Changes in permeability of the plasma membrane of myoblasts to fluorescent dyes with different molecular masses under sustained uniaxial stretching

The complex interplay between mechanical forces, tissue response and individual susceptibility to pressure ulcers

OBJECTIVE

The most recent edition of the International Clinical Practice Guideline for the Prevention and Treatment of Pressure Ulcers/Injuries was released in 2019. Shortly after, in 2020, the first edition of the SECURE Prevention expert panel report, focusing on device-related pressure ulcers/injuries, was published as a special issue in the Journal of Wound Care. A second edition followed in 2022. This article presents a comprehensive summary of the current understanding of the causes of pressure ulcers/injuries (PU/Is) as detailed in these globally recognised consensus documents.

METHOD

The literature reviewed in this summary specifically addresses the impact of prolonged soft tissue deformations on the viability of cells and tissues in the context of PU/Is related to bodyweight or medical devices.

RESULTS

Prolonged soft tissue deformations initially result in cell death and tissue damage on a microscopic scale, potentially leading to development of clinical PU/Is over time. That is, localised high tissue deformations or mechanical stress concentrations can cause microscopic damage within minutes, but it may take several hours of continued mechanical loading for this initial cell and tissue damage to become visible and clinically noticeable. Superficial tissue damage primarily stems from excessive shear loading on fragile or vulnerable skin. In contrast, deeper PU/Is, known as deep tissue injuries, typically arise from stress concentrations in soft tissues at body regions over sharp or curved bony prominences, or under stiff medical devices in prolonged contact with the skin.

CONCLUSION

This review promotes deeper understanding of the pathophysiology of PU/Is, indicating that their primary prevention should focus on alleviating the exposure of cells and tissues to stress concentrations. This goal can be achieved either by reducing the intensity of stress concentrations in soft tissues, or by decreasing the exposure time of soft tissues to such stress concentrations.

Using pressure mapping intraoperatively to prevent pressure ulcers-A quasi-experimental study

Background and Aim

Patients undergoing surgery are at high risk of developing pressure ulcers. However, pressure ulcer prevention in the operating room department is demanding and restricted. New techniques, such as continuous pressure mapping that visualizes interface pressure, are now available. The aim of the study was to determine whether pressure mapping information of interface pressure intraoperatively leads to (1) more frequent intraoperative micro repositioning and a reduced amount of pressure on the sacrum area and (2) a lower frequency of pressure ulcer development.

Methods

A quasi-experimental ABA design was used. A total of 116 patients undergoing surgery were included. During the B phase, the need to consider repositioning the patient according to interface pressure readings was initiated.

Results

The result showed that there was significantly higher interface pressure in the A2 phase than in the B phase. Micro repositioning of the patient during surgery was performed in the B phase, but not in the A phase. The regression model showed that a higher BMI was associated with higher interface pressure. None of the patients developed hospital-acquired pressure ulcers up to Day 1 postoperatively.

Conclusion

Pressure mapping involves moving away from expert opinion and tradition towards objective assessment and flexibility and we see the benefits of using pressure-mapping equipment in operating room contexts. However, more research is needed in this area.

Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries

In 2019, the third and updated edition of the Clinical Practice Guideline (CPG) on Prevention and Treatment of Pressure Ulcers/Injuries has been published. In addition to this most up‐to‐date evidence‐based guidance for clinicians, related topics such as pressure ulcers (PUs)/pressure injuries (PIs) aetiology, classification, and future research needs were considered by the teams of experts. To elaborate on these topics, this is the third paper of a series of the CPG articles, which summarises the latest understanding of the aetiology of PUs/PIs with a special focus on the effects of soft tissue deformation. Sustained deformations of soft tissues cause initial cell death and tissue damage that ultimately may result in the formation of PUs/PIs. High tissue deformations result in cell damage on a microscopic level within just a few minutes, although it may take hours of sustained loading for the damage to become clinically visible. Superficial skin damage seems to be primarily caused by excessive shear strain/stress exposures, deeper PUs/PIs predominantly result from high pressures in combination with shear at the surface over bony prominences, or under stiff medical devices. Therefore, primary PU/PI prevention should aim for minimising deformations by either reducing the peak strain/stress values in tissues or decreasing the exposure time.

The mechanobiology theory of the development of medical device-related pressure ulcers revealed through a cell-scale computational modeling framework

Pressure ulcers are localized sites of tissue damage which form due to the continuous exposure of skin and underlying soft tissues to sustained mechanical loading, by bodyweight forces or because a body site is in prolonged contact with an interfacing object. The latter is the common cause for the specific sub-class of pressure ulcers termed ‘medical device-related pressure ulcers’, where the injury is known to have been caused by a medical device applied for a diagnostic or therapeutic purpose. Etiological research has established three key contributors to pressure ulcer formation, namely direct cell and tissue deformation, inflammatory edema and ischemic damage which are typically activated sequentially to fuel the injury spiral. Here, we visualize and analyze the above etiological mechanism using a new cell-scale modeling framework. Specifically, we consider here the deformation-inflicted and inflammatory contributors to the damage progression in a medical device-related pressure ulcer scenario, forming under a continuous positive airway pressure ventilation mask at the microarchitecture of the nasal bridge. We demonstrate the detrimental effects of exposure to high-level continuous external strains, which causes deformation-inflicted cell damage almost immediately. This in turn induces localized edema, which exacerbates the cell-scale mechanical loading state and thereby progresses cell damage further in a nonlinear, escalating pattern. The cell-scale quantitative description of the damage cascade provided here is important not only from a basic science perspective, but also for creating awareness among clinicians as well as industry and regulators with regards to the need for improving the design of skin-contacting medical devices.

Ultrasound elastography reveals the relation between body posture and soft-tissue stiffness which is relevant to the etiology of sitting-acquired pressure ulcers

OBJECTIVE

Sitting-acquired pressure ulcers (PUs) are common in wheelchair users. These PUs are often serious and may involve deep tissue injury (DTI). Investigating the mechanical properties of the tissues susceptible to DTI may help in guiding the prevention and early detection of PUs. In this study, shear wave elastography (SWE) was used to measure the normative mechanical properties of the soft tissues of the buttocks, i.e. skeletal muscle and subcutaneous fat, under the ischial tuberosities, in a convenient sample of healthy adults without weight bearing and with weight bearing of different times.

APPROACH

We compared the stiffness properties of these soft tissues between the lying prone and sitting postures, to determine whether there are detectable property changes that may be associated with the type of posture. We hypothesized that muscle contractions and 3D tissue configurations associated with the posture may influence the measured tissue stiffnesses.

MAIN RESULTS

Our results have shown that indeed, SWE values differed significantly across postures, but not over time in a specific posture or for the right versus left sides of the body.

SIGNIFICANCE

We have therefore demonstrated that soft-tissue stiffness increases when sitting with weight bearing and may contribute to increasing the potential PU risk in sitting compared to lying prone, given the stiffer behavior of tissues observed in sitting postures.

A novel system for dynamic stretching of cell cultures reveals the mechanobiology for delivering better negative pressure wound therapy

Serious wounds, both chronic and acute (e.g., surgical), are among the most common, expensive and difficult-to-treat health problems. Negative pressure wound therapy (NPWT) is considered a mainstream procedure for treating both wound types. Soft tissue deformation stimuli are the crux of NPWT, enhancing cell proliferation and migration from peri-wound tissues which contributes to healing. We developed a dynamic stretching device (DSD) contained in a miniature incubator for applying controlled deformations to fibroblast wound assays. Prior to the stretching experiments, fibroblasts were seeded in 6-well culture plates with elastic substrata and let to reach confluency. Squashing damage was then induced at the culture centers, and the DSD was activated to deliver stretching regimes that represented common clinical NPWT protocols at two peak strain levels, 0.5% and 3%. Analyses of the normalized maximal migration rate (MMR) data for the collective cell movement revealed that for the 3% strain level, the normalized MMR of cultures subjected to a 0.1 Hz stretch frequency regime was ~ 1.4 times and statistically significantly greater (p < 0.05) than that of the cultures subjected to no-stretch (control) or to static stretch (2nd control). Correspondingly, analysis of the time to gap closure data indicated that the closure time of the wound assays subjected to the 0.1 Hz regime was ~ 30% shorter than that of the cultures subjected to the control regimes (p < 0.05). Other simulated NPWT protocols did not emerge as superior to the controls. The present method and system are a powerful platform for further revealing the mechanobiology of NPWT and for improving this technology.

In vitro evaluation and in vivo use of a novel surgical stent to minimize suture pressure necrosis

OBJECTIVE

To evaluate the efficacy of stents to distribute pressure when incorporated into tension-relieving sutures.

STUDY DESIGN

An in vitro study and case report.

ANIMAL

One common bottlenose dolphin (Tursiops truncates).

METHODS

Three novel silicone stents, a traditional stent, and a control were tested in vitro by using a suture simulator. Stent surface area was measured by using a pressure mapping sensor. Pressure was derived from the measured surface area and the downward force of the suture simulator. Novel silicone stents were also used in the closure of an incision in a bottlenose dolphin.

RESULTS

No difference was found in surface area or pressure among the three silicone stents (adjusted P > .05). Silicone stents yielded an average, 2.69 cm² more surface area and 842.37 kPa less pressure compared with the control as well as 1.67 cm² more surface area and 110.67 kPa less pressure compared with the traditional stent. The traditional stent yielded 1.02 cm² more surface area and 731.7 kPa less pressure compared with the control. Incision site and silicone stent assessment performed postoperatively revealed no obvious pressure necrosis.

CONCLUSION

Stents improved distribution of suture pressure, and novel silicone stents were more effective compared with traditional stents. Novel silicone stents appear to have preliminary clinical success in vivo.

CLINICAL SIGNIFICANCE

Our study provides evidence that stents effectively help distribute suture pressure, and their incorporation might minimize the risk of suture pressure necrosis. Novel silicone stents should be integrated into tension-relieving suture patterns when closing wounds and incisions, particularly in aquatic animals.

Sodium pyruvate pre-treatment prevents cell death due to localised, damaging mechanical strains in the context of pressure ulcers

We demonstrate sodium pyruvate (NaPy) pre-treatment as a successful approach for pressure ulcer (PU) prevention by averting their aetiological origin-cell-level damage and death by large, sustained mechanical loads. We evaluated the NaPy pre-treatment effect on permeability changes in the cell's plasma membrane (PM) following application of in vitro damaging-level strains. Fibroblasts or myoblasts, respectively, models for superficial or deep-tissue damage were grown in 0 or 1 mM NaPy, emulating typical physiological or cell culture conditions. Cells were pre-treated for 4 hours with 0 to 5 mM NaPy prior to 3-hour sustained, damaging-level loads (12% strain). PM permeability was quantified by the cell uptake of small (4 kDa), fluorescent dextran compared with unstrained control using fluorescence-activated cell sorting (FACS). Pre-treatment with 1 mM, and especially 5 mM, NaPy significantly reduces damage to PM integrity. Long-term NaPy pre-exposure can improve protective treatment, affecting fibroblasts and myoblasts differently. Pre-treating with NaPy, a natural cell metabolite, allows cells under damaging-level mechanical loads to maintain their PM integrity, that is, to avoid loss of homeostasis and inevitable, eventual cell death, by preventing initial, microscale stages of PU formation. This pre-treatment may be applied prior to planned periods of immobility, for example, planned surgery or transport, to prolong safe time in a position by preventing initial cell damage that can cascade and lead to PU formation.

Why is the heel particularly vulnerable to pressure ulcers?

In this article, the vulnerability of the soft tissues of the heel to pressure ulcers (injuries) is explained from a biomechanical engineering perspective, and emerging technologies for protecting the heel, particularly low-friction garments, are reviewed. Sustained deformations in the soft tissue of the weight-bearing posterior heel cause progressive cell and tissue damage due to loss of homeostasis in the cells, as the cytoskeleton and plasma membranes of the affected cells lose integrity and functionality. This deformation damage onsets and evolves rapidly when there is no relief of the tissue distortion (e.g. in supine motionless lying). Hence, prevention should be timely and be applied across all patient populations that are at risk. In particular there is a need to protect tissues from the action of frictional forces that are shearing not only the skin but also the deep tissue structures of the heel. The internal anatomy and physiology of the posterior heel, the common hospital conditions (lying supine, head of the bed elevated) and medical conditions involving neuropathy and perfusion impairments may impose specific risk for heel (pressure) ulcers. There is growing evidence that low-friction-fabric garments may provide added benefits in preventing heel ulcers when used in addition to standard clinical and technology-supported pressure ulcer prevention strategies, as the low-friction fabric structures absorb frictional forces before these are able to considerably distort the susceptible heel tissues.

Preventing pressure injuries in the emergency department: Current evidence and practice considerations

The emergency department (ED) is at the front line of hospital pressure injury (PI) prevention, yet ED clinicians must balance many competing clinical priorities in the care of seriously ill patients. This paper presents the current biomechanical and clinical evidence and management considerations to assist EDs to continue to develop and implement evidence-based PI prevention protocols for the high-risk emergency/trauma patient. The prevention of hospital-acquired pressure injuries has received significant focus internationally over many years because of the additional burden that these injuries place on the patient, the additional costs and impact to the efficiency of the hospital, and the potential for litigation. The development of a PI is the result of a complex number of biomechanical, physiological, and environmental interactions. Our understanding of the interaction of these factors has improved significantly over the past 10 years. We have demonstrated that large reductions in PI incidence rates can be achieved in critical care and general hospital wards through the application of advanced evidence-based prevention protocols and believe that further improvement can be achieved through the application of these approaches in the ED.

Non-damaging stretching combined with sodium pyruvate supplement accelerate migration of fibroblasts and myoblasts during gap closure

BACKGROUND

Sustained, low- and mid-level (3-6%), radial stretching combined with varying concentrations of sodium pyruvate (NaPy) supplement increase the migration rate during microscale gap closure following an in vitro injury; NaPy is a physiological supplement often used in cell-culture media. Recently we showed that low-level tensile strains accelerate in vitro kinematics during en masse cell migration; topically applied mechanical deformations also accelerate in vivo healing in larger wounds. The constituents and nutrients at injury sites change. Thus, we combine a supplement with stretching conditions to effectively accelerate wound healing.

METHODS

Monolayers of murine fibroblasts (NIH3T3) or myoblasts (C2C12) were cultured in 1 mM NaPy on stretchable, linear-elastic substrates. Monolayers were subjected to 0, 3, or 6% stretching using a custom three-dimensionally printed stretching apparatus, micro-damage was immediately induced, media was replaced with fresh media containing 0, 1, or 5 mM NaPy, and cell migration kinematics during gap-closure were quantitatively evaluated.

FINDINGS

In myoblasts, the smallest evaluated strain (3%, minimal risk of damage) combined with preinjury (1 mM) and post-injury exogenous NaPy supplements accelerated gap closure in a statistically significant manner; response was NaPy concentration dependent. In both fibroblasts and myoblasts, when cells were pre-exposed to NaPy, yet no supplement was provided post-injury, mid-level stretches (6%) compensated for post-injury deficiency in exogenous NaPy and accelerated gap-closure in a statistically significant manner.

INTERPRETATION

Small deformations combined with NaPy supplement prior-to and following cell-damage accelerate en masse cell migration and can be applied in wound healing, e.g. to preventatively accelerate closure of microscale gaps.

Promoting intracellular delivery of sub-25 nm nanoparticles via defined levels of compression

Many investigations into the interactions between nanoparticles and mammalian cells entail the use of culture systems that do not account for the effect of extracellular mechanical cues, such as compression. In this work, we present an experimental set-up to systematically investigate the combined effects of nanoparticle size and compressive stress on the cellular uptake and intracellular localization of poly(ethylene glycol)-coated gold nanoparticles (Au-PEG NPs). Specifically, we employ an automated micromechanical system to apply defined levels of compressive strain to an agarose gel, which transmits defined amounts of unconfined, uniaxial compressive stress to a monolayer of C2C12 mouse myoblasts seeded underneath the gel without compromising cell viability. Notably, uptake of Au-PEG NPs smaller than 25 nm by compressed myoblasts is up to 5-fold higher than that by uncompressed cells. The optimal compressive stress for maximizing the cellular uptake of sub-25 nm NPs monotonically increases with NP size. With and without compression, the Au-PEG NPs enter C2C12 cells via energy-dependent uptake; they also enter compressed cells via clathrin-mediated endocytosis as the major pathway. Upon cellular entry, the Au-PEG NPs more readily reside in the late endosomes or lysosomes of compressed cells than uncompressed cells. Results from our experimental set-up yield mechanistic insights into the delivery of NPs to cell types under extracellular compression.

A randomised controlled trial of the clinical effectiveness of multi-layer silicone foam dressings for the prevention of pressure injuries in high-risk aged care residents: The Border III Trial

Pressure injuries are prevalent in highly dependent aged care residents. This study investigated the clinical effectiveness of the application of the Mepilex Border Sacrum and Mepilex Heel dressings to prevent the development of facility-acquired pressure injuries. A total of 288 recently admitted residents were enrolled from 40 Australian nursing homes into a randomised controlled trial. Residents randomised to standard care (n = 150) received pressure injury prevention as recommended by international guidelines. Residents randomised to the intervention (n = 138) received standard pressure injury prevention care and had dressings applied to their sacrum and heels. Participants were comparable on demographic and physiological parameters. More residents in the control group developed pressure injuries than in the intervention group (16 vs 3, P = 0.004), and they developed more pressure injuries in total than residents in the intervention group. The results represent a relative risk reduction of 80% for residents treated with the dressings and for every 12 patients that we treated we prevented one pressure injury. Based on our findings, we conclude that the use of the Mölnlycke Mepilex Border Sacrum and Mepilex Heel dressings confers a significant additional protective benefit to nursing home residents with a high risk of developing a facility-acquired pressure injury.

Blood flow responses over sacrum in nursing home residents during one hour bed rest

Objectives

To describe individual BF responses in a nursing home resident population for one‐hour periods of bed rest.

Methods

BF was measured for one hour over the sacrum in 0° supine position and 30° supine tilt position in 25 individuals aged 65 y or older while lying on a pressure‐redistributing mattress. Measurements were made at three tissue depths (1, 2, and 10 mm) using the noninvasive optical techniques, LDF and PPG.

Results

Eleven participants had a PIV response at 1 mm depth in both positions and seven participants had a lack of this response at this depth and positions. The BF response at 1 mm depth appeared immediately and remained over, or below, baseline for the entire 60 min of loading in both positions. These BF patterns were also seen in deeper tissue layers.

Conclusions

The cutaneous BF response among the nursing home residents was distinct, appeared early, and remained during the one hour of loading.

Activation of Na+/H+ exchanger other than formation of transmembrane pore underlies the cytotoxicity of nematocyst venom from Chrysaora helvola Brandt jellyfish

We previously reported unexpected apoptosis-like cell death induced by nematocyst venom (NV) from Chrysaora helvola Brandt (C. helvola) jellyfish. To assess whether the pore formation mechanism underlay the action of NV, the change in cell membrane permeability was studied in both chicken erythrocytes and human CNE-2 cells. Initially, paradoxical results were derived from osmoprotectant protection assays. Polyethylene glycol (PEG)₂₀₀₀, which completely inhibited the NV induced hemolysis, failed to protect CNE-2 cells. Detailed experiments showed that PEG protection from hemolysis is concentration dependent and indicated caution when estimating the pore size formed by NV with the osmotic protection method. NV-treated CNE-2 cells remained impermeable to dyes with various molecular weights (MWs) (622.6-40,000 Da). Furthermore, membrane depolarization and selective permeability to Na⁺ other than K⁺ were induced in CNE-2 cells. No oxidative damage to the cell membrane was detected. Amiloride, an inhibitor of Na⁺/H⁺ exchanger (NHE), substantially protected both CNE-2 cells and erythrocytes from NV. Combined with the previously reported increase in intracellular pH, we supposed that NV activated plasma membrane NHE without forming transmembrane pores. Interestingly, glutathione (GSH) showed significant protection to CNE-2 cells while potentiating the hemolytic power of NV. This finding may suggest a key role of reactive oxygen species (ROS) in the cytotoxicity of NV. To the best of our knowledge, this is the first report that a hemolytic jellyfish venom acts through NHE in a manner other than compromising membrane integrity. The current work provides new insight into the arsenal of toxic jellyfishes.

Computational simulation of static/cyclic cell stimulations to investigate mechanical modulation of an individual mesenchymal stem cell using confocal microscopy

It has been found that cells react to mechanical stimuli, while the type and magnitude of these cells are different in various physiological and pathological conditions. These stimuli may affect cell behaviors via mechanotransduction mechanisms. The aim of this study is to evaluate mechanical responses of a mesenchymal stem cell (MSC) to a pressure loading using finite elements method (FEM) to clarify procedures of MSC mechanotransduction. The model is constructed based on an experimental set up in which statics and cyclic compressive loads are implemented on a model constructed from a confocal microscopy 3D image of a stem cell. Both of the applied compressive loads are considered in the physiological loading regimes. Moreover, a viscohyperelastic material model was assumed for the cell through which the finite elements simulation anticipates cell behavior based on strain and stress distributions in its components. As a result, high strain and stress values were captured from the viscohyperelastic model because of fluidic behavior of cytosol when compared with the obtained results through the hyperelastic models. It can be concluded that the generated strain produced by cyclic pressure is almost 8% higher than that caused by the static load and the von Mises stress distribution is significantly increased to about 150kPa through the cyclic loading. In total, the results does not only trace the efficacy of an individual 3D model of MSC using biomechanical experiments of cell modulation, but these results provide knowledge in interpretations from cell geometry. The current study was performed to determine a realistic aspect of cell behavior.

Strengthening of C2C12 mouse myoblasts against compression damage by mild cyclic compressive stimulation

Deep tissue injury (DTI) is a severe kind of pressure ulcers formed by sustained deformation of muscle tissues over bony prominences. As a major clinical issue, DTI affects people with physical disabilities, and is obviously related to the load-bearing capacity of muscle cells in various in-vivo conditions. It is important to provide a preventive approach to help muscle cells from being damaged by compressive stress. In this study, we hypothesized that cyclic compressive stimulation could strengthen muscle cells against compressive damage and enhance the cell plasma membrane resealing capability. Monolayer of myoblasts was cultured in the cell culture dish covered by a cylinder 0.5% agarose gel. The platen indenter was applied with 20% strain on the agarose gel in the Mach-1 micromechanical system. The vibration was 1Hz sinusoidal function with amplitude 0.2% strain based on 20% gel strain. Cyclic compressive stimulation for 2h could enhance the compressive stress damage threshold of muscle cells, the muscle cell plasma membrane resealing ratio and viability of muscle cell under static loading as preventive approach. This approach might help to reduce the risk of DTI in clinic.

Membrane permeability during pressure ulcer formation: A computational model of dynamic competition between cytoskeletal damage and repair

Pressure ulcers are debilitating wounds that arise frequently in people who have lost mobility. Mechanical stress, oxidative stress and ischemia-reperfusion injury are potential sources of damage during pressure ulcer formation, but cross-talk between these sources has rarely been investigated. In vitro experiments with mechanically-induced cell damage previously demonstrated that non-lethal amounts of static cell deformation could induce myoblast membrane permeabilization. Permeabilization, in turn, has the potential to induce oxidative stress via leakage of calcium, myoglobin or alarmins. In this work, we constructed a hypothetical causal network of cellular-scale effects resulting from deformation and permeabilization, and we investigated the theoretical sensitivity of cell death toward various parameters and pathways of the model. Simulations showed that the survival/death outcome was particularly sensitive to the speed of membrane repair. The outcome was also sensitive to whether oxidative stress could decrease the speed of membrane repair. Finally, using the assumption that apoptosis and necrosis would have opposite effects on membrane leakage in dying cells, we showed that promoting apoptosis might under certain conditions have the paradoxical effect of decreasing, rather than increasing, total cell death. Our work illustrates that apoptosis may have hidden benefits at preventing spatial spread of death. More broadly, our work shows the importance of membrane repair dynamics and highlights the need for experiments to measure the effects of ischemia, apoptosis induction, and other co-occurring sources of cell stress toward the speed of membrane repair.