admitted to the Emergency Surgery Department of the First Affiliated Hospital of Anhui Medical University between January 1, 2020, and December 31, 2022. Patients were included based on specific criteria. Wound drainage samples from patients with postoperative incisional infections were collected for bacterial culture and drug susceptibility testing. Patients were randomly divided into a training set (n = 231) and a validation set (n = 98) at a 7:3 ratio. Least Absolute Shrinkage and Selection Operator (LASSO) regression was employed to screen variables and select predictors. Multivariate logistic regression was utilized to analyze risk factors and develop a predictive model. The area under the curve (AUC) was calculated to assess the model's discriminatory ability, and calibration and decision curve analyses were performed.

RESULTS

Among the 329 patients, 37 (11.25%) developed postoperative incisional infections. Bacterial cultures were positive in 32 of 37 infected patients (86.48%). Gram-negative bacteria, primarily Escherichia coli, accounted for 65.63% of isolates, while gram-positive bacteria, predominantly Enterococcus faecium, comprised 28.12%. Fungi, mainly Candida albicans, constituted 6.25%. Gram-negative bacteria exhibited high resistance to ceftriaxone but low resistance to imipenem. Gram-positive bacteria demonstrated higher resistance to erythromycin than ciprofloxacin, with no vancomycin-resistant strains identified. LASSO regression identified seven variables, which were further analyzed using multivariate logistic regression to identify six independent risk factors for incisional infection. A predictive model was developed based on these six factors: age ≥ 60 years, diabetes history, operative time ≥ 3 h, colorectal obstruction, enterostomy, and hemoglobin (HGB). The AUCs for the training and validation sets were 0.952 (95% CI 0.914-0.990) and 0.982 (95% CI 0.959-1.000), respectively. Hosmer-Lemeshow goodness-of-fit tests and calibration curves demonstrated good model fit. Decision curve analysis indicated a significant clinical net benefit of the predictive model.

CONCLUSION

Gram-negative bacteria constitute the primary causative agents of postoperative incisional infections in patients with acute intestinal obstruction. Moreover, these bacteria exhibit significant resistance to commonly used antibiotics. To mitigate the risk of such infections, clinicians should prioritize the monitoring of gram-negative bacterial growth. Prophylactic antibiotic administration can further reduce the incidence of these infections. Additionally, a predictive model incorporating six key variables-age ≥ 60 years, diabetes mellitus, operative time ≥ 3 h, colorectal obstruction, enterostomy, and HGB-can aid in identifying high-risk patients. This model enables clinicians to implement targeted early monitoring and preventive strategies, ultimately improving patient outcomes.

Mesenchymal Stem Cell-Derived Exosomes Hold Promise in the Treatment of Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) represent one of the most common side effects of diabetes, significantly impacting patients' quality of life and imposing considerable financial burdens on families and society at large. Despite advancements in therapies targeting lower limb revascularization and various medications and dressings, outcomes for patients with severe lesions remain limited. A recent breakthrough in DFU treatment stems from the development of mesenchymal stem cells (MSCs). MSCs have shown promising results in treating various diseases and skin wounds due to their ability for multidirectional differentiation and immunomodulation. Recent studies highlight that MSCs primarily repair tissue through their paracrine activities, with exosomes playing a crucial role as the main biologically active components. These exosomes transport proteins, mRNA, DNA, and other substances, facilitating DFU treatment through immunomodulation, antioxidant effects, angiogenesis promotion, endothelial cell migration and proliferation, and collagen remodeling. Mesenchymal stem cell-derived exosomes (MSC-Exo) not only deliver comparable therapeutic effects to MSCs but also mitigate adverse reactions like immune rejection associated with MSCs transplantation. This article provides an overview of DFU pathophysiology and explores the mechanisms and research progress of MSC-Exo in DFU therapy.

Resveratrol Promotes Wound Healing by Enhancing Angiogenesis via Inhibition of Ferroptosis

Diabetic wound healing critically depends on functional endothelial cells for angiogenesis, yet the hyperglycemic microenvironment induces endothelial dysfunction through oxidative stress, inflammation, and senescence. Although ferroptosis has been recognized as a critical pathological factor contributing to impaired diabetic wound healing, the therapeutic potential of resveratrol (Res), a natural polyphenol with well-documented antioxidant and anti-ferroptotic properties, remains underexplored in this context. This study aimed to investigate the protective effects of Res on endothelial cells and elucidate its underlying mechanisms in diabetic wound healing. In vitro experiments systematically evaluated Res's impact on cellular inflammatory responses, senescence levels, and angiogenic capacity. Subsequent in vivo studies assessed Res's therapeutic potential by monitoring diabetic wound healing progression and analyzing associated histological changes. To clarify the mechanisms underlying Res's promotion of diabetic wound healing, we conducted comprehensive analyses measuring intracellular reactive oxygen species, lipid peroxidation levels, mitochondrial membrane potential and morphology, ferroptosis-related marker expression, and upstream signaling pathway regulation. Res significantly reduced HG-induced inflammatory responses and cellular senescence in human umbilical vein endothelial cells while enhancing their angiogenic potential in vitro. In vivo results showed that Res not only markedly accelerated diabetic wound healing but also demonstrated multiple beneficial effects, including effective suppression of cellular senescence, decreased ferroptosis levels, and significantly promoted angiogenesis. Mechanistic investigations confirmed that Res achieves these effects by inhibiting ferroptosis through activation of the PI3K-AKT-Nrf2 signaling axis. Our results demonstrate that Res protects endothelial cells from HG-induced ferroptosis by activating PI3K-AKT-Nrf2 signaling, thereby promoting angiogenesis and diabetic wound healing. These findings highlight Res as a promising therapeutic candidate for impaired diabetic wound repair and justify further clinical investigation.

FG-4592 combined with PRP significantly accelerates the healing of refractory diabetic wounds by upregulating HIF-1α

Chronic refractory wounds are a common, costly and recurrent complication of diabetes. Platelet-rich plasma (PRP), a new therapy for chronic wounds, is limited by a long treatment period and unstable effects. FG-4592(Roxadustat) is a new prolyl-4-hydroxylation domain(PHD) inhibitor, which can stabilize hypoxia-inducible factor-1α(HIF-1α) effectively. It is a promising drug for wound repair and needs to be demonstrated via various appropriate application scenarios. This study investigated the effects of combining FG-4592 and PRP to promote diabetic wound healing. Diabetic rats were randomly assigned to five groups: nondiabetic control, diabetic untreated, diabetic + PRP, diabetic + FG-4592, and diabetic + PRP + FG-4592. Diabetes was induced with streptozotocin (STZ). A full-thickness skin defect was created, and FG-4592 (peritoneal injection) and PRP (periwound injection) were administered alone or together. Wound healing was assessed by histological analysis (Hematoxylin-Eosin (HE) and Masson staining) and protein expression of HIF-1α, VEGF(vascular endothelial growth factor), α-SMA(α-smooth muscle actin), CoL1α1(collagen type 1 alpha 1), and SDF-1(Stromal Cell-derived Factor 1) via Western blotting and qRT-PCR(Quantitative real time polymerase chain reaction). Immunohistochemistry(IHC) and immunofluorescence(IF) were also used to evaluate CD34 (Cluster of Differentiation 34), CD31(Cluster of Differentiation 31), VEGF(vascular endothelial growth factor), SDF-1(Stromal Cell-derived Factor 1), PCNA(Proliferating Cell Nuclear Antigen), and Integrin-β1 expression. The untreated diabetic group exhibited impaired wound healing, histological damage, and reduced expression of key proteins compared to the nondiabetic control group. Both PRP and FG-4592 alone improved wound healing, reduced damage, and upregulated protein expression. However, the combination of FG-4592 and PRP showed the most significant improvement. This study suggests that FG-4592 combined with PRP accelerates diabetic wound healing by enhancing endothelial progenitor cell recruitment, neovascularization, and cell proliferation and migration via upregulation of HIF-1α and its target genes. This combination therapy may provide a novel approach for treating chronic diabetic wounds.

Efficacy and safety of hyperbaric oxygen therapy for radiation-induced dermatitis in patients with breast cancer: a randomized pilot study

PURPOSE

Radiation-induced dermatitis (RID) is a common adverse effect of adjuvant radiotherapy in patients with breast cancer, often leading to discomfort and reduced quality of life. Hyperbaric oxygen therapy (HBOT) has been proposed as a potential intervention to mitigate RID, but its efficacy remains uncertain. This pilot study aimed to assess the feasibility, safety, and preliminary efficacy of HBOT in reducing RID severity.

METHODS

This single-institution, randomized, controlled pilot study included 30 patients undergoing adjuvant radiotherapy for breast cancer. Participants were assigned to either HBOT (100% oxygen at 1.5 atmospheres absolute, 30 min per session, three times per week, for 7 weeks) or standard care. The primary outcome was to determine whether HBOT reduces the incidence of grade 2 or higher RID, based on Radiation Therapy Oncology Group criteria. Secondary outcomes included the Skindex-29, Catterall Skin Scoring Profile, Numeric Rating Scale (NRS), and EORTC QLQ Core Questionnaire-C30 scores.

RESULTS

Twenty-five patients completed the study. The incidence of grade 2 or higher RID was 73.3% in both the HBOT and control groups, with no significant difference (p = 0.700). No statistically significant differences were observed in primary or secondary endpoints. Trends toward lower skin-related discomfort and improved patient-reported outcomes in the HBOT group were noted but did not reach statistical significance. HBOT was well tolerated, with no serious adverse events reported.

CONCLUSION

This pilot study did not demonstrate a significant reduction in RID severity with HBOT. However, the therapy was safe and well tolerated, with potential benefits in patient comfort and quality of life. Larger trials with optimized HBOT protocols are needed to clarify its role in RID management. Trial Registration Number and the date of registration: NCT06158347 (28/11/2023) and KCT0009847 (15/10/2024).

Microenvironment of diabetic foot ulcers: Implications for healing and therapeutic strategies

Diabetic foot ulcers (DFUs) are a common yet serious complication in individuals with diabetes, often presenting as chronic, nonhealing wounds that significantly impair quality of life. The healing process of DFUs is largely influenced by the local microenvironment, which encompasses factors such as hypoxia, inflammation, and the involvement of various cell types. Poor blood circulation in the affected area results in hypoxia, compromising cellular function and restricting nutrient supply, thereby delaying wound healing. In addition, chronic inflammation disrupts immune system balance, with excessive pro-inflammatory cytokines not only failing to facilitate tissue repair but also exacerbating tissue damage. Moreover, key cell types, including fibroblasts, keratinocytes, and macrophages, play crucial roles at different stages of the healing process, contributing to collagen production and skin regeneration. A comprehensive understanding of the complex dynamics within the DFU microenvironment is essential for developing more precise therapeutic approaches, such as advanced drug delivery systems and bioactive materials, aimed at promoting wound healing and reducing the risk of recurrence.

Single-cell RNA sequencing reveals a new mechanism of endothelial cell heterogeneity and healing in diabetic foot ulcers

Diabetic foot ulcers (DFU) are a common and severe complication among diabetic patients, posing a significant burden on patients' quality of life and healthcare systems due to their high incidence, amputation rates, and mortality. This study utilized single-cell RNA sequencing technology to deeply analyze the cellular heterogeneity of the skin on the feet ofDFU patients and the transcriptomic characteristics of endothelial cells, aiming to identify key cell populations and genes associated with the healing and progression of DFU. The study found that endothelial cells from DFU patients exhibited significant transcriptomic differences under various conditions, particularly in signaling pathways related to inflammatory responses and angiogenesis. Through trajectory analysis and cell communication research, we revealed the key role of endothelial cell subsets in the development of DFU and identified multiple important gene modules associated with the progression of DFU. Notably, the promoting effect of the SH3BGRL3 gene on endothelial cell proliferation, migration, and angiogenic capabilities under high glucose conditions was experimentally verified, providing a new potential target and theoretical basis for the treatment of DFU. This study not only enhances the understanding of the pathogenesis ofDFU but also provides a scientific basis for the development ofnew therapeutic strategies.

MiR-185-5p is Involved in Regulating the Abnormal Proliferation of Retinal Microvascular Endothelial Cells via Targeting CXCR4

PURPOSE

This study aimed to explore the expression profile of miR-185-5p in proliferative DR (PDR), and further evaluate its diagnostic value and possible mechanism of miR-185-5p in PDR.

METHODS

The level of miR-185-5p was detected by qRT-PCR. The ROC curve was established to estimate the diagnostic ability of miR-185-5p. Transwell experiment and cell counting kit-8 (CCK-8) assays were conducted to assess the effect of miR-185-5p on the migration and proliferation of human retinal endothelial cells (HRECs) induced by high glucose. Enzyme linked immunosorbent assay (ELISA) was used to detect the concentrations of inflammatory factors. The luciferase reporter gene experiment was used to prove the interaction between miR-185-5p and CXCR4.

RESULTS

Compared to the control group, the expression of miR-185-5p was significantly up-regulated in both the type 2 diabetes mellitus (T2DM) group and the PDR groups, with higher levels in the PDR group than in the T2DM group. The ROC curve reveals that serum miR-185-5p can distinguish PDR patients from T2DM patients. MiR-185-5p levels in HRECs increased significantly after high glucose induction. High glucose induction also promoted the migration, proliferation and inflammation response of HRECs. However, when the intracellular miR-185-5p level was down-regulated by miR-185-5p inhibitor transfection, these effects were inhibited. The luciferase reporter gene assay showed that miR-185-5p directly targets CXCR4.

CONCLUSION

The expression of miR-185-5p is out of balance in PDR and it may be involved in regulating the migration and proliferation of HRECs by regulating CXCR4.

Exploring the molecular mechanisms by which secretory phospholipase a2 regulates lymphatic endothelial cell dysfunction by activating macrophages

This study offers new insights into the dual role of secretory phospholipase A2 (sPLA2) in lymphedema, highlighting its impact on lymphatic endothelial cell (LEC) functionality. Through transcriptomic analyses and co-culture experiments, we observed that sPLA2 has both protective and detrimental effects on human LECs (HLECs), mediated by macrophage activation. Our findings reveal that while low levels of sPLA2 promote LEC health, excessive sPLA2 leads to dysfunction, emphasizing the significance of the sPLA2/PLA2R axis and arachidonic acid metabolism (AA) in lymphedema pathology. The study suggests targeting sPLA2 and its downstream pathways as a novel therapeutic strategy for lymphedema, aiming to mitigate its progression by safeguarding HLEC integrity. This research underscores the importance of balanced sPLA2 activity in maintaining lymphatic vessel health and presents a new avenue for lymphedema management and treatment.

Efficacy of Hyperbaric Oxygen Therapy as an Adjunct in Aesthetic Surgery: A Systematic Review and Meta-analysis of Postoperative Outcomes and Complications

INTRODUCTION

Aesthetic surgery has gained significant popularity due to advancements in techniques and increased societal acceptance. However, it is not without risks, including complications and delayed healing, which have sparked interest in adjunctive therapies such as hyperbaric oxygen therapy (HBOT). This systematic review and meta-analysis evaluates the efficacy of HBOT in improving postoperative outcomes in aesthetic surgery.

METHODS

A comprehensive literature search was conducted across multiple databases in December 2024, identifying studies involving patients who underwent aesthetic surgeries and received HBOT. Inclusion criteria focused on studies reporting outcomes related to wound healing, complication rates, and patient satisfaction. Primary outcomes assessed were healing time and complication rates, while secondary outcomes included patient satisfaction and overall aesthetic results. Study quality and risk of bias were evaluated using standardized assessment tools.

RESULTS

Eleven studies with 734 patients were included, with 416 (56.7%) receiving HBOT. Predominantly used postoperatively (90.9%), HBOT reduced healing times, with a pooled mean healing time of 11.30 days [95% CI: 10.46, 12.14]. Procedures included abdominoplasty (36.4%) and breast aesthetic surgeries (27.3%). HBOT protocols varied, with sessions lasting 45-120 minutes at pressures of 2.0-3.0 ATA. Patient satisfaction was consistently high, with early satisfaction rates up to 88.2%.

CONCLUSION

HBOT is an effective adjunct in aesthetic surgery, promoting faster recovery and greater patient satisfaction. However, the variability in study designs and HBOT protocols underscores the need for well-designed randomized controlled trials to establish standardized guidelines for its application in aesthetic and reconstructive procedures.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors  www.springer.com/00266 .

Gentiopicroside targeting AKT1 activates HIF-1α/VEGF axis promoting diabetic ulcer wound healing

Backgound

Gentiopicroside (GSP) have been proven to accelerate the healing of diabetic ulcers (DU), but the underlying molecular mechanisms remain unclear. This study aims to explore the mechanism by which GSP accelerates the healing of DU.

Method

The targets of GSP were firstly predicted using the SuperPred, SwissTargetPrediction, and Pharmmapper databases; DU-related transcriptome data were obtained from the GEO database, including GSE147890, GSE68183, and GSE199939; differential expression analysis was conducted using the Limma package, and DU-related targets were identified after summarization and de-duplication. Then, Potential targets for GSP treatment of DU were screened by Venn analysis; core targets for GSP treatment of DU were selected by constructing a protein-protein interaction (PPI) network; the mechanism of GSP treatment of DU was predicted by GO and KEGG enrichment analysis. Finally, the target binding of GSP to core targets was evaluated by molecular docking and CETSA assay, and in vitro experiments were conducted using L929 cells to validate the findings.

Result

A total of 538 targets of GSP and 10795 DU-related targets were predicted; Venn analysis identified 215 potential targets for GSP to accelerate DU wound healing; PPI network analysis suggested that AKT1 may be core targets for GSP treatment of DU; GO and KEGG enrichment analysis showed that pathways such as HIF-1 and VEGF are closely related to the treatment of DU with GSP, and it also participates in the regulation of various biological processes such as small molecule catabolism and leukocyte migration to exert its therapeutic effect on DU. Molecular docking and CETSA detection indicated that GSP can target bind to AKT1. The experimental results confirmed that GSP can significantly promote the proliferation and migration of L929 cells. Westen Blot results showed that GSP can accelerate DU wound healing via AKT1/HIF-1α/VEGF axis.

Conclusion

GSP target binding to AKT1 accelerates DU wound healing via the regulation of HIF-1α/VEGF axis.

CXXC5 function blockade promotes diabetic wound healing through stimulating fibroblast and vascular endothelial cell activation

BACKGROUND

Extracellular matrix (ECM) and angiogenesis are critical controls of wound regeneration, and their dysfunction delays diabetes recovery. CXXC5 belongs to the CXXC protein family that can regulate the function of human dermal fibroblasts (HDFs) and human umbilical vein endothelial cells (HUVECs); However, awareness of its functional role remains limited.

METHODS

Mice were divided into control (CON), diabetic (DM), diabetic + KY19382 (DM + KY19382), and diabetic + vehicle (DM + Vehicle) groups. HDFs and HUVECs were stimulated under different CXXC5 conditions and mice were treated with KY19382, followed by the application of assays including Western blotting (WB), immunofluorescence (IF) and quantitative reverse transcription-PCR (qRT-PCR) to assess wound healing and molecular signaling.

RESULTS

Mice in DM had fewer blood vessels, a slower wound healing rate, and more disrupted collagen than CON. Application of KY19382 improved these conditions, which promoted fibroblast activation and vascularization in high glucose environments and DM. Mechanistically, blocking CXXC5 promotes Wnt/β-catenin-mediated stabilization by reducing the binding of the deterrent factor CTBP1 to β-catenin, which induces dermal fibroblast activation and facilitates HUVECs tube formation and migration via VEGFA/VEGFR2 and NFκB signaling pathways. KY19382 promotes HUVECs activation by blocking CTBP1 transcription to activate the NFκB signaling pathway, thus wound re-vascularization.

CONCLUSION

CXXC5 is an essential regulatory factor of wound healing and a prospective therapeutic target for treating chronic wound damage in diabetes.

Utilizing bioinformatics and machine learning to identify CXCR4 gene-related therapeutic targets in diabetic foot ulcers

Background

Diabetic foot ulcers (DFUs) are a serious complication of diabetes mellitus that manifests as chronic, non-healing wounds that have a significant impact on patients quality of life. Identifying key molecular targets associated with DFUs could help develop targeted therapies to promote wound healing and prevent further complications. The CXCR4 gene is known to play a key role in cell migration, immunology response, and tissue repair, and thus may be an important target for DFU treatment.

Methods

We used the GEO database (Gene Expression Omnibus database) to obtain DFU-related gene expression data, identified differentially expressed genes (DEGs), and performed enrichment analysis to reveal the related biological pathways. Meanwhile, protein-protein interaction (PPI) networks were constructed using STRING to identify core genes. Feature selection methods such as LASSO, SVM-RFE and random forest algorithm were applied to localize possible therapeutic target genes. Finally, We analyzed the molecular pathways of CXCR4 in DFUs by Gene set enrichment analysis (GSEA).

Results

We identified a total of 751 differential genes, of which 409 genes were significantly upregulated and 342 genes were downregulated in diabetic foot ulcer tissues. Functional enrichment analysis showed that these genes were mainly involved in pathways such as oxidative phosphorylation, phagosome, synaptic vesicle cycle, and pathways of neurodegeneration. We integrated the genes screened by three machine learning models (LASSO, SVM, and Random Forest), and CXCR4 was identified as a key gene with potential therapeutic value in DFUs. Gene set enrichment analysis (GSEA) showed that CXCR4 was closely associated with pathways related to immunology regulation and tissue repair.

Conclusion

The findings suggest that CXCR4 and its related pathways play an important role in the pathogenesis of DFUs, providing a new perspective on targeted therapy for wound healing in diabetic patients. Further validation of the role of CXCR4 is expected to establish it as an important target in DFU management.

Hyperbaric oxygen therapy in the treatment of severe gastric laceration with active bleeding: A case report

BACKGROUND

Endoscopic therapy is the primary approach for treating Mallory-Weiss syndrome, particularly under conditions of mucosal protection and gastric acid suppression. However, for a subset of patients who cannot undergo endoscopic intervention or for whom such treatment proves ineffective, alternative measures like arterial embolization or surgical intervention may be required. While hyperbaric oxygen therapy (HBOT) has been applied across a range of medical conditions, its application in managing hemorrhage due to gastric tears remains undocumented.

CASE SUMMARY

A 52-year-old patient was admitted with symptoms of hematemesis and melena, and an endoscopy revealed a gastric fundus tear approximately 4 cm × 5 cm in size. The lesion was considered unsuitable for endoscopic repair by the attending endoscopist. Despite conservative measures, including fasting and acid suppression, the patient experienced persistent bleeding and a substantial decrease in hemoglobin levels relative to admission values. Following a multidisciplinary consultation, HBOT was initiated, resulting in the cessation of bleeding and rapid wound healing.

CONCLUSION

For patients with gastric tears presenting with active hemorrhage, HBOT might offer an effective alternative when conventional endoscopic therapies are not viable or have been unsuccessful.

Hyperbaric Oxygen Therapy as a Renewed Hope for Ischemic Craniomaxillofacial Diseases

Although the advancements in craniomaxillofacial surgery have been significant, ischemic craniomaxillofacial diseases remain challenging to treat due to insufficient blood supply. Hyperbaric oxygen therapy (HBOT) has emerged as a promising adjunctive treatment, exhibiting the potential to promote angiogenesis, exert anti-inflammatory effects, enhance bone regeneration, and possess antibacterial properties. Numerous studies have demonstrated its efficacy in stimulating healing processes, particularly in cases such as medication-related osteonecrosis of the jaw, osteoradionecrosis, chronic jaw osteomyelitis, and refractory wounds. Hyperbaric oxygen therapy not only accelerates healing and shortens recovery times but also reduces postoperative complications, infection risks, and enhances patients' overall quality of life. This review aims to synthesize the research progress on the application of hyperbaric oxygen therapy in ischemic craniomaxillofacial diseases, providing a valuable reference for clinicians.

Microenvironmental pH modulating oxygen self-boosting microalgal prodrug carboxymethyl chitosan/hyaluronic acid/puerarin hydrogel for accelerating wound healing in diabetic rats

Chronic diabetic wounds are characterized by a range of detrimental features, including hypoxia, elevated levels of reactive oxygen species, impaired angiogenesis, chronic inflammation, and an increased susceptibility to bacterial infections. We have developed an innovative multifunctional hydrogel system based on carboxymethyl chitosan, which incorporates embedded microalgae PCC7942 along with hyaluronic acid and puerarin, termed PCC7942@carboxymethyl chitosan/hyaluronic acid/puerarin hydrogel. It demonstrated outstanding capabilities in exudate absorption, mechanical flexibility, hemostatic action, and antibacterial efficacy. Furthermore, it effectively modulated the pH of wound microenvironment through the hydrolysis of amide bonds, thereby establishing a favorable low-pH microenvironment. Microalgae in hydrogel covered in the wound exhibited stable and continuous oxygen production within 24 h, with more efficiency in dissolved oxygen penetration through skin. Furthermore, prodrugs such as hyaluronic acid and puerarin from hydrogel displayed the controlled release behavior and facilitated the fast and enhanced accumulation of drugs at wound site, thereby accelerating the process of wound healing via enhanced angiogenesis and anti-inflammation effects. In summary, the healing-promoting effect of PCC7942@carboxymethyl chitosan/hyaluronic acid/puerarin hydrogel in type 1 diabetic rats can be attributed to the synergistic effects of microalgae, hyaluronic acid, and puerarin, which collectively accelerated wound healing rate and improved the quality of wound recovery.

Cellular and molecular roles of reactive oxygen species in wound healing

Wound healing is a highly coordinated spatiotemporal sequence of events involving several cell types and tissues. The process of wound healing requires strict regulation, and its disruption can lead to the formation of chronic wounds, which can have a significant impact on an individual's health as well as on worldwide healthcare expenditure. One essential aspect within the cellular and molecular regulation of wound healing pathogenesis is that of reactive oxygen species (ROS) and oxidative stress. Wounding significantly elevates levels of ROS, and an array of various reactive species are involved in modulating the wound healing process, such as through antimicrobial activities and signal transduction. However, as in many pathologies, ROS play an antagonistic pleiotropic role in wound healing, and can be a pathogenic factor in the formation of chronic wounds. Whilst advances in targeting ROS and oxidative stress have led to the development of novel pre-clinical therapeutic methods, due to the complex nature of ROS in wound healing, gaps in knowledge remain concerning the specific cellular and molecular functions of ROS in wound healing. In this review, we highlight current knowledge of these functions, and discuss the potential future direction of new studies, and how these pathways may be targeted in future pre-clinical studies.

Loureirin B Accelerates Diabetic Wound Healing by Promoting TGFβ/Smad-Dependent Macrophage M2 Polarization: A Concerted Analytical Approach Through Single-Cell RNA Sequencing and Experimental Verification

Diabetic wound (DW) represent a significant clinical challenge and often fail to heal effectively. Loureirin B (LB), a flavonoid extracted from dragon's blood, has shown potential by influencing macrophage polarization and promoting wound healing. However, its mechanisms and efficacy in DW remain to be explored. This study employed single-cell RNA sequencing to analyze the classification of cells in diabetic foot ulcers and to identify the related mechanisms influenced by macrophages. Molecular docking was used to predict the interactions of LB with key proteins in the TGFβ/Smad signaling pathway. The effects of LB on macrophage polarization and wound healing were further validated through in vitro and in vivo experiments using a DW model. Single-cell analysis identified specific macrophage subtypes involved in the DW healing process and highlighted the role of the TGFβ/Smad pathway. Molecular docking suggested the potential action within the TGFβ/Smad pathway. In vitro studies showed that under high glucose conditions, LB promoted macrophage polarization from pro-inflammatory M1 to healing-promoting M2 and ECM production in fibroblasts by activating TGF-β/Smad signaling. In vivo, LB treatment enhanced wound healing rates in diabetic mice and promoted macrophage M2 polarization and fibroblast synthesis of ECM by activating TGF-β/Smad signaling. LB regulates macrophage M2 polarization and fibroblast synthesis of ECM by activating TGF-β/Smad signaling to promote DW healing. These findings suggest that LB could be a potential therapeutic agent for improving DW healing, emphasizing the need for further clinical studies to explore its efficacy and mechanisms in human subjects.

Therapeutic potential of silkworm sericin in wound healing applications

Chronic wounds are characterised by an imbalance between pro and anti-inflammatory signals, which result in permanent inflammation and delayed re-epithelialization, consequently hindering wound healing. They are associated with bacterial infections, tissue hypoxia, local ischemia, reduced vascularization and MMP-9 upregulation. The global prevalence of chronic wounds has been estimated at 40 million in the adult population, with an alarming annual growth rate of 6.6%, making it an increasingly significant clinical problem. Sericin is a natural hydrophilic protein obtained from the silkworm cocoon. Due to its biocompatibility, biodegradability, non-immunogenicity and oxidation resistance, coupled with its excellent affinity for target biomolecules, it holds great potential in wound healing applications. The silk industry discards 50,000 tonnes of sericin annually, making it a readily available material. Sericin increases cell union sites and promotes cell proliferation in fibroblasts and keratinocytes, thanks to its cytoprotective and mitogenic effects. Additionally, it stimulates macrophages to release more therapeutic cytokines, thus improving vascularization. This review focuses on the biological properties of sericin that contribute towards enhanced wound healing process and its mechanism of interaction with important biological targets involved in wound healing. Emphasis is placed on diverse wound dressing products that are sericin based and the utilisation of nanotechnology to design sericin nanoparticles that aid in chronic wound management.

Exosome-based cell therapy for diabetic foot ulcers: Present and prospect

Diabetic foot ulcers (DFUs) represent a serious complication of diabetes with high incidence, requiring intensive treatment, prolonged hospitalization, and high costs. It poses a severe threat to the patient's life, resulting in substantial burdens on patient and healthcare system. However, the therapy of DFUs remains challenging. Therefore, exploring cell-free therapies for DFUs is both critical and urgent. Exosomes, as crucial mediators of intercellular communication, have been demonstrated potentially effective in anti-inflammation, angiogenesis, cell proliferation and migration, and collagen deposition. These functions have been proven beneficial in all stages of diabetic wound healing. This review aims to summarize the role and mechanisms of exosomes from diverse cellular sources in diabetic wound healing research. In addition, we elaborate on the challenges for clinical application, discuss the advantages of membrane vesicles as exosome mimics in wound healing, and present the therapeutic potential of exosomes and their mimetic vesicles for future clinical applications.

Magnetic gelatin-hesperidin microrobots promote proliferation and migration of dermal fibroblasts

Dermal fibroblasts play a crucial role in the formation of granulation tissue in skin wounds. Consequently, the differentiation, migration, and proliferation of dermal fibroblasts are considered key factors in the skin wound healing process. However, in patients with diabetic foot ulcers, the proliferation and migration of fibroblasts are impaired by reactive oxygen species and inflammatory factors impair. Therefore, a novel magnetic gelatin-hesperidin microrobots drug delivery system was developed using microfluidics. The morphology, motility characteristics, and drug release of the microrobot were assessed, along with its impact on the proliferation and migration of human dermal fibroblasts under high-glucose conditions. Subjected to a rotating magnetic field, the microrobots exhibit precise, controllable, and flexible autonomous motion, achieving a maximum speed of 9.237 μm/s. In vitro drug release experiments revealed that approximately 78% of the drug was released within 30 min. It was demonstrated through cellular experiments that the proliferation of human dermal fibroblasts was actively promoted by the nanorobot, the migration ability of fibroblasts in a high-glucose state was enhanced, and good biocompatibility was exhibited. Hence, our study may provide a novel drug delivery system with significant potential for promoting the healing of diabetic foot wounds.

The screening of α-glucosidase inhibitory peptides from β-conglycinin and hypoglycemic mechanism in HepG2 cells and zebrafish larvae

Inhibition of carbohydrate digestive enzymes is a key focus across diverse fields, given the prominence of α-glucosidase inhibitors as preferred oral hypoglycaemic drugs for diabetes treatment. β-conglycinin is the most abundant functional protein in soy; however, it is unclear whether the peptides produced after its gastrointestinal digestion exhibit α-glucosidase inhibitory properties. Therefore, we examined the α-glucosidase inhibitory potential of soy peptides. Specifically, β-conglycinin was subjected to simulated gastrointestinal digestion by enzymatically cleaving it into 95 peptides with gastric, pancreatic and chymotrypsin enzymes. Eight soybean peptides were selected based on their predicted activity; absorption, distribution, metabolism, excretion and toxicity score; and molecular docking analysis. The results indicated that hydrogen bonding and electrostatic interactions play important roles in inhibiting α-glucosidase, with the tripeptide SGR exhibiting the greatest inhibitory effect (IC50 = 10.57 μg/mL). In vitro studies revealed that SGR markedly improved glucose metabolism disorders in insulin-resistant HepG2 cells without affecting cell viability. Animal experiments revealed that SGR significantly improved blood glucose and decreased maltase activity in type 2 diabetic zebrafish larvae, but it did not result in the death of zebrafish larvae. Transcriptomic analysis revealed that SGR exerts its anti-diabetic and hypoglycaemic effects by attenuating the expression of several genes, including Slc2a1, Hsp70, Cpt2, Serpinf1, Sfrp2 and Ggt1a. These results suggest that SGR is a potential food-borne bioactive peptide for managing diabetes.

Current progress of protein-based dressing for wound healing applications - A review

Protein-based wound dressings have garnered increasing interest in recent years owing to their distinct physical, chemical, and biological characteristics. The intricate molecular composition of proteins gives rise to unique characteristics, such as exceptional biocompatibility, biodegradability, and responsiveness, which contribute to the promotion of wound healing. Wound healing is an intricate and ongoing process influenced by multiple causes, and it consists of four distinct phases. Various treatments have been developed to repair different types of skin wounds, thanks to advancements in medical technology and the recognition of the diverse nature of wounds. This review has literature reviewed within the last 3-5 years-the recent progress and development of protein in wound dressings and the fundamental properties of an ideal wound dressing. Herein, the recent strides in protein-based state-of-the-art wound dressing emphasize the significant challenges and summarize future perspectives for wound healing applications.

Bilayer hydrogel with a protective film and a regenerative hydrogel for effective diabetic wound treatment

Diabetic foot ulcers (DFUs) are one of the most serious complications of diabetes, often leading to necrosis and amputation. DFU is caused by the intricate diabetic microenvironment, including ischemia, hypoxia, hyperinflammation, reduced angiogenesis, and persistent infection. Traditional wound dressings made of single or mixed materials often struggle to meet all the requirements for effective diabetic wound healing. In contrast, multilayer dressings comprising more than single layers have the potential to address these challenges by combining their diverse chemical and physical properties. In this study, we developed a bilayer hydrogel comprising a GelMA-ALG-nano-ZnO protective film and a COL1-PRP regenerative hydrogel for facilitating diabetic wound healing. We demonstrated the protective properties against bacterial infection of the protective film, while highlighting the regenerative potential of the COL1-PRP hydrogel in promoting fibroblast and MUVEC migration, extracellular matrix secretion and deposition, and angiogenesis. Importantly, the bilayer hydrogel exhibited superior efficacy in promoting full-thickness wound healing in a diabetic rat model compared to its single-layer hydrogel counterparts. This multi-layer approach offers a promising strategy for addressing the complexities of diabetic foot treatment and improving clinical outcomes.

Physiological skin oxygen levels: An important criterion for skin cell functionality and therapeutic approaches

The skin is made up of different layers with various gradients, which maintain a complex microenvironment, particularly in terms of oxygen levels. However, all types of skin cells are cultured in conventional incubators that do not reproduce physiological oxygen levels. Instead, they are cultured at atmospheric oxygen levels, a condition that is far removed from physiology and may lead to the generation of free radicals known to induce skin ageing. This review aims to summarize the current literature on the effect of physiological oxygen levels on skin cells, highlight the shortcomings of current in vitro models, and demonstrate the importance of respecting skin oxygen levels. We begin by clarifying the terminology used about oxygen levels and describe the specific distribution of oxygen in the skin. We review and discuss how skin cells adapt their oxygen consumption and metabolism to oxygen levels environment, as well as the changes that are induced, particularly, their redox state, life cycle and functions. We examine the effects of oxygen on both simple culture models and more complex reconstructed skin models. Finally, we present the implications of oxygen modulation for a more therapeutic approach.

Vascular endothelial growth factor accelerates healing of foot ulcers in diabetic rats via promoting M2 macrophage polarization

AIM

The objective was to investigate the specific role and the regulatory mechanism of vascular endothelial growth factor (VEGF) during wound healing in diabetic foot ulcer (DFU).

METHODS

Streptozotocin-induced diabetic rats were used to establish a DFU animal model. VEGF and Axitinib (a specific inhibitor of VEGFR) were used for treatment in vivo. The wounds at different time points were imaged and histological analysis of the wounds were performed by haematoxylin and eosin (H&E) staining and Masson's trichrome staining. Immunohistochemical staining was conducted to examine CD31 and eNOS expression in the wounds. Immunofluorescence assay and quantitative real-time PCR were performed to examine macrophage markers. In addition, THP-1 was differentiated to macrophages, and then treated with interleukin (IL)-4 to induce M2 macrophages, followed by VEGF treatment. The conditional medium (CM) from VEGF-mediated macrophages were collected to culture human dermal fibroblasts (HDFs). Cell viability and migration were measured by Cell Counting Kit (CCK)-8, wound-healing and Transwell assays, respectively.

RESULTS

VEGF treatment remarkably accelerated wound healing of DFU rats. VEGF promoted collagen deposition and elevated CD31 and eNOS expression, confirming the pro-angiogenesis of VEGF around diabetic wound in rats. Meanwhile, VEGF restricted pro-inflammatory cytokines and increased F4/80 and CD206 expression, highlighting the activated macrophages and enhanced M2 macrophages following VEGF treatment in diabetic wounds of DFU rats. However, Axitinib exerted an opposite function to VEGF in DFU rats. Moreover, VEGF directly promoted macrophage polarization toward M2 phenotype in vitro, and the CM from VEGF-mediated M2 macrophages markedly promoted HDFs proliferation, migration and collagen deposition.

CONCLUSION

VEGF might accelerate the wound healing of DFU through promoting M2 macrophage polarization and fibroblast migration.

The Application of Regenerated Silk Fibroin in Tissue Repair

Silk fibroin (SF) extracted from silk is non-toxic and has excellent biocompatibility and biodegradability, making it an excellent biomedical material. SF-based soft materials, including porous scaffolds and hydrogels, play an important role in accurately delivering drugs to wounds, creating microenvironments for the adhesion and proliferation of support cells, and in tissue remodeling, repair, and wound healing. This article focuses on the study of SF protein-based soft materials, summarizing their preparation methods and basic applications, as well as their regenerative effects, such as drug delivery carriers in various aspects of tissue engineering such as bone, blood vessels, nerves, and skin in recent years, as well as their promoting effects on wound healing and repair processes. The authors expect SF soft materials to play an important role in the field of tissue repair.

Promoting the healing of infected diabetic wound by nanozyme-containing hydrogel with anti-bacterial inflammation suppressing, ROS-scavenging and oxygen-generating properties

Bacterial infections already pose a significant threat to skin wounds, especially in diabetic patients who have difficulty healing wounds. However, wound or bacterial infections are known to produce excess reactive oxygen species (ROS), and hypoxia may further hinder wound healing and the development of chronic wounds. In this study, a multifunctional hydrogel for ROS scavenging and bacterial inhibition was developed by cross-linking polyvinyl alcohol (PVA) and sodium alginate (SA) with graphene oxide (GO) loaded with silver-platinum hybrid nanoparticles (GO@Ag-Pt). The PVA/SA hydrogel loaded with GO@Ag-Pt exhibited the ability to scavenge different types of ROS, generate O2, and kill a broad spectrum of bacteria in vitro. The silver-platinum hybrid nanoparticles significantly increased the antibacterial ability against Escherichia coli and Staphylococcus aureus compared with silver nanoparticles (AgNps). GO@Ag-Pt loaded hydrogel was effective in treating infections caused by S.aureus, thereby significantly promoting wound healing during the inflammatory phase. Hydrogel therapy significantly reduced the level of ROS and alleviated inflammation levels. Notably, our ROS-scavenging, antibacterial hydrogels can be used to effectively treat various types of wounds, including difficult-to-heal diabetic wounds with bacterial infections. Thus, this study proposes an effective strategy for various chronic wound healing based on ROS clearance and bacteriostatic hydrogels.

USP7-stabilised HIPK2 promotes high glucose-induced endothelial cell dysfunctions to accelerate diabetic foot ulcers

Background: This study aimed to explore the molecular mechanism of homeodomain-interacting protein kinase 2 (HIPK2) in diabetic foot ulcers (DFU).

Methods: High glucose (HG)-induced human umbilical vein endothelial cells (HUVECs) were used to construct DFU cell models. Cell functions were determined using CCK8 assay, EdU assay, flow cytometry, transwell assay, wound healing assay and tube formation assay. Quantitative real-time PCR and western blot were applied to measure the gene expression.

Results: HG treatment suppressed HUVECs proliferation, invasion, migration, and angiogenesis, while enhanced apoptosis. HIPK2 was overexpressed in DFU patients, and its knockdown alleviated HG-induced HUVECs dysfunctions. USP7 stabilised HIPK2 protein by reducing its ubiquitination. USP7 overexpression promoted HG-induced HUVECs dysfunctions, and HIPK2 upregulation also reversed the regulation of USP7 knockdown on HG-induced HUVECs dysfunctions. USP7/HIPK2 axis inhibited the activity of PI3K/AKT pathway.

Conclusion: Our study revealed that USP7-stabilised HIPK2 contributed to HG-induced HUVECs dysfunctions, thus accelerating DFU process.

Integrating bioinformatics and multiple machine learning to identify mitophagy-related targets for the diagnosis and treatment of diabetic foot ulcers: evidence from transcriptome analysis and drug docking

Background

Diabetic foot ulcers are the most common and serious complication of diabetes mellitus, the high morbidity, mortality, and disability of which greatly diminish the quality of life of patients and impose a heavy socioeconomic burden. Thus, it is urgent to identify potential biomarkers and targeted drugs for diabetic foot ulcers.

Methods

In this study, we downloaded datasets related to diabetic foot ulcers from gene expression omnibus. Dysregulation of mitophagy-related genes was identified by differential analysis and weighted gene co-expression network analysis. Multiple machine algorithms were utilized to identify hub mitophagy-related genes, and a novel artificial neural network model for assisting in the diagnosis of diabetic foot ulcers was constructed based on their transcriptome expression patterns. Finally, potential drugs that can target hub mitophagy-related genes were identified using the Enrichr platform and molecular docking methods.

Results

In this study, we identified 702 differentially expressed genes related to diabetic foot ulcers, and enrichment analysis showed that these genes were associated with mitochondria and energy metabolism. Subsequently, we identified hexokinase-2, small ribosomal subunit protein us3, and l-lactate dehydrogenase A chain as hub mitophagy-related genes of diabetic foot ulcers using multiple machine learning algorithms and validated their diagnostic performance in a validation cohort independent of the present study (The areas under roc curve of hexokinase-2, small ribosomal subunit protein us3, and l-lactate dehydrogenase A chain are 0.671, 0.870, and 0.739, respectively). Next, we constructed a novel artificial neural network model for the molecular diagnosis of diabetic foot ulcers, and the diagnostic performance of the training cohort and validation cohort was good, with areas under roc curve of 0.924 and 0.840, respectively. Finally, we identified retinoic acid and estradiol as promising anti-diabetic foot ulcers by targeting hexokinase-2 (-6.6 and -7.2 kcal/mol), small ribosomal subunit protein us3 (-7.5 and -8.3 kcal/mol), and l-lactate dehydrogenase A chain (-7.6 and -8.5 kcal/mol).

Conclusion

The present study identified hexokinase-2, small ribosomal subunit protein us3 and l-lactate dehydrogenase A chain, and emphasized their critical roles in the diagnosis and treatment of diabetic foot ulcers through multiple dimensions, providing promising diagnostic biomarkers and targeted drugs for diabetic foot ulcers.

Gases and gas-releasing materials for the treatment of chronic diabetic wounds

Chronic non-healing wounds are a common consequence of skin ulceration in diabetic patients, with severe cases such as diabetic foot even leading to amputations. The interplay between pathological factors like hypoxia-ischemia, chronic inflammation, bacterial infection, impaired angiogenesis, and accumulation of advanced glycosylation end products (AGEs), resulting from the dysregulation of the immune microenvironment caused by hyperglycemia, establishes an unending cycle that hampers wound healing. However, there remains a dearth of sufficient and effective approaches to break this vicious cycle within the complex immune microenvironment. Consequently, numerous scholars have directed their research efforts towards addressing chronic diabetic wound repair. In recent years, gases including Oxygen (O2), Nitric oxide (NO), Hydrogen (H2), Hydrogen sulfide (H2S), Ozone (O3), Carbon monoxide (CO) and Nitrous oxide (N2O), along with gas-releasing materials associated with them have emerged as promising therapeutic solutions due to their ability to regulate angiogenesis, intracellular oxygenation levels, exhibit antibacterial and anti-inflammatory effects while effectively minimizing drug residue-induced damage and circumventing drug resistance issues. In this review, we discuss the latest advances in the mechanisms of action and treatment of these gases and related gas-releasing materials in diabetic wound repair. We hope that this review can provide different ideas for the future design and application of gas therapy for chronic diabetic wounds.

Extracellular Matrix-Mimetic Intrinsic Versatile Coating Derived from Marine Adhesive Protein Promotes Diabetic Wound Healing through Regulating the Microenvironment

The management of diabetic wound healing remains a severe clinical challenge due to the complicated wound microenvironments, including abnormal immune regulation, excessive reactive oxygen species (ROS), and repeated bacterial infections. Herein, we report an extracellular matrix (ECM)-mimetic coating derived from scallop byssal protein (Sbp9Δ), which can be assembled in situ within 30 min under the trigger of Ca2+ driven by strong coordination interaction. The biocompatible Sbp9Δ coating and genetically programmable LL37-fused coating exhibit outstanding antioxidant, antibacterial, and immune regulatory properties in vitro. Proof-of-concept applications demonstrate that the coating can reliably promote wound healing in animal models, including diabetic mice and rabbits, ex vivo human skins, and Staphylococcus aureus-infected diabetic mice. In-depth mechanism investigation indicates that improved wound microenvironments accelerated wound repair, including alleviated bacterial infection, lessened inflammation, appearance of abundant M2-type macrophages, removal of ROS, promoted angiogenesis, and re-epithelialization. Collectively, our investigation provides an in situ, convenient, and effective approach for diabetic wound repair.

Bioactive triterpenoid compounds of Poria cocos (Schw.) Wolf in the treatment of diabetic ulcers via regulating the PI3K-AKT signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Diabetic ulcers represent a chronic condition characterized by prolonged hyperglycemia and delayed wound healing, accompanied by endocrine disorders, inflammatory responses, and microvascular damage in the epidermal tissue, demanding effective clinical treatment approaches. For thousands of years, ancient Chinese ethnopharmacological studies have documented the use of Poria cocos (Schw.) Wolf in treating diabetic ulcers. Recent research has substantiated the diverse pharmacological effects of Poria cocos (Schw.) Wolf, including its potential to alleviate hyperglycemia and exhibit anti-inflammatory, antioxidant, and immune regulatory properties, which could effectively mitigate diabetic ulcer symptoms. Furthermore, being a natural medicine, Poria cocos (Schw.) Wolf has demonstrated promising therapeutic effects and safety in the management of diabetic ulcers, holding significant clinical value. Despite its potential clinical efficacy and applications in diabetic ulcer treatment, the primary active components and underlying pharmacological mechanisms of Poria cocos (Schw.) Wolf remains unclear. Further investigations are imperative to establish a solid foundation for drug development in this domain.

AIM OF THE STUDY AND MATERIALS AND METHODS

In this study, we aimed to identify the active compounds and potential targets of Poria cocos (Schw.) Wolf using UHPLC-Q-TOF-MS and TCMSP databases. Additionally, we attempt to identify targets related to diabetic ulcers. Following enrichment analysis, a network of protein-protein interactions was constructed to identify hub genes based on the common elements between the two datasets. To gain insights into the binding activities of the hub genes and active ingredients, molecular docking analysis was employed. Furthermore, to further validate the therapeutic effect of Poria cocos (Schw.) Wolf, we exerted in vitro experiments using human umbilical vein vascular endothelial cells and human myeloid leukemia monocytes (THP-1). The active ingredient of Poria cocos (Schw.) Wolf was applied in these experiments. Our investigations included various assays, such as CCK-8, scratch test, immunofluorescence, western blotting, RT-PCR, and flow cytometry, to explore the potential of Poria cocos (Schw.) Wolf triterpenoid extract (PTE) in treating diabetic ulcers.

RESULTS

The findings here highlighted PTE as the primary active ingredient in Poria cocos (Schw.) Wolf. Utilizing network pharmacology, we identified 74 potential targets associated with diabetic ulcer treatment for Poria cocos (Schw.) Wolf, with five hub genes (JUN, MAPK1, STAT3, AKT1, and CTNNB1). Enrichment analysis revealed the involvement of multiple pathways in the therapeutic process, with the PI3K-AKT signaling pathway showing significant enrichment. Through molecular docking, we discovered that relevant targets within this pathway exhibited strong binding with the active components of Poria cocos (Schw.) Wolf. In vitro experiments unveiled that PTE (10 mg/L) facilitated the migration of human umbilical vein vascular endothelial cells (P < 0.05). PTE also increased the expression of CD31 and VEGF mRNA (P < 0.05) while activating the expressions of p-PI3K and p-AKT (P < 0.05). Moreover, PTE demonstrated its potential by reducing the expression of IL-1β, IL-6, TNF-α, and NF-κB mRNA in THP-1 (P < 0.05) and fostering M2 macrophage polarization. These results signify the potential therapeutic effects of PTE in treating diabetic ulcers, with its beneficial actions mediated through the PI3K-AKT signaling pathway.

CONCLUSIONS

PTE is the main active ingredient in Poria cocos (Schw.) Wolf that exerts therapeutic effects. Through PI3K-AKT signaling pathway activation and inflammatory response reduction, PTE promotes angiogenesis, thereby healing diabetic ulcers.

Hyperbaric oxygen therapy: future prospects in regenerative therapy and anti-aging

Hyperbaric Oxygen Therapy (HBOT) utilizes 100% oxygen at high atmospheric pressure for clinical applications. HBOT has proven to be an effective supplementary treatment for a variety of clinical and pathological disorders. HBOT's therapeutic results are based on the physiological effects of increased tissue oxygenation, or improved oxygen bioavailability. HBOT's current indications in illnesses like as wound healing, thermal or radiation burns, and tissue necrosis point to its function in facilitating the regeneration process. Various research has revealed that HBOT plays a function in vascularization, angiogenesis, and collagen production augmentation. Individual regeneration capacity is influenced by both environmental and genetic factors. Furthermore, the regenerating ability of different types of tissues varies, and this ability declines with age. HBOT affects physiological processes at the genetic level by altering gene expression, delaying cell senescence, and assisting in telomere length enhancement. The positive results in a variety of indications, ranging from tissue regeneration to better cognitive function, indicate that it has enormous potential in regenerative and anti-aging therapy.

Epidermal Stem Cell Derived Exosomes Alleviate Excessive Autophagy Induced Endothelial Cell Apoptosis by Delivering miR200b-3p to Diabetic Wounds

The dysfunction of endothelial cells caused by hyperglycemia is observed as a decrease in neovascularization in diabetic wound healing. Studies have found that epidermal stem cells (EpiSCs) can promote the angiogenesis of full-thickness wounds. To further explain the therapeutic effect of EpiSCs, EpiSC-derived exosomes (EpiSC-EXOs) are considered the main substance contributing to stem cell effectivity. In our study, EpiSCs and EpiSC-EXOs were supplied to the dorsal wounds of db/db mice. Results showed that EpiSCs could colonize in the wound area and both EpiSCs and EpiSC-EXOs could accelerate diabetic wound healing by promoting angiogenesis. In vitro, persistent high glucose led to the malfunction and apoptosis of endothelial cells. The apoptosis induced by high glucose is due to excessive autophagy and was alleviated by EpiSC-EXOs. RNA sequencing of EpiSC-EXOs showed that miR200b-3p was enriched in EpiSC-EXOs and alleviated the apoptosis of endothelial cells. Synapse defective rho GTPase homolog 1 was identified the target of miR200b-3p and affected the phosphorylation of ERK to regulate intracellular autophagy and apoptosis. Furthermore, animal experiments validated the angiogenic effect of miR200b-3p. Collectively, our results verified the effect of EpiSC-EXOs on apoptosis caused by hyperglycemia in endothelial cells through the miR200b-3p/synapse defective rho GTPase homolog 1 /RAS/ERK/autophagy pathway, providing a theoretical basis for EpiSC in treating diabetic wounds.

Hyperbaric oxygen therapy promotes the browning of white fat and contributes to the healing of diabetic wounds

Non-healing wounds are one of the chronic complications of diabetes and have remained a worldwide challenge as one of the major health problems. Hyperbaric oxygen (HBO) therapy is proven to be very successful for diabetic wound treatment, for which the molecular basis is not understood. Adipocytes regulate multiple aspects of repair and may be therapeutic for inflammatory diseases and defective wound healing associated with aging and diabetes. Endothelial cell-derived extracellular vesicles could promote wound healing in diabetes. To study the mechanism by which HBO promotes wound healing in diabetes, we investigated the effect of HBO on fat cells in diabetic mice. A diabetic wound mouse model was established and treated with HBO. Haematoxylin and eosin (H&E) staining and immunofluorescence were used for the analysis of wound healing. To further explore the mechanism, we performed whole-genome sequencing on extracellular vesicles (EVs). Furthermore, we conducted in vitro experiments. Specifically, exosomes were collected from human umbilical vein endothelial cell (HUVEC) cells after HBO treatment, and then these exosomes were co-incubated with adipose tissue. The wound healing rate in diabetic mice treated with HBO was significantly higher. HBO therapy promotes the proliferation of adipose precursor cells. HUVEC-derived exosomes treated with HBO significantly promoted fat cell browning. These data clarify that HBO therapy may promote vascular endothelial cell proliferation and migration, and promote browning of fat cells through vascular endothelial cells derived exosomes, thereby promoting diabetic wound healing. This provides new ideas for the application of HBO therapy in the treatment of diabetic trauma.

The new insights of hyperbaric oxygen therapy: focus on inflammatory bowel disease

Inflammatory bowel diseases (IBD), with an increasing incidence, pose a significant health burden. Although there have been significant advances in the treatment of IBD, more progress is still needed. Hyperbaric oxygen therapy (HBOT) has been shown to treat a host of conditions such as carbon monoxide poisoning, decompression sickness, and gas gangrene. In the last few years, there has been an increase in research into the use of HBOT as an adjunct to conventional treatment for IBD. Related research has shown that HBOT may exert its therapeutic effects by decreasing oxidative stress, inhibiting mucosal inflammation, promoting ulcer healing, influencing gut microbes, and reducing the incidence of IBD complications. This paper aims to provide a comprehensive review of experimental and clinical trials exploring HBOT as a supplement to IBD treatment strategies.

Identification and clinical validation of the role of anoikis-related genes in diabetic foot

This study aims to investigate the role of anoikis-related genes in diabetic foot (DF) by utilizing bioinformatics analysis to identify key genes associated with anoikis in DF. We selected the GEO datasets GSE7014, GSE80178 and GSE68183 for the extraction and analysis of differentially expressed anoikis-related genes (DE-ARGs). GO analysis and KEGG analysis indicated that DE-ARGs in DF were primarily enriched in apoptosis, positive regulation of MAPK cascade, anoikis, focal adhesion and the PI3K-Akt signalling pathway. Based on the LASSO and SVM-RFE algorithms, we identified six characteristic genes. ROC curve analysis revealed that these six characteristic genes had an area under the curve (AUC) greater than 0.7, indicating good diagnostic efficacy. Expression analysis in the validation set revealed downregulation of CALR in DF, consistent with the training set results. GSEA results demonstrated that CALR was mainly enriched in blood vessel morphogenesis, endothelial cell migration, ECM-receptor interaction and focal adhesion. The HPA database revealed that CALR was moderately enriched in endothelial cells, and CALR was found to interact with 63 protein-coding genes. Functional analysis with DAVID suggested that CALR and associated genes were enriched in the phagosome component. CALR shows promise as a potential marker for the development and treatment of DF.

Efficacy and safety of hyperbaric oxygen therapy in the management of diabetic foot ulcers: A systematic review and meta-analysis

Diabetic foot ulcers (DFUs) represent a major health concern for diabetic patients, often leading to debilitating complications. Hyperbaric oxygen therapy (HBOT) has been posited as an adjunctive therapeutic strategy to augment the healing rates of these ulcers. This systematic review and meta-analysis sought to critically evaluate the efficacy and safety of HBOT in the context of DFUs management. A rigorous search, adhering to PRISMA guidelines, was conducted across multiple electronic databases. Randomized controlled trials (RCTs) assessing the impact of HBOT on DFUs were included. Outcome measures were complete ulcer healing, major and minor amputation rates and adverse reactions. The analysis employed both fixed and random-effects models, contingent on the heterogeneity levels detected. Seven studies met the inclusion criteria. HBOT was found to significantly improve the complete healing rates of DFUs with a risk ratio (RR) of 3.59 (95% CI: 1.56-8.29, p < 0.001). However, HBOT's impact on both major and minor amputation rates did not yield statistically significant results. The sensitivity analysis underscored the robustness of the principal outcomes, and the publication bias assessment suggested the absence of any significant bias. Hyperbaric oxygen therapy stands out as a potent therapeutic tool in promoting the complete healing of diabetic foot ulcers, offering a promising adjunct to standard care protocols, while ensuring patient safety.

Role of Oxygen and Its Radicals in Peripheral Nerve Regeneration: From Hypoxia to Physoxia to Hyperoxia

Oxygen is compulsory for mitochondrial function and energy supply, but it has numerous more nuanced roles. The different roles of oxygen in peripheral nerve regeneration range from energy supply, inflammation, phagocytosis, and oxidative cell destruction in the context of reperfusion injury to crucial redox signaling cascades that are necessary for effective axonal outgrowth. A fine balance between reactive oxygen species production and antioxidant activity draws the line between physiological and pathological nerve regeneration. There is compelling evidence that redox signaling mediated by the Nox family of nicotinamide adenine dinucleotide phosphate (NADPH) oxidases plays an important role in peripheral nerve regeneration. Further research is needed to better characterize the role of Nox in physiological and pathological circumstances, but the available data suggest that the modulation of Nox activity fosters great therapeutic potential. One of the promising approaches to enhance nerve regeneration by modulating the redox environment is hyperbaric oxygen therapy. In this review, we highlight the influence of various oxygenation states, i.e., hypoxia, physoxia, and hyperoxia, on peripheral nerve repair and regeneration. We summarize the currently available data and knowledge on the effectiveness of using hyperbaric oxygen therapy to treat nerve injuries and discuss future directions.

HMOX1-overexpressing mesenchymal stem cell-derived exosomes facilitate diabetic wound healing by promoting angiogenesis and fibroblast function

Many scholars have suggested that exosomes (Exos) can carry active molecules to induce angiogenesis and thus accelerate diabetic wound healing. Heme oxygenase-1 (HO-1) encoded by the gene HMOX1 promotes wound healing in DM by enhancing angiogenesis. Nevertheless, whether HMOX1 regulates wound healing in DM through mesenchymal stem cell-derived exosomes (MSC-Exos) remains to be further explored. The primary isolated- and cultured-cells expressed MSC-specific marker proteins, and had low immunogenicity and multi-differentiation potential, which means that MSCs were successfully isolated in this study. Notably, HO-1 protein expression was significantly higher in Exo-HMOX1 than in Exos, indicating that HMOX1 could be delivered to Exos as an MSCs-secreted protein. After verifying the -Exo structure, fibroblasts, keratinocytes, and human umbilical vein endothelial cells (HUVECs) were incubated with Exo-HMOX1 or Exo, and the findings displayed that Exo-HMOX1 introduction promoted the proliferation and migration of fibroblasts, keratinocytes and the angiogenic ability of HUVECs in vitro study. After establishing diabetic wound model mice, PBS, Exo, and Exo-HMOX1 were subcutaneously injected into multiple sites on the 1st, 3rd, 7th, and 14th day, DM injected with Exo-HMOX1 showed faster wound healing, re-epithelialization, collagen deposition, and angiogenesis than those in PBS and Exo groups in vitro study. In summary, Exo-HMOX1 could enhance the activity of fibroblasts, keratinocytes, and HUVEC, and accelerate wound healing by promoting angiogenesis in DM.

Hyperbaric oxygen augments susceptibility to C. difficile infection by impairing gut microbiota ability to stimulate the HIF-1α-IL-22 axis in ILC3

Hyperbaric oxygen (HBO) therapy is a well-established method for improving tissue oxygenation and is typically used for the treatment of various inflammatory conditions, including infectious diseases. However, its effect on the intestinal mucosa, a microenvironment known to be physiologically hypoxic, remains unclear. Here, we demonstrated that daily treatment with hyperbaric oxygen affects gut microbiome composition, worsening antibiotic-induced dysbiosis. Accordingly, HBO-treated mice were more susceptible to Clostridioides difficile infection (CDI), an enteric pathogen highly associated with antibiotic-induced colitis. These observations were closely linked with a decline in the level of microbiota-derived short-chain fatty acids (SCFAs). Butyrate, a SCFA produced primarily by anaerobic microbial species, mitigated HBO-induced susceptibility to CDI and increased epithelial barrier integrity by improving group 3 innate lymphoid cell (ILC3) responses. Mice displaying tissue-specific deletion of HIF-1 in RORγt-positive cells exhibited no protective effect of butyrate during CDI. In contrast, the reinforcement of HIF-1 signaling in RORγt-positive cells through the conditional deletion of VHL mitigated disease outcome, even after HBO therapy. Taken together, we conclude that HBO induces intestinal dysbiosis and impairs the production of SCFAs affecting the HIF-1α-IL-22 axis in ILC3 and worsening the response of mice to subsequent C. difficile infection.

Oxygen-Generating Hydrogels as Oxygenation Therapy for Accelerated Chronic Wound Healing

Hypoxia in chronic wounds impairs the activities of reparative cells, resulting in tissue necrosis, bacterial infections, decreased angiogenesis, and delayed wound healing. To achieve effective oxygenation therapy and restore oxygen homeostasis, oxygen-generating hydrogels based on different oxygen sources have been developed to release dissolved oxygen in the wound bed, which not only alleviate hypoxia, but also accelerate chronic wound healing. This review first discusses the vital role of oxygen and hypoxia in the wound healing process. The advancements in oxygen-generating hydrogels, which produce oxygen through the decomposition of hydrogen peroxide, metal peroxides, glucose-activated cascade reactions, and photosynthesis of algae microorganisms for chronic wound healing, are discussed and summarized. The therapeutic effects and challenges of using oxygen-generating hydrogels for the clinical treatment of chronic wounds are concluded and prospected.

A temperature and pH dual-responsive injectable self-healing hydrogel prepared by chitosan oligosaccharide and aldehyde hyaluronic acid for promoting diabetic foot ulcer healing

Chronic wound, such as skin defect after burn, pressure ulcer, and diabetic foot ulcer is very difficult to cure. Its pathological process is often accompanied with local temperature rise, pH decrease, and other phenomena. Owing to their outstanding hydrophilic, biocompatibility, and responsive properties, hydrogels could accelerate the healing process. In this study, we chose chitosan oligosaccharide (COS) grafted with Pluronic F127 (F127-COS). Aldehyde hyaluronic acid (A-HA) oxidized by NaIO4. And added boric acid (BA) to prepare a thermosensitive and pH-responsive injectable self-healing F127-COS/A-HA/COS/BA (FCAB) hydrogel, loaded with drug deferoxamine (DFO) in order to have an accurate release and promote angiogenesis of diabetic foot ulcer. In vitro experiments had verified that the FCAB hydrogel system loaded with DFO (FCAB/D) could promote migration and angiogenesis of HUVEC. A diabetes rat back wound model further confirmed its role in promoting angiogenesis in wound repair process. The results showed that the FCAB/D hydrogel exhibited unique physicochemical properties, excellent biocompatibility, and significantly enhanced therapeutic effects for diabetic foot ulcer.

Single-cell profiling reveals transcriptomic signatures of vascular endothelial cells in non-healing diabetic foot ulcers

Background

The treatment of diabetic foot ulcers (DFUs) poses a challenging medical problem that has long plagued individuals with diabetes. Clinically, wounds that fail to heal for more than 12 weeks after the formation of DFUs are referred to as non-healing/chronic wounds. Among various factors contributing to the non-healing of DFUs, the impairment of skin microvascular endothelial cell function caused by high glucose plays a crucial role. Our study aimed to reveal the transcriptomic signatures of non-healing DFUs endothelial cells, providing novel intervention targets for treatment strategies.

Methods

Based on the GEO dataset (GSE165816), we selected DFU-Healer, DFU-Non-healer, and healthy non-diabetic controls as research subjects. Single-cell RNA transcriptomic sequencing technology was employed to analyze the heterogeneity of endothelial cells in different skin tissue samples and identify healing-related endothelial cell subpopulations. Immunofluorescence was applied to validate the sequencing results on clinical specimens.

Results

The number of endothelial cells and vascular density showed no significant differences among the three groups of skin specimens. However, endothelial cells from non-healing DFUs exhibited apparent inhibition of angiogenesis, inflammation, and immune-related signaling pathways. The expression of CCND1, ENO1, HIF1α, and SERPINE1 was significantly downregulated at the transcriptomic and histological levels. Further analysis demonstrated that healing-related endothelial cell subpopulations in non-healing DFUs has limited connection with other cell types and weaker differentiation ability.

Conclusion

At the single-cell level, we uncovered the molecular and functional specificity of endothelial cells in non-healing DFUs and highlighted the importance of endothelial cell immune-mediated capability in angiogenesis and wound healing. This provides new insights for the treatment of DFUs.

Preparation and Properties of Antibacterial Silk Fibroin Scaffolds

The development of a wound dressing with both antibacterial and healing-guiding functions is a major concern in the treatment of open and infected wounds. In this study, poly(hexamethylene biguanide) hydrochloride (PHMB) was loaded into a 3D silk fibroin (SF) scaffold based on electrostatic interactions between PHMB and SF, and PHMB/SF hybrid scaffolds were prepared via freeze-drying. The effects of the PHMB/SF ratio on the antibacterial activity and cytocompatibility of the hybrid scaffold were investigated. The results of an agar disc diffusion test and a bacteriostasis rate examination showed that when the mass ratio of PHMB/SF was greater than 1/100, the scaffold exhibited obvious antibacterial activity against E. coli and S. aureus. L-929 cells were encapsulated in the PHMB/SF scaffolds and cultured in vitro. SEM, laser scanning confocal microscopy, and CCK-8 assay results demonstrated that hybrid scaffolds with a PHMB/SF ratio of less than 2/100 significantly promoted cell adhesion, spreading, and proliferation. In conclusion, a hybrid scaffold with a PHMB/SF ratio of approximately 2/100 not only effectively inhibited bacterial reproduction but also showed good cytocompatibility and is expected to be usable as a functional antibacterial dressing for wound repair.

Rational Design of Multifunctional Hydrogels for Wound Repair

The intricate microenvironment at the wound site, coupled with the multi-phase nature of the healing process, pose significant challenges to the development of wound repair treatments. In recent years, applying the distinctive benefits of hydrogels to the development of wound repair strategies has yielded some promising results. Multifunctional hydrogels, by meeting the different requirements of wound healing stages, have greatly improved the healing effectiveness of chronic wounds, offering immense potential in wound repair applications. This review summarized the recent research and applications of multifunctional hydrogels in wound repair. The focus was placed on the research progress of diverse multifunctional hydrogels, and their mechanisms of action at different stages of wound repair were discussed in detail. Through a comprehensive analysis, we found that multifunctional hydrogels play an indispensable role in the process of wound repair by providing a moist environment, controlling inflammation, promoting angiogenesis, and effectively preventing infection. However, further implementation of multifunctional hydrogel-based therapeutic strategies also faces various challenges, such as the contradiction between the complexity of multifunctionality and the simplicity required for clinical translation and application. In the future, we should work to address these challenges, further optimize the design and preparation of multifunctional hydrogels, enhance their effectiveness in wound repair, and promote their widespread application in clinical practice.

Subvacuum environment-enhanced cell migration promotes wound healing without increasing hypertrophic scars caused by excessive cell proliferation

Cell migration and proliferation are conducive to wound healing; however, regulating cell proliferation remains challenging, and excessive proliferation is an important cause of scar hyperplasia. Here, we aimed to explore how a subvacuum environment promotes wound epithelisation without affecting scar hyperplasia. Human immortalized keratinocyte cells and human skin fibroblasts were cultured under subvacuum conditions (1/10 atmospheric pressure), and changes in cell proliferation and migration, target protein content, calcium influx, and cytoskeleton and membrane fluidity were observed. Mechanical calcium (Ca2+ ) channel blockers were used to prevent Ca2+ influx for reverse validation. A rat wound model was used to elucidate the mechanism of the subvacuum dressing in promoting healing. The subvacuum environment was observed to promote cell migration without affecting cell proliferation; intracellular Ca2+ concentrations and PI3K, p-PI3K, AKT1, p-AKT 1 levels increased significantly. The cytoskeleton was depolymerized, pseudopodia were reduced or absent, and membrane fluidity increased. The use of Ca2+ channel blockers weakened or eliminated these changes. Animal experiments confirmed these phenomena and demonstrated that subvacuum dressings can effectively promote wound epithelisation. Our study demonstrates that the use of subvacuum dressings can enhance cell migration without affecting cell proliferation, promote wound healing, and decrease the probability of scar hyperplasia.