Lyophilized keratinocyte cell lysates contain multiple mitogenic activities and stimulate closure of meshed skin autograft-covered burn wounds with efficiency similar to that of fresh allogeneic keratinocyte cultures

Industrial Biotechnology Conservation Processes: Similarities with Natural Long-Term Preservation of Biological Organisms

Cryopreservation and lyophilization processes are widely used for conservation purposes in the pharmaceutical, biotechnological, and food industries or in medical transplantation. Such processes deal with extremely low temperatures (e.g., -196 °C) and multiple physical states of water, a universal and essential molecule for many biological lifeforms. This study firstly considers the controlled laboratory/industrial artificial conditions used to favor specific water phase transitions during cellular material cryopreservation and lyophilization under the Swiss progenitor cell transplantation program. Both biotechnological tools are successfully used for the long-term storage of biological samples and products, with reversible quasi-arrest of metabolic activities (e.g., cryogenic storage in liquid nitrogen). Secondly, similarities are outlined between such artificial localized environment modifications and some natural ecological niches known to favor metabolic rate modifications (e.g., cryptobiosis) in biological organisms. Specifically, examples of survival to extreme physical parameters by small multi-cellular animals (e.g., tardigrades) are discussed, opening further considerations about the possibility to reversibly slow or temporarily arrest the metabolic activity rates of defined complex organisms in controlled conditions. Key examples of biological organism adaptation capabilities to extreme environmental parameters finally enabled a discussion about the emergence of early primordial biological lifeforms, from natural biotechnology and evolutionary points of view. Overall, the provided examples/similarities confirm the interest in further transposing natural processes and phenomena to controlled laboratory settings with the ultimate goal of gaining better control and modulation capacities over the metabolic activities of complex biological organisms.

A Prospective Multicenter Study of the Efficacy and Tolerability of Cryopreserved Allogenic Human Keratinocytes to Treat Venous Leg Ulcers

Allogeneic human keratinocyte cultures have been used to treat burn wounds, donor sites, and chronic skin ulcers with some success. Cryopreservation of these cultures allows for the production of large standardized batches that are readily available for use. The aim of the study presented in this report was to study effects of cryopreserved cultured allogenic human keratinocytes (Cryo Ceal) on chronic lower extremity wounds. Parameters were measured to study efficacy, tolerability, pain associated with chronic wounds, and quality of life of patients. Twenty-seven patients with hard-to-heal venous leg ulcers received a maximum of 9 applications of Cryo Ceal in a prospective, uncontrolled multicenter study lasting 48 weeks. Eleven out of 27 patients (41%; 95% CI: 22%-61%) had complete wound closure within 24 weeks (1 week). The time required for complete wound closure in these 11 patients ranged from 4.1 to 24.9weeks. Only 1 patient had recurrence of the ulcer at 48 weeks. Local (wound) pain scores decreased from a mean of 2.5 at baseline to 0.9 at week 24. Fifty percent of the patients attained a pain score of 0 after 12 weeks and remained stable at this score until the end of the study. Overall, the patient quality of life was better at week 24, compared to baseline values. The treatment was well tolerated, and wound infection was the most frequently occurring adverse event.

Outcome of Burns Treated With Autologous Cultured Proliferating Epidermal Cells: A Prospective Randomized Multicenter Intrapatient Comparative Trial

Standard treatment for large burns is transplantation with meshed split skin autografts (SSGs). A disadvantage of this treatment is that healing is accompanied by scar formation. Application of autologous epidermal cells (keratinocytes and melanocytes) may be a suitable therapeutic alternative, since this may enhance wound closure and improve scar quality. A prospective, multicenter randomized clinical trial was performed in 40 adult patients with acute full thickness burns. On two comparable wound areas, conventional treatment with SSGs was compared to an experimental treatment consisting of SSGs in combination with cultured autologous epidermal cells (ECs) seeded in a collagen carrier. The primary outcome measure was wound closure after 5-7 days. Secondary outcomes were safety aspects and scar quality measured by graft take, scar score (POSAS), skin colorimeter (DermaSpectrometer) and elasticity (Cutometer). Wound epithelialization after 5-7 days was significantly better for the experimental treatment (71%) compared to the standard treatment (67%) (p = 0.034, Wilcoxon), whereas the take rates of the grafts were similar. No related adverse events were recorded. Scar quality was evaluated at 3 (n = 33) and 12 (n = 28) months. The POSAS of the observer after 3 and 12 months and of the patient after 12 months were significantly better for the experimental area. Improvements between 12% and 23% (p ≤ 0.010, Wilcoxon) were detected for redness, pigmentation, thickness, relief, and pliability. Melanin index at 3 and 12 months and erythema index at 12 months were closer to normal skin for the experimental treatment than for conventional treatment (p ≤ 0.025 paired samples t-test). Skin elasticity showed significantly higher elasticity (p = 0.030) in the experimental area at 3 months follow-up. We showed a safe application and significant improvements of wound healing and scar quality in burn patients after treatment with ECs versus SSGs only. The relevance of cultured autologous cells in treatment of extensive burns is supported by our current findings.

Evidence-Based Approach to Advanced Wound Care Products

There is increasing pressure from industry to use advanced wound care products and technologies. Many are very expensive but promise to reduce overall costs associated with wound care. Compelling anecdotal evidence is provided that inevitably shows wounds that failed all other treatments but responded positively to the subject product. Evidence-based medicine is the standard by which physician-scientists must make their clinical care decisions. In an attempt to provide policy makers with the most current evidence on advanced wound care products, the Department of Veteran Affairs conducted an Evidence-based Synthesis Program review of advanced wound care products. This paper suggests how to take this information and apply it to policy to drive evidence-based care to improve outcomes and fiduciary responsibility.

Progress towards cell-based burn wound treatments

Cell therapy as part of the concept of regenerative medicine represents an upcoming platform technology. Although cultured epidermal cells have been used in burn treatment for decades, new developments have renewed the interest in this type of treatment. Whereas early results were hampered by long culture times in order to produce confluent sheets of keratinocytes, undifferentiated proliferating cells can nowadays be applied on burns with different application techniques. The application of cells on carriers has improved early as well as long-term results in experimental settings. The results of several commercially available epidermal substitutes for burn wound treatment are reviewed in this article. These data clearly demonstrate a lack of randomized comparative trials and application of measurable outcome parameters. Experimental research in culture systems and animal models has demonstrated new developments and proof of concepts of further improvements in epidermal coverage. These include combinations of epidermal cells and mesenchymal stem cells, and the guidance of both material and cell interactions towards regeneration of skin appendages as well as vascular and nerve structures.

Wound-healing potential of Cultured Epidermal Sheets is unaltered after lyophilization: a preclinical study in comparison to cryopreserved CES

Lyophilized Cultured Epidermal Sheets (L-CES) have been reported to be as effective as the cryopreserved CES (F-CES) in treating skin ulcers. However, unlike F-CES, no preclinical study assessing wound-healing effects has been conducted for L-CES. The present study was set out to investigate the microstructure, cytokine profile, and wound-healing effects of L-CES in comparison to those of F-CES. Keratinocytes were cultured to prepare CES, followed by cryopreservation at −70°C and lyophilization. Under microscopic observation, intact cells with apparent intracellular junctions were observed in L-CES. The L-CES, like fresh CES, consisted of three to four well-maintained epidermal layers, as shown by the expression of keratins, involucrin, and p63. There were no differences in the epidermal layer or protein expression between L-CES and F-CES, and both CES were comparable to fresh CES. TGF-α, EGF, VEGF, IL-1α, and MMPs were detected in L-CES at levels similar to those in F-CES. In a mouse study, wounds treated with L-CES or F-CES completely healed at least 4 days faster than untreated wounds. CES-treated wounds completely healed by day 10, while the untreated wounds did not heal by day 14. Masson's trichrome staining showed that collagen deposition in the CES-treated wounds was highly increased in the dermis of the wound center compared to that in the control wounds. Thus, this study demonstrates that L-CES is as clinically effective as F-CES for wound treatment.

Wound dressing material containing lyophilized allogeneic cultured cells

Although topical application of a single growth factor is known to accelerate wound healing, treatment with allogeneic cultured cells is more efficient and physiological, because they release various mediators that interact and regulate the wound healing mechanism. However, in clinics, the cells must be cryopreserved until use. To overcome this inconvenience, we designed novel wound dressing materials containing lyophilized allogeneic cultured epithelial cells and/or fibroblasts. This study aimed to confirm growth factor release from those lyophilized products. The results revealed that the cultured cells retained their morphology even after lyophilization and released growth factors. When fibroblasts were used alone, they released growth factors in significantly higher concentrations after lyophilization than after cryopreservation. In particular, bFGF release was almost a hundredfold higher in the lyophilized group compared to the cryopreserved group. When epithelial cells and fibroblasts were co-cultured, both bFGF and VEGF were released in higher concentrations by the cryopreserved dressing material than by the lyophilized dressing material. The growth factors' release was probably regulated by interaction between epithelial cells and fibroblasts. We speculate that repeated application may be necessary for treating difficult wounds with the lyophilized product, because the lyophilized cells release the mediators in a single, transient burst.

Feeder layer- and animal product-free culture of neonatal foreskin keratinocytes: improved performance, usability, quality and safety

Since 1987, keratinocytes have been cultured at the Queen Astrid Military Hospital. These keratinocytes have been used routinely as auto and allografts on more than 1,000 patients, primarily to accelerate the healing of burns and chronic wounds. Initially the method of Rheinwald and Green was used to prepare cultured epithelial autografts, starting from skin samples from burn patients and using animal-derived feeder layers and media containing animal-derived products. More recently we systematically optimised our production system to accommodate scientific advances and legal changes. An important step was the removal of the mouse fibroblast feeder layer from the cell culture system. Thereafter we introduced neonatal foreskin keratinocytes (NFK) as source of cultured epithelial allografts, which significantly increased the consistency and the reliability of our cell production. NFK master and working cell banks were established, which were extensively screened and characterised. An ISO 9001 certified Quality Management System (QMS) governs all aspects of testing, validation and traceability. Finally, as far as possible, animal components were systematically removed from the cell culture environment. Today, quality controlled allograft production batches are routine and, due to efficient cryopreservation, stocks are created for off-the-shelf use. These optimisations have significantly increased the performance, usability, quality and safety of our allografts. This paper describes, in detail, our current cryopreserved allograft production process.

Glycerol treatment as recovery procedure for cryopreserved human skin allografts positive for bacteria and fungi

Human donor skin allografts are suitable and much used temporary biological (burn) wound dressings. They prepare the excised wound bed for final autografting and form an excellent substrate for revascularisation and for the formation of granulation tissue. Two preservation methods, glycerol preservation and cryopreservation, are commonly used by tissue banks for the long-term storage of skin grafts. The burn surgeons of the Queen Astrid Military Hospital preferentially use partly viable cryopreserved skin allografts. After mandatory 14-day bacterial and mycological culture, however, approximately 15% of the cryopreserved skin allografts cannot be released from quarantine because of positive culture. To maximize the use of our scarce and precious donor skin, we developed a glycerolisation-based recovery method for these culture positive cryopreserved allografts. The inactivation and preservation method, described in this paper, allowed for an efficient inactivation of the colonising bacteria and fungi, with the exception of spore-formers, and did not influence the structural and functional aspects of the skin allografts.

Treatment of gun-shot defect of the foot with bovine collagen matrix application

Nonoperative therapy might be chosen for patients with small wounds or defects around the foot and ankle region. Lyophilized bovine collagen matrix is one of ideal biological dressings used in wound treatment. We present an example of type 1 bovine collagen (Gelfix, Euroresearch, Inc., Milano, Italy) usage in a complex gun-shot wound of the foot and relevant literature is discussed.

Keratinocyte regulation of TGF-beta and connective tissue growth factor expression: a role in suppression of scar tissue formation

Allogeneic keratinocytes applied to large full-thickness wounds promote healing while suppressing scar tissue formation. This effect may be mediated in part by their effect on the levels of transforming growth factor-betas (TGF-betas) and connective tissue growth factor (CTGF) in the wound and subsequent modulation of fibroblast activity. We have examined the levels of TGF-beta and CTGF produced by keratinocytes and fibroblasts, and the effect of keratinocyte-conditioned medium using monolayer and living skin-equivalent cultures. Keratinocyte monolayers did not release any detectable TGF-beta1, but released moderate levels of TGF-beta2 into culture medium, and stained strongly for TGF-beta1, but only weakly for TGF-beta2. Fibroblasts released large amounts of TGF-beta1, no TGF-beta2, and stained strongly for TGF-beta1. Neither cell type released TGF-beta3, but both stained strongly for TGF-beta3. Keratinocyte-conditioned medium suppressed the levels of TGF-betas and CTGF associated with the fibroblasts compared with fibroblasts incubated in Dulbecco's minimal essential medium and fibroblast-conditioned medium. In living skin equivalents, keratinocytes stained very strongly for TGF-beta1 and CTGF, moderately strongly for TGF-beta3, and only weakly for TGF-beta2. Fibroblasts stained strongly for TGF-beta1 and 3 and CTGF. These observations suggest that keratinocytes may affect the TGF-beta profile in such a way as to suppress the formation of scar tissue.

Role of keratinocyte?fibroblast cross-talk in development of hypertrophic scar

The ability to generate or repair injured tissue is essential to the continuity of human life. As in all other organs, wound healing in the skin is a dynamic process involving tissue response to different types of insults. This process involves a continuous sequence of signals and responses in which platelets, fibroblasts, epithelial, endothelial, and immune cells come together outside their usual domains to orchestrate a very complex event that results in tissue repair. These signals, which are mainly growth factors and cytokines, orchestrate the initiation, continuation, and termination of wound healing. An imbalance in the synthesis and release of these cytokines and growth factors at the wound site, therefore, may result in either retarded wound healing, as is seen in diabetic patients and the elderly population, or overhealing wounds such as fibroproliferative disorders frequently seen following surgical incision, traumatic wounds, and severe electrical and thermal injury. In general, regardless of the site of injury, in any phase of the dynamic healing process, a fine balance between synthesis of extracellular matrix and degradation by a large family of enzymes, known as matrix metalloproteinases, is required for maintaining the structural integrity of healing tissue. The availability of new models such as organotypic co-culture systems have allowed us to gain new insight into the cell-cell interactions at both cellular and molecular levels. Recent evidence indicates that mesenchymal-epithelial interactions play a critical role in regulation of skin homeostasis and this cross-talk is mediated by soluble factors acting as autocrine/paracrine regulators of fibroblast and keratinocyte growth, function, and differentiation. In this review we address the question of how keratinocyte-fibroblast interaction plays a role in controlling the expression of key extracellular matrix molecules such as matrix metalloproteinases, which are critical in the healing process following any types of insults to the skin.

Does the Presence of Unwanted Dermal Fibroblasts Limit the Usefullness of Autologous Epidermal Keratinocyte Grafts?

OBJECTIVES

Fibroblasts sometimes occur after enzymatic isolation of epidermis. They proliferate quickly, overgrowing the culture. A pure epithelial culture is essential for therapy using a keratinocyte graft. The aim of this study was to determine the possibility of fibroblast elimination from culture to prevent fibroblast overgrowth and obtain a pure monolayer of keratinocytes.

MATERIAL AND METHODS

We analyzed three epidermal-derived cultures. Cells were cultured in medium contained Dulbecco's Modified Eagle Medium (DMEM) and Ham's F-12 at a 3:1 ratio with 5% autologous serum and additives. The epithelial culture was confirmed using pancytokeratin MMF. If fibroblast like cells were present, they were removed using 0.01% edetate disodium dihydrate (Na2EDDA). This procedure was repeated until we obtained pure primary keratinocyte cultures.

RESULTS

Fibroblast detachment was observed after Na2EDDA treatment. The procedure was performed twice and pure primary cultures of keratinocyte were achieved in two cases. These two cultures maintained their epithelial-like morphology and cytokeratin expression. One culture was treated four times with Na2EDDA with no effect; the morphology of the cultures became fibroblast-like with no observed cytokeratin expression.

CONCLUSIONS

Unwanted dermal fibroblasts can be separated from primary keratinocyte cultures during the first few days after the isolation. Cocultures of unwanted dermal fibroblasts and epidermal keratinocytes can be reverted to pure keratinocyte monolayers suitable as grafts for transplantation.

Interaction of keratinocytes and fibroblasts modulates the expression of matrix metalloproteinases-2 and -9 and their inhibitors

Disruption of epidermal-mesenchymal communication due to a delay in epithelialization, increases the frequency of developing fibrotic conditions in skin. As matrix metalloproteinases-2 (MMP-2) and -9 (MMP-9) are two key enzymes involved in wound healing and tissue remodeling, here we examined the efficacy of keratinocyte-fibroblast interaction on modulation of these enzymes and their inhibitors. The conditioned media derived from keratinocytes and fibroblasts grown in upper and lower chambers of a co-culture system, respectively, were analyzed for MMP-2 and -9. Keratinocyte or fibroblast conditioned medium (FCM) was used as a control. Gelatinolytic activity analyzed by zymography showed that keratinocytes mainly express MMP-9 and to a lesser extent MMP-2; while fibroblasts express only MMP-2. In a co-culture system, the activities of both MMP-2 and MMP-9 markedly increased in conditioned media collected from bottom chambers. These findings were consistent with the level of MMP-2 and MMP-9 measured by Western blot. Using the same experimental setting, the levels of tissue inhibitors of MMPs (TIMPs) secreted by keratinocytes and fibroblasts grown in the same co-culture system were also evaluated. Western blot showed that fibroblasts secrete only TIMP-1 and TIMP-2 whose levels were increased by co-culturing fibroblasts with keratinocytes. In contrary the level of TIMP-3, which was mainly expressed by keratinocytes, increased by co-culturing these cells with fibroblasts. In conclusion, interaction of fibroblast-keratinocyte modulates the levels of MMP-2 and -9 and their inhibitors produced by these cells and this interaction may be critical for a better healing quality at a late stage of the wound healing process.

Efficacy and safety of the freeze-dried cultured human keratinocyte lysate, LyphoDermtm 0.9%, in the treatment of hard-to-heal venous leg ulcers

LyphoDerm (XCELLentis, Belgium) is an end-sterilized, freeze-dried lysate from cultured allogeneic epidermal keratinocytes, formulated into a hydrophilic gel. Its efficacy and safety were evaluated, in combination with standard care (hydrocolloid dressing and compression therapy), in 194 patients suffering from hard-to-heal (lasting more than 6 weeks and not responding to conventional therapy) venous leg ulcers. Two control groups received standard care, with or without vehicle, respectively. Patients had a median age of 67.5 years and the majority were females (61%). The median duration of the ulcer was 43 weeks and in 39% of the subjects it had been present for more than 1 year. Thirty-eight percent of the patients in the standard care + LyphoDerm group had complete ulcer healing within 24 weeks (primary end point) compared to 27% of patients in the standard care + vehicle pooled groups (P = 0.114) in the "as treated" intent-to-treat cohort (37% vs. 27% in the "as randomized intent-to-treat cohort; p = 0.137). In the subgroup of patients with enlarging ulcers, the difference between the two groups was significant (30% vs. 11%; p = 0.024 in the "as treated" intent-to-treat cohort and 31% vs. 9%; p = 0.005 in the "as randomized" intent-to-treat cohort). LyphoDerm was well tolerated and safe, and no differences in the frequency of adverse events were noted between the treatment groups. Although the primary objective of the study was not achieved, the exploratory analysis carried out in patients with enlarging ulcers suggests that LyphoDerm could offer a new prospect for the treatment of patients with venous ulcers that may prove to be a significant adjunct to the overall provision of care.

Cryopreserved and lyophilized cultured epidermal allografts in the treatment of leg ulcers: a pilot study

BACKGROUND

In the conservative therapy of venous leg ulcers modern types of dressings are used most frequently. In the past 20 years 'active wound dressings' - cultured epidermal keratinocytes as autografts and allografts - were also introduced in the management of leg ulcers.

METHODS

The aim of our study was to compare the effect of cryopreserved and lyophilized cultured epidermal allografts in the treatment of venous leg ulcers. Evaluation of the therapy was documented as photodocumentation, planimetry, healing time and evaluation of pain relief over a 3-month period after application. Fifty patients with venous leg ulcers were selected. Twenty-five patients (group I) were treated with cryopreserved keratinocytes and 25 (group II) with lyophilized keratinocytes.

RESULTS

The final evaluation 3 months after the application of allografts showed 84% of healed ulcers in group I and 80% in group II. The number of healed ulcers and the healing rate both showed no statistically significant differences. The size of the ulcer was reduced by half during the first week in both groups. The size differences during the first week are statistically significant in both groups and they are comparable (P < 0.001). The intensity of the pain was statistically significantly reduced during the first week after application in both groups (P < 0.001).

CONCLUSIONS

The cryopreserved and lyophilized cultured allografts are comparable in healing rate, course of healing and relief of pain, and also in planimetric changes during the healing of venous leg ulcers. Lyophilized allografts are more convenient for routine use than cryopreserved allografts as they can be stored at room temperature. These results could give rise to the more frequent use of lyophilized allografts in slow-healing venous leg ulcers.

So-called biological dressing effects of cultured epidermal sheets are mediated by the production of EGF family, TGF-β and VEGF

BACKGROUND

Cultured epidermal sheet (CES) grafts accelerate wound healing as a result of so-called biological dressing effect, which is thought to be mediated by various growth factors. However, the profile of growth factor expression in CESs is unclear.

OBJECTIVE

To investigate whether CESs produce growth factors along with stratification we investigated the production of growth factors and their regulation in CESs.

METHODS

CESs conditioned medium was harvested and the concentration of TGF-alpha, TGF-beta1, TGF-beta2, and VEGF was measured using ELISA. The mRNA of EGF family, TGF-beta family and VEGF was detected by Northern blot or RNase protection assay.

RESULTS

The concentration of TGF-alpha was 100 pg/ml in the monolayer culture, but dramatically increased to 600 pg/ml 2 days after stratification. It decreased to baseline, and then gradually increased to 300 pg/ml in the presence of EGF and remained at that level until day 20. TGF-beta1 increased from 50 to 400 pg/ml after stratification, and remained at that level day 20. TGF-beta2 was undetectable in the monolayer culture, but dramatically increased to 200 pg/ml 2 days after stratification. Unlike TGF-beta1, TGF-beta2 gradually increased over time after stratification. VEGF increased with stratification from 500 to 1500 pg/ml. The addition of EGF upregulated EGF family, TGF-beta, and VEGF production in CESs, as confirmed by ELISA, Northern blot, and RNase protection assay.

CONCLUSION

These results indicate that so-called biological dressing effect of CESs is mediated by production of the EGF family, TGF-beta, and VEGF. Our results also demonstrate the ability of EGF to enhance growth factor production in CESs.

Expression of a releasable form of annexin II by human keratinocytes

Annexin II is a multifunctional calcium-dependent phospholipid binding protein whose presence in epidermis has previously been reported. However, like other members of annexin family, annexin II has been regarded as either an intracellular protein or associated with the cellular membrane. Here, we report the presence of a releasable annexin II and p11, two monomers of annexin II tetramer, in keratinocyte-conditioned medium (KCM). Proteins present in KCM were fractionated on a gel filtration column and following further evaluation, a releasable protein with apparent MW of 36 kDa was identified. Further characterization identified this protein as the p36 monomer of annexin II tetramer. The phospho-tyrosine antibody did not visualize this protein as the phosphorylated form of p36. Several experiments were conducted to examine whether this protein is soluble or associated with keratinocyte cell membranes in the conditioned medium. A centrifugation of conditioned medium was not able to bring this protein down into the pellet. Surprisingly, the results of Western analysis identified p36 and p11, two monomers of the annexin II tetramer, in conditioned medium derived from either keratinocytes cultured alone or keratinocytes co-cultured with fibroblasts. In contrast to the keratinocyte-conditioned medium in which annexin II was easily detectable, both monomers were barely detectable in conditioned medium collected from dermal fibroblasts. This finding was in contrast to the cell lysates in which p36 was detectable in both keratinocytes and fibroblasts. However, the amount of this protein was markedly higher in keratinocyte lysate relative to that of dermal fibroblasts. Conditioned medium derived from keratinocyte established from adult showed a higher level of annexin II compared to that of keratinocytes established from newborn babies. The expression of p11 seems to increase with differentiation of keratinocytes derived from either adult or newborn skin samples. When the site of annexin synthesis in human skin was examined by immunohistochemical staining, the antibody for p36 localized the annexin to the keratinocyte cell members in the basal and suprabasal keratinocytes. In conclusion, Western blot detection of both p36 and p11 in conditioned medium from skin cells revealed that human keratinocytes, but not fibroblasts, express a releasable monomer form of annexin II which is regulated by differentiation status of keratinocytes. This finding is consistent with the localization of annexin II detected by immunohistochemical staining.

Keratinocyte differentiation inversely regulates the expression of involucrin and transforming growth factor beta1

Extensive skin loss from a variety of conditions such as severe thermal injury is associated with significant functional morbidity and mortality. In recent years, the healing quality has been improved for patients who suffer burns due in part to the usage of skin replacement mainly prepared from multi-layered sheets of cultured keratinocytes. Although it is known that keratinocytes are a rich source of wound healing promoting factors such as transforming growth factor-beta1 (TGF-beta1), it is not clear whether differentiated keratinocytes in a multi-layer form release this multi-functional growth factor and has any functional influence on dermal fibroblasts. This study examined the hypothesis that keratinocytes in mono- and multi-layer forms express different levels of TGF-beta1. To address this hypothesis, keratinocytes were grown in serum free medium (KSFM) supplemented with bovine pituitary extract (50 microg/ml) and EGF (5 microg/ml). When cells reached confluency, conditioned medium was removed and replaced with 50% KSFM with no additives and 50% DMEM without serum and cells were allowed to form multi-layers and differentiate. The conditioned medium was then collected every 48 h up to 24 days and the level of TGF-beta1 and the efficacy of a keratinocyte released fibroblast mitogenic factor were evaluated by ELISA and (3)H-thymidine incorporation, respectively. Northern analysis was also employed to evaluate the expression of TGF-beta1, involucrin, TIMP-1, and 18 S ribosomal RNA in keratinocytes at different times of the onset of differentiation. The microscopic morphology of keratinocytes at different times of induction of cell differentiation showed detachments (nodules) of many regions of keratinocyte sheet from culture substratum within 1-2 weeks. The numbers and sizes of these nodules were increased as the process of keratinocyte differentiation proceed. The results of TGF-beta1 evaluation revealed that mono-layers of cultured keratinocytes which were round, attached, and proliferating in KSFM + BPE and EGF containing medium released a significantly higher level of TGF-beta1 (196 +/- 58 pg /ml) relative to those grown in multi-layer forms (28 +/- 7.8 pg/ml). A longitudinal experiment was then conducted and the results showed that cells on the onset of differentiation released even greater level of TGF-beta1 (388 +/- 53 pg/ml) relative to those grown in KSFM + BPE and EGF. This finding was consistent with the expression of TGF-beta1 mRNA evaluated in keratinocytes grown in test medium for various duration. In general, the level of TGF-beta1 protein and mRNA gradually reduced to its lowest level within 12 days of growing cells in our test medium. When aliquots of the collected keratinocyte conditioned medium were added to dermal fibroblasts, the level of (3)H-thymidine incorporation increased only in those cells receiving aliquots of conditioned medium containing high levels of TGF-beta1. When involucrin was used as a differentiation marker for keratinocytes at different time points, the highest level of involucrin mRNA expression was found at the later stage of cell differentiation. In conclusion, high involucrin expressing differentiated keratinocytes seem to be quiescent in releasing both TGF-beta1 and a fibroblast mitogenic factor.

KERATINOCYTE-DRIVEN CONTRACTION OF RECONSTRUCTED HUMAN SKIN

We have previously reported that reconstructed human skin, using deepidermized acellular sterilized dermis and allogeneic keratinocytes and fibroblasts, significantly contracts in vitro. Contracture of split skin grafts in burns injuries remains a serious problem and this in vitro model provides an opportunity to study keratinocyte/mesenchymal cell interactions and cell interactions with extracted normal human dermis. The aim of this study was to investigate the nature of this in vitro contraction and explore several approaches to prevent or reduce contraction. Three different methodologies for sterilization of the dermal matrix were examined: glycerol, ethylene oxide and a combination of glycerol and ethylene oxide. While the nature of the sterilization technique influenced the extent of contraction and thinner dermal matrices contracted proportionately more than thicker matrices, in all cases contraction was driven by the keratinocytes with relatively little influence from the fibroblasts. The contraction of the underlying dermis did not represent any change in tissue mass but rather a reorganization of the dermis which was rapidly reversed (within minutes) when the epidermal layer was removed. Pharmacological approaches to block contraction showed forskolin and mannose-6-phosphate to be ineffective and ascorbic acid-2-phosphate to exacerbate contraction. However, Galardin, a matrix metalloproteinase inhibitor and keratinocyte conditioned media, both inhibited contraction.

Human three-dimensional fibroblast cultures express angiogenic activity

Human neonatal fibroblasts were cultured on a lactate-glycollate copolymer scaffold for 12-16 days to form a three-dimensional dermal equivalent tissue. The cellular content of vascular endothelial growth factor (VEGF) mRNA in these three-dimensional cultures was 22-fold greater than that observed in the same fibroblasts grown as monolayers. No induction was shown by hepatocyte growth factor (HGF) or angiopoietin 1 indicating that the effect was specific to VEGF. The predominant VEGF splice variant, detected by RT-PCR corresponded to the 121 amino acid form, with less of the 165 amino acid form. The cell-associated forms (189 and 206 amino acids) comprised less than 1% of the total VEGF mRNA. VEGF and HGF proteins, determined by ELISA, were secreted in physiologically significant amounts, 0.5-4 ng per 24 h/10(6) cells. Conditioned medium from the three-dimensional cultures stimulated proliferation of endothelial cells in a dose-dependent manner and induced cellular expression of integrin alpha(v)beta(3). Conditioned medium from the same dermal fibroblasts cultured in monolayer showed little angiogenic activity in any of these assays. Using the chorioallantoic membrane (CAM) angiogenesis assay, the cultures stimulated blood vessel production 2.8-fold over scaffold alone. VEGF-neutralizing antibody reduced the vessel development in the CAM to the level in the scaffold control. Anti-HGF antibody had no significant effect. In conclusion, three-dimensional cultures of dermal equivalent tissue express angiogenic activity to a greater extent than monolayer cultures, some of which can be assigned to VEGF.

Use of a lyophilized bovine collagen matrix in postoperative wound healing

BACKGROUND

Immediate reconstruction is the preferred approach to the management of defects following Mohs micrographic surgery. In a minority of patients, however, reconstruction is contraindicated, and a long-term biological dressing that stimulates wound healing and minimizes wound care is desirable.

OBJECTIVE

We wanted to assess the utility of a lyophilized, type I bovine collagen matrix (SkinTemp) in wound care and wound healing following Mohs micrographic surgery.

METHODS

Fifteen patients were treated with a bovine collagen matrix following Mohs micrographic surgery. Study wounds were evaluated for time to complete granulation, time to complete epithelialization, and adverse reactions including infection and allergy. The time to complete healing (granulation and epithelialization) for this group was compared to 15 size- and site-matched surgical defects.

RESULTS

The use of bovine collagen matrix provided more rapid wound healing than traditional second intention healing at all anatomic sites studied. The time to complete healing averaged 6.1 weeks with bovine collagen matrix versus 9.4 weeks for the control group. Use of bovine collagen matrix required an average of 3.0 dressing changes weekly compared to 7.0 changes weekly in the control group. There were no wound infections or allergic reactions to it.

CONCLUSIONS

A Type I bovine collagen matrix provided a safe, readily available alternative to traditional methods of second intention healing. It minimized wound care while reducing the time for complete healing. A larger study should be performed to confirm the results of this pilot study.

Burns (Part 2). Tops and flops using cultured epithelial autografts in children

The goal of this article is to review the status of cultured epithelial autografts in clinical practice with particular focus on the pediatric subset of patients. The current indications include massive deep burns (>60 - 70% total body surface area), resurfacing-type postburn scar revisions, and skin defect coverage following excision of large skin lesions like giant nevi. Although this method can be lifesaving for massively burned patients, and although excellent functional and cosmetic results may be obtained under ideal circumstances, formidable problems continue to exist. Take is inconsistent, cultured grafts are extremely susceptible to infection, and skin breakdown during the first months post grafting may occur due to mechanical instability of the regenerating skin. It may take one more decade of concerted research, jointly performed by clinicians and tissue culture technology experts in order to fabricate more skin-like grafts which are robust, reliable, and less expensive. Then, "cultured skin" will conquer the world and benefit countless patients.