Microcirculation of the diabetic foot

Recombinant human annexin A5 accelerates diabetic wounds healing by regulating skin inflammation

Background

One of the key obstacles to the healing of diabetic wound is the persistence of active inflammation. We previously demonstrated the potential of cell-free fat extract (CEFFE) to promote the healing of diabetic wounds, and annexin A5 (A5) is a crucial anti-inflammatory protein within CEFFE. This study aimed to evaluate the therapeutic potential of A5 in diabetic wounds.

Methods

A5 was loaded into GelMA hydrogels and applied to skin wounds of diabetic mice in vivo. The diabetic wounds with the treatment of GelMA-A5 were observed for 14 days and evaluated by histological analysis. Accessment of inflammation regulation were conducted through anti-CD68 staining, anti-CD86 and anti-CD206 staining, and qRT-PCR of wound tissue. In presence of A5, macrophages stimulated by lipopolysaccharide (LPS) in vitro, and detected through qRT-PCR, flow cytometry, and immunocytofluorescence staining. Besides, epithelial cells were co-cultured with A5 for epithelialization regulation by CCK-8 assay and cell migration assay.

Results

A5 could promote diabetic wound healing and regulate inflammations by promoting the transition of macrophages from M1 to M2 phenotype. In vitro experiments demonstrated that A5 exerted a significant effect on reducing pro-inflammatory factors and inhibiting the polarization of macrophages from M0 toward M1 phenotype. A5 significantly promoted the migration of epithelial cells.

Conclusion

Annexin A5 has a significant impact on the regulation of macrophage inflammation and promotion of epithelialization.

Sodium alginate/polyvinyl alcohol nanofibers loaded with Shikonin for diabetic wound healing: In vivo and in vitro evaluation

Diabetic wounds are typically chronic wounds and the healing process is limited by problems such as high blood glucose levels, bacterial infections, and other issues that make wound healing difficult. Designing drug-loaded wound dressings is an effective way to promote diabetic wound healing. In this study, we developed an SA/PVA nanofiber (SPS) containing Shikonin (SK) for the treatment of diabetic wounds. The prepared nanofibers were uniform in diameter, had good hydrophilicity and high water vapor permeability, and effectively promoted gas exchange between the wound site and the outside world. The results of in vitro experiments showed that SPS was effective in antimicrobial, antioxidant, and biocompatible. In vivo tests showed that the wound healing rate of mice treated with SPS reached 85.5 %. Immunohistochemical staining results showed that SPS was involved in the diabetic wound healing process through the up-regulation of growth factors (CD31, HIF-1α) and the down-regulation of inflammatory factors (CD68). Western blotting experiments showed that SPS attenuated the inflammation through the inhibition of the IκBα/NF-κB signaling pathway. These results suggest that SPS is a promising candidate for future clinical application of chronic wound dressings.

Use of consecutive transcutaneous oxygen measurement when assessing the need for revascularization and association with the outcomes of ischemic diabetic ulcers

This study compared the ankle-brachial index (ABI) with transcutaneous oxygen pressure (TcPO2 ) in assessing peripheral vascular disease (PVD) prevalence in 100 diabetic foot ulcer (DFU) patients. Patients were categorized into vascular or nonvascular reconstruction groups and underwent both ABI and TcPO2 measurements four times over 6 months. Predictive validity for PVD diagnosis was analysed using the area under the receiver-operating characteristic curve (AUC). The study found TcPO2 to be a superior predictor of PVD than ABI. Among the DFU patients, 51 with abnormal TcPO2 values underwent vascular reconstruction. Only TcPO2 values showed significant pretreatment differences between the groups and increased post-reconstruction. These values declined over a 6-month follow-up, whereas ABI values rose. For those with end-stage renal disease (ESRD), TcPO2 values saw a sharp decrease within 3 months. Pre-reconstruction TcPO2 was notably lower in amputation patients versus limb salvage surgery patients. In conclusion, TcPO2 is more effective than ABI for evaluating ischemic limb perfusion and revascularization necessity. It should be prioritized as the primary follow-up tool, especially for ESRD patients.

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.

Diabetic microvascular disease in non-classical beds: the hidden impact beyond the retina, the kidney, and the peripheral nerves

Diabetes microangiopathy, a hallmark complication of diabetes, is characterised by structural and functional abnormalities within the intricate network of microvessels beyond well-known and documented target organs, i.e., the retina, kidney, and peripheral nerves. Indeed, an intact microvascular bed is crucial for preserving each organ's specific functions and achieving physiological balance to meet their respective metabolic demands. Therefore, diabetes-related microvascular dysfunction leads to widespread multiorgan consequences in still-overlooked non-traditional target organs such as the brain, the lung, the bone tissue, the skin, the arterial wall, the heart, or the musculoskeletal system. All these organs are vulnerable to the physiopathological mechanisms that cause microvascular damage in diabetes (i.e., hyperglycaemia-induced oxidative stress, inflammation, and endothelial dysfunction) and collectively contribute to abnormalities in the microvessels' structure and function, compromising blood flow and tissue perfusion. However, the microcirculatory networks differ between organs due to variations in haemodynamic, vascular architecture, and affected cells, resulting in a spectrum of clinical presentations. The aim of this review is to focus on the multifaceted nature of microvascular impairment in diabetes through available evidence of specific consequences in often overlooked organs. A better understanding of diabetes microangiopathy in non-target organs provides a broader perspective on the systemic nature of the disease, underscoring the importance of recognising the comprehensive range of complications beyond the classic target sites.

High glucose-induced IL-7/IL-7R upregulation of dermal fibroblasts inhibits angiogenesis in a paracrine way in delayed diabetic wound healing

It is widely acknowledged that diabetes leads to slow wound healing and ulceration, and severe serious diabetic foot ulceration may result in amputation. In recent years, much emphasis has been placed on exploring diabetic wound healing to protect patients from adverse events. We recently found interleukin-7 (IL-7), a growth factor for B-cells and T-cells, and its receptor was significantly upregulated in high glucose-induced fibroblasts and skin of diabetic mice. Moreover, IL-7 stimulated fibroblasts secreted ANGPTL4, which inhibited angiogenesis of endothelial cells resulting in delayed wound healing. In our previous study, fibroblasts, endothelial cells and keratinocytes were exposed to normal glucose (5.5 mM) or high glucose (30 mM) medium for 24 h, and RNA sequencing showed that IL-7 and IL-7R were significantly upregulated in fibroblasts. To remove the effect of high glucose and explore the influence of IL-7, exogenous rMuIL-7 used to treat normal mice led to delayed wound healing by inhibiting angiogenesis. Vitro experiments revealed that IL-7-induced fibroblasts inhibited endothelial cell proliferation, migration and angiogenesis. Further experiments showed that fibroblast angiopoietin-like-4 (ANGPTL4) secretion exhibited the inhibitory effect which was blocked by culture with the corresponding neutralizing antibody. Overall, our study revealed signaling pathways associated with diabetic wound healing and provided the foothold for further studies on delayed wound healing in this patient population. Mechanism that high glucose activates IL-7-IL-7R-ANGPTL4 signal pathway in delayed wound healing. High glucose upregulates IL-7 and IL-7R in dermal fibroblasts. IL-7 stimulates dermal fibroblasts secreting Angptl4 which inhibits proliferation, migration and angiogenesis of endothelial cells in a paracrine way.

Circulating Angiogenic Factors and Ischemic Diabetic Foot Syndrome Advancement-A Pilot Study

Despite clear evidence of inadequate angiogenesis in ischemic diabetic foot syndrome (DFS) pathogenesis, angiogenic factor level changes in patients with ischemic DFS remain inconsistent. This study aimed to assess circulating angiogenic factors concerning ischemic DFS advancement and describe their relationships with patients' clinical characteristics, microvascular parameters, and diabetic control. The study included 41 patients with ischemic DFS (67.3 (8.84) years; 82.9% males). Angiogenic processes were assessed by identifying circulating concentrations of five pro- and two anti-angiogenic factors. We found that penetrating ulcers were related to a significantly higher FGF-2 level (8.86 (5.29) vs. 5.23 (4.17) pg/mL, p = 0.02). Moreover, plasma FGF-2 showed a significant correlation with the SINBAD score (r = 0.32, p = 0.04), platelet count (r = 0.43, p < 0.01), white cell count (r = 0.42, p < 0.01), and age (r = -0.35, p = 0.03). We did not observe any significant linear relationship between the studied biomarkers and microcirculatory parameters, nor for glycemic control. In a univariate analysis using logistic regression, an increase in plasma FGF-2 was tied to greater odds of high-grade ulcers (OR 1.16; 95% CI 1.02-1.38, p = 0.043). This suggests that circulating FGF-2 may serve as a potential biomarker for predicting DFU advancement and progression. It is necessary to conduct further studies with follow-up observations to confirm this hypothesis.

Therapeutic role of growth factors in treating diabetic wound

Wounds in diabetic patients, especially diabetic foot ulcers, are more difficult to heal compared with normal wounds and can easily deteriorate, leading to amputation. Common treatments cannot heal diabetic wounds or control their many complications. Growth factors are found to play important roles in regulating complex diabetic wound healing. Different growth factors such as transforming growth factor beta 1, insulin-like growth factor, and vascular endothelial growth factor play different roles in diabetic wound healing. This implies that a therapeutic modality modulating different growth factors to suit wound healing can significantly improve the treatment of diabetic wounds. Further, some current treatments have been shown to promote the healing of diabetic wounds by modulating specific growth factors. The purpose of this study was to discuss the role played by each growth factor in therapeutic approaches so as to stimulate further therapeutic thinking.

All-in-one bioactive properties of photothermal nanofibers for accelerating diabetic wound healing

Diabetic wound healing has attracted widespread attention in biomedical engineering. However, the harsh hypoxic microenvironment (HME) comprising high glucose levels, local bleeding, and bacterial infection often leads to the formation of hyperplastic scars, increasing the clinical demand for wound dressings. Here, we report a comprehensive strategy using near-infrared NIR-assisted oxygen delivery combined with the bioactive nature of biopolymers for remodeling the HME. Black phosphorus (BP) nanosheets and hemoglobin (Hb) were self-assembled layerwise onto electrospun poly-l-lactide (PLLA) nanofibers using charged quaternized chitosan (QCS) and hyaluronic acid. BP converts NIR radiation into heat and stimulates Hb to release oxygen in situ. QCS is a hemostatic and broad-spectrum antibacterial material. Moderate BP-derived photothermal therapy can increase the sensitivity of bacteria to QCS. A series of composite wound dressings (coded as PQBH-n) with different numbers of layers were fabricated, and the in vivo diabetic wound healing potentials were tested. The molecular mechanism can be partly attributed to the cytokine-cytokine receptor interaction. Notably, this comprehensive strategy based on NIR-assisted oxygen delivery combined with the bioactive properties of biopolymers is not only applicable for fabricating multifunctional wound dressings but also has a great potential in expanding biomedical engineering fields.

Pharmacological blockade of HDAC3 accelerates diabetic wound healing by regulating macrophage activation

AIMS

Here, we report the effect of histone deacetylase 3 (HDAC3) inhibition associated with macrophage activation, IL-1β expression, angiogenesis and wound healing in diabetic mice.

MAIN METHODS

To determine the expression of HDAC3 in diabetic mice wounds, hyperglycemia was induced in C57BL/6 mice with streptozotocin followed by induction of 6 mm wounds. To understand the effect of HDAC3 selective inhibitor, BG45, wound tissues were isolated for analysing M1/M2 markers expression, immune cells infiltration, angiogenesis and healing factors expression. CD11b⁺F4/80⁺ cells were sorted from the wound tissues and analysed for the expression of M1/M2 markers using RT-qPCR and flow cytometer. In cell based assays, HDAC3 expression was measured in macrophages stimulated with high glucose (HG) plus LPS. Macrophages treated with BG45 and HG + LPS were analysed for the expression of pro-IL-1β, mature IL-1β, oxidative stress and pro-inflammatory (M1) and anti-inflammatory (M2) factors.

KEY FINDINGS

HDAC3 was found to be upregulated in impaired diabetic mice wounds and in macrophages stimulated with HG + LPS. Topical application of BG45 loaded gel accelerated the wound healing in diabetic mice and was evident by improved expression of Collagen-1A, IL-10, TGF-β, and angiogenesis (CD31, VEGF). BG45 treatment decreased the expression of IL-1β, TNF-α, and IL-6 (M1 phenotype), reduced oxidative stress and promoted the expression of Arginase-1 and YM1/2 (M2 phenotype) in macrophages treated with HG + LPS. BG45 also improved the expression of CD11b⁺F4/80⁺CD206⁺ cells in wound tissues and reduced expression of inflammatory markers.

SIGNIFICANCE

HDAC3 is upregulated in diabetic mice wounds and HDAC3 selective inhibitor promotes the wound healing by regulating macrophage activation, angiogenesis and IL-1β.

Chitosan-based electrospun nanofibers for diabetic foot ulcer management; recent advances

Diabetic foot ulcer (DFU) healing has long been a major medical challenge. The type of dressing is an essential factor in wound healing, prevention of local infection, and scar formation. Today, smart wound dressings or wound healing patches can precisely control drug delivery to the target tissue and prevent this significant complication. Nanofiber (NF) wound dressings are effective in reducing wound scarring and helping to speed up the healing process for DFU. The electrospun NFs have a suitable surface topography, density, and three-dimensional structure, which can be considered an efficient method to produce a substrate for tissue engineering and wound healing. Chitosan (CS) is one of the most well-known biopolymers in wound healing tissue engineering and drug delivery systems. The unique properties of CS make it suitable for biomedical applications. Based on new studies in the field of hemostatic and antimicrobial effects of CS in controlling bleeding and wound healing and application of NF wound dressings, the purpose of this study is a review relevant works on CS-based NFs to improve the DFU.

Monitoring and recovery of hyperglycaemia-induced endothelial dysfunction with rheopheresis in diabetic lower extremity ulceration with hyperviscosity

AIMS

Rheopheresis is an extracorporeal haematotherapy that improves haemorheological status by filtering proteins that enhance blood viscosity. It also has anti-inflammatory effects by removing inflammatory cytokines. Our study aims to examine the effects of rheopheresis on the endothelial status in diabetic lower extremity ulceration.

METHODS

In vitro experiments were performed in a HUVEC model to mimic hyperglycaemic stress. We determined the changes in gene expression levels of IL-6, IL-8, TNF-alpha, endothelin convertase enzyme, ET-1, and NO synthase, as well as the ROS and intracellular GSH levels upon hyperglycaemia. In in vivo studies, two rheopheresis procedures were performed on seven patients with diabetic lower extremity ulceration with hyperviscosity, and we measured the changes in plasma concentrations of ET-1, TXB2, SOD enzyme activity, and extracellular components of the glutathione pool depending on treatments.

RESULTS

Our results showed that hyperglycaemia increases endothelial expression of inflammatory cytokines, ET-1, and endothelin convertase enzyme, while NO synthase was decreased. As a result of rheopheresis, we observed decreased ET-1 and TXB2 concentrations in the plasma and beneficial changes in the parameters of the glutathione pool.

CONCLUSION

To summarize our results, hyperglycaemia-induced oxidative stress and endothelial inflammation can be moderated by rheopheresis in diabetic lower extremity ulceration with hyperviscosity.

Topical Wound Treatment with a Nitric Oxide-Releasing PDE5 Inhibitor Formulation Enhances Blood Perfusion and Promotes Healing in Mice

Chronic, non-healing wounds constitute a major health problem, and the current therapeutic options are limited. Therefore, pharmaceuticals that can be locally applied to complicated wounds are urgently needed. Such treatments should directly target the underlying causes, which include diabetes mellitus, chronic local pressure and/or vascular insufficiency. A common consequence of these disorders is impaired wound angiogenesis. Here, we investigated the effect of topical application of a nitric oxide-releasing phosphodiesterase 5 inhibitor (TOP-N53)-containing liquid hydrogel on wound repair in mice. The drug-loaded hydrogel promoted re-epithelialization and angiogenesis in wounds of healthy and healing-impaired diabetic mice. Using a non-invasive label-free optoacoustic microscopy approach combined with automated vessel analysis, we show that the topical application of TOP-N53 formulation increases the microvascular network density and promotes the functionality of the newly formed blood vessels, resulting in enhanced blood perfusion of the wounds. These results demonstrate a remarkable healing-stimulating activity of topically applied TOP-N53 formulation, supporting its further development as a wound therapeutic.

Evolving spectrum of diabetic wound: Mechanistic insights and therapeutic targets

Diabetes mellitus is a chronic metabolic disorder resulting in an increased blood glucose level and prolonged hyperglycemia, causes long term health conse-quences. Chronic wound is frequently occurring in diabetes patients due to compromised wound healing capability. Management of wounds in diabetic patients remains a clinical challenge despite many advancements in the field of science and technology. Increasing evidence indicates that alteration of the biochemical milieu resulting from alteration in inflammatory cytokines and matrix metalloproteinase, decrease in fibroblast and keratinocyte functioning, neuropathy, altered leukocyte functioning, infection, etc., plays a significant role in impaired wound healing in diabetic people. Apart from the current pharmacotherapy, different other approaches like the use of conventional drugs, antidiabetic medication, antibiotics, debridement, offloading, platelet-rich plasma, growth factor, oxygen therapy, negative pressure wound therapy, low-level laser, extracorporeal shock wave bioengineered substitute can be considered in the management of diabetic wounds. Drugs/therapeutic strategy that induce angiogenesis and collagen synthesis, inhibition of MMPs, reduction of oxidative stress, controlling hyperglycemia, increase growth factors, regulate inflammatory cytokines, cause NO induction, induce fibroblast and keratinocyte proliferation, control microbial infections are considered important in controlling diabetic wound. Further, medicinal plants and/or phytoconstituents also offer a viable alternative in the treatment of diabetic wound. The focus of the present review is to highlight the molecular and cellular mechanisms, and discuss the drug targets and treatment strategies involved in the diabetic wound.

Aerobic exercise-induced circulating extracellular vesicle combined decellularized dermal matrix hydrogel facilitates diabetic wound healing by promoting angiogenesis

Background: Insufficient blood supply results in unsatisfactory wound healing, especially for challenging wound repair such as diabetic wound defects. Regular exercise training brings a lot of benefits to cardiovascular fitness and metabolic health including attenuation of T2DM progression. Circulating extracellular vesicles (EVs) are postulated to carry a variety of signals involved in tissue crosstalk by their modified cargoes, representing novel mechanisms for the effects of exercise. Prominently, both acute and chronic aerobic exercise training can promote the release of exercise-induced cytokines and enhance the angiogenic function of circulating angiogenic cell–derived EVs.

Methods: We investigated the possible angiogenesis potential of aerobic exercise-induced circulating EVs (EXE-EVs) on diabetic wound healing. Circulating EVs were isolated from the plasma of rats subjected to 4 weeks of moderate aerobic exercise or sedentariness 24 h after the last training session. The therapeutic effect of circulating EVs was evaluated in vitro by proliferation, migration, and tube formation assays of human umbilical vein endothelial cells (HUVECs), as well as in vivo by quantification of angiogenesis and cutaneous wound healing in diabetic rats.

Results: The number of circulating EVs did not change significantly in exercised rats 24 h post-exercise in comparison with the sedentary rats. Nevertheless, EXE-EVs showed remarkable pro-angiogenic effect by augmenting proliferation, migration, and tube formation of HUVECs. Furthermore, the findings of animal experiments revealed that the EXE-EVs delivered by decellularized dermal matrix hydrogel (DDMH) could significantly promote the repair of skin defects through stimulating the regeneration of vascularized skin.

Discussion: The present study is the first attempt to demonstrate that aerobic exercise-induced circulating EVs could be utilized as a cell-free therapy to activate angiogenesis and promote diabetic wound healing. Our findings suggest that EXE-EVs may stand for a potential strategy for diabetic soft tissue wound repair.

Immunomodulatory Bandage for Accelerated Healing of Diabetic Wounds

Diabetic foot ulcers are challenging to treat. Current strategies to treat these wounds focus on preventing infection and promoting tissue regrowth but are ineffective in many individuals. Low-grade chronic inflammation is present in individuals with diabetes, and altering the inflammatory responses at the wound site could be an alternate approach to promote healing. We hypothesized that immunomodulation of the wound microenvironment would result in accelerated healing. To test this hypothesis, we began by characterizing the changes in the myeloid cell phenotype in a mouse model [leptin receptor knockout (KO) mouse] that closely mimics the type 2 diabetes condition observed in humans. We observed increased numbers of monocytes and neutrophils in the circulation of the KO mice compared to that in wild-type control mice. We also observed several phenotypic changes in neutrophils from the KO diabetic mice, suggesting low-grade systemic inflammation. Hence, we developed a rapamycin-loaded chitosan scaffold that may be used to modulate immune responses. The use of these immunomodulatory scaffolds at a wound site resulted in accelerated healing compared to the healing using blank scaffolds. In summary, our data suggest that immunomodulation may be a viable strategy to promote the healing of wounds in individuals with diabetes.

Copper and cobalt doped bioactive glass-fish dermal collagen electrospun mat triggers key events of diabetic wound healing in full-thickness skin defect model

The wounds arising out of underlying hyperglycemic conditions such as diabetic foot ulcers demand a multifunctional tissue regeneration approach owing to several deficiencies in the healing mechanisms. Herein, four different types of electrospun microfibers by combining Rohu fish skin-derived collagen (Fcol) with a bioactive glass (BAG)/ion-doped bioactive glass, namely, Fcol/BAG, Fcol/CuBAG, Fcol/CoBAG, and Fcol/CuCoBAG was developed to accelerate wound healing through stimulation of key events such as angiogenesis and ECM re-construction under diabetic conditions. SEM analysis shows the porous and microfibrous architecture, while the EDX mapping provides evidence of the incorporation of dopants inside various inorganic-organic composite mats. The viscoelastic properties of the microfibrous mats as measured by a nano-DMA test show a higher damping factor non-uniform tan-delta value. The maximum ultimate tensile strength and toughness are recorded for fish collagen with copper doped bioactive glass microfibers while the least values are demonstrated by microfibers with cobalt dopant. In vitro results demonstrate excellent cell-cell and cell-material interactions when human dermal fibroblasts (HDFs) were cultured over the microfibers for 48 h. When these mats were applied over full-thickness diabetic wounds in the rabbit model, early wound healing is attained with Fcol/CuBAG, Fcol/CoBAG, and Fcol/CuCoBAG microfibers. Notably, these microfibers-treated wounds demonstrate a significantly (p < 0.01) higher density of blood vessels by CD-31 immunostaining than control, Duoderm, and Fcol/BAG treated wounds. Mature collagen deposition and excellent ECM remodeling are also evident in wounds treated with fish collagen/ion-doped bioactive glass microfibers suggesting their positive role in diabetic wound healing.

Preparation and characterization of vaccarin, hypaphorine and chitosan nanoparticles and their promoting effects on chronic wounds healing

Chronic wounds have become an important factor hindering human health, affecting tens of millions of people worldwide, especially diabetic wounds. Based on the antibacterial properties of chitosan, the angiogenesis promoting effect of vaccarin (VAC) and the anti-inflammatory effect of hypaphorine (HYP), nanoparticles with high bioavailability were prepared. VAC, HYP and chitosan nanoparticles (VAC + HYP-NPS) were used to the treatment of chronic wounds. Transmission electron microscopy (TEM) images showed the nanoparticles were spherical. ZetaPALS showed the potential of nanoparticles were -12.8 ± 5.53 mV and the size were 166.8 ± 29.95 nm. Methyl thiazolyl tetrazolium (MTT) assay showed that VAC + HYP-NPS had no toxicity and the biocompatibility was satisfactory. In the treatment of chronic wounds in diabetic rats, VAC + HYP-NPS significantly promoted the re-epithelialization of chronic wounds and accelerated the healing of chronic wounds. In the process of chronic wounds healing, VAC + HYP-NPS played the antibacterial effect of chitosan, the angiogenic effect of VAC and the anti-inflammatory effect of HYP, and finally promoted the chronic wounds healing. Overall, the developed VAC + HYP-NPS have potential application in chronic wounds healing. In view of the complexity of the causes of chronic wounds, multi-target drug administration may be an effective way to treat chronic wounds.

Vascular ageing and peripheral pulse: an improved model for assessing their relationship

Objective.Vascular ageing is associated with several alterations, including arterial stiffness and endothelial dysfunction. Such alterations represent an independent factor in the development of cardiovascular disease (CVD). In our previous works we demonstrated the alterations occurring in the vascular system are themselves reflected in the shape of the peripheral waveform; thus, a model that describes the waveform as a sum of Gaussian curves provides a set of parameters that successfully discriminate betweenunder(≤35 years old) andoversubjects (>35 years old). In the present work, we explored the feasibility of a new decomposition model, based on a sum of exponential pulses, applied to the same problem.Approach.The first processing step extracts each pulsation from the input signal and removes the long-term trend using a cubic spline with nodes between consecutive pulsations. After that, a Least Squares fitting algorithm determines the set of optimal model parameters that best approximates each single pulse. The vector of model parameters gives a compact representation of the pulse waveform that constitutes the basis for the classification step. Each subject is associated to his/her 'representative' pulse waveform, obtained by averaging the vector parameters corresponding to all pulses. Finally, a Bayesan classifier has been designed to discriminate the waveforms of under and over subjects, using the leave-one-subject-out validation method.Main results.Results indicate that the fitting procedure reaches a rate of 96% in under subjects and 95% in over subjects and that the Bayesan classifier is able to correctly classify 91% of the subjects with a specificity of 94% and a sensibility of 84%.Significance.This study shows a sensible vascular age estimation accuracy with a multi-exponential model, which may help to predict CVD.

11,12 Epoxyeicosatrienoic Acid Rescues Deteriorated Wound Healing in Diabetes

Epoxyeicosatrienoic acids (EET) facilitate regeneration in different tissues, and their benefit in dermal wound healing has been proven under normal conditions. In this study, we investigated the effect of 11,12 EET on dermal wound healing in diabetes. We induced diabetes by i.p. injection of streptozotocin 2 weeks prior to wound creation on the dorsal side of the mouse ear. 11,12 EET was applied every second day on the wound, whereas the control groups received only solvent. Epithelialization was monitored every second day intravitally up to wound closure. Wounds were stained for VEGF, CD31, TGF-β, TNF-α, SDF-1α, NF-κB, and Ki-67, and fibroblasts were counted after hematoxylin-eosin stain on days 3, 6, 9, and 16 after wounding. After induction of diabetes, wounds closed on day 13.00 ± 2.20 standard deviation (SD). Local 11,12 ETT application improved wound closure significantly to day 8.40 ± 1.39 SD. EET treatment enhanced VEGF and CD31 expression in wounds on day 3. It also seemed to raise TNF-α level on all days investigated as well as TGF-β level on days 3 and 6. A decrease in NF-κB could be observed on days 9 and 16 after EET application. The latter findings were not significant. SDF-1α expression was not influenced by EET application, and Ki-67 was significantly less in the EET group on day 9 after EET application. The number of fibroblasts was significantly increased on day 9 after the 11,12 EET application. 11,12 EET improve deteriorated wound healing in diabetes by enhancing neoangiogenesis, especially in the early phase of wound healing. Furthermore, they contribute to the dissolution of the initial inflammatory reaction, allowing the crucial transition from the inflammatory to proliferative phase in wound healing.

The effect of rheopheresis treatment on the cytokine profile in diabetic foot syndrome with hyperviscosity in the aspect of clinical changes: A preliminary study

BACKGROUND

Rheopheresis is a selective extracorporal double cascade filtration treatment, which can extract high molecular weight proteins being responsible for hyperviscosity. As the whole blood and plasma viscosity decrease microcirculation improves.

OBJECTIVE

In this preliminary study we aimed to analyze additional beneficial effects of rheopheresis treatment with changes of pro-inflammantory cytokine levels in diabetic foot syndrome patients.

METHODS

Two rheopheresis treatments were performed for 6 patients with diabetic foot ulcer and/or neuropathy on consecutive days. Before and after the treatments whole blood and plasma viscosity, as well as IL-6, IL-8, and TNF-alpha serum levels were determined, and complex angiological and ENG examinations were performed.

RESULTS

Rheopheresis decreased the whole blood and plasma viscosity, and the serum levels of IL-6, IL-8, and TNF-alpha were markedly reduced. The life quality of the patients improved, the ulcers healed, the pain decreased. Daily dose of analgesics decreased in the follow-up period (6 months). The ENG showed improving amplitude and/or normalizing conduction speed.

CONCLUSION

Application of rheopheresis in patients with diabetic foot syndrome has a beneficial effect, providing favorable rheological condition, normalizing cytokine profile and reducing the sensorineural symptoms.

Chemokine-Capturing Wound Contact Layer Rescues Dermal Healing

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

An Integrated Smart Sensor Dressing for Real-Time Wound Microenvironment Monitoring and Promoting Angiogenesis and Wound Healing

Prolonged chronic wound healing not only places great stress on patients but also increase the health care burden. Fortunately, the emergence of tissue-engineered dressings has provided a potential solution for these patients. Recently, the relationship between the wound microenvironment and wound healing has been gradually clarified. Therefore, the state of wounds can be roughly ascertained by monitoring the microenvironment in real time. Here, we designed a three-layer integrated smart dressing, including a biomimetic nanofibre membrane, microenvironment sensor and β-cyclodextrin-containing gelatine methacryloyl (GelMA + β-cd) UV-crosslinked hydrogel. The hydrogel helped increase the expression of vascular endothelial growth factor (VEGF) through hypoxia-inducible factor-1α (HIF-1α) to promote neovascularization and wound healing. The microenvironment sensor, combined with the biological dressings, exhibited satisfactory measurement accuracy, stability, durability and biocompatibility. A BLE4.0 antenna was used to receive, display and upload wound microenvironment data in real time. Such integrated smart dressings can not only achieve biological functions but also monitor changes in the wound microenvironment in real time. These dressings can overcome the challenge of not knowing the state of the wound during the healing process and provide support for clinical work.

Macrophage regulation of angiogenesis in health and disease

Macrophages are primarily known as phagocytic innate immune cells, but are, in fact, highly dynamic multi-taskers that interact with many different tissue types and have regulatory roles in development, homeostasis, tissue repair, and disease. In all of these scenarios angiogenesis is pivotal and macrophages appear to play a key role in guiding both blood vessel sprouting and remodelling wherever that occurs. Recent studies have explored these processes in a diverse range of models utilising the complementary strengths of rodent, fish and tissue culture studies to unravel the mechanisms underlying these interactions and regulatory functions. Here we discuss how macrophages regulate angiogenesis and its resolution as embryonic tissues grow, as well as their parallel and different functions in repairing wounds and in pathologies, with a focus on chronic wounds and cancer.

Impaired dermal microvascular reactivity and implications for diabetic wound formation and healing: an evidence review

Diabetic foot ulcers (DFUs) are among the most consequential and costly complications faced by patients with diabetes and the global healthcare system. Acknowledged risk factors for DFUs include diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD), microtrauma and foot deformities. Research on additional risk factors for DFUs has recently focused on dysregulated, autonomic vasomotor control in the skin of patients with DPN. In particular, impaired dermal microvascular reactivity (IDMR) with its attendant reduction in nutritive capillary blood flow has been identified as an emerging risk factor. This especially relates to refractory wounds noted in patients without overt PAD signs. In this paper, evidence will be reviewed supporting the evolving understanding of IDMR and its impact on DFU formation and healing. Advances in diagnostic instrumentation driving this research along with the most promising potential therapies aimed at improving microvascular function in the diabetic foot will be discussed in brief.

Polymeric Composite Dressings Containing Calcium-Releasing Nanoparticles Accelerate Wound Healing in Diabetic Mice

Objective: Wound healing is a complex process that involves the interaction between different cell types and bioactive factors. Impaired wound healing is characterized by a loss in synchronization of these interactions, resulting in nonhealing chronic wounds. Chronic wounds are a socioeconomic burden, one of the most prominent clinical manifestations of diabetes, however, they lack satisfactory treatment options. The objective of this study was to develop polymeric composites that deliver ions having wound healing properties and evaluate its performance using a pressure ulcer model in diabetic mice. Approach: To develop a polymeric composite wound dressing containing ion-releasing nanoparticles for chronic wound healing. This composite was chemically and physically characterized and evaluated using a pressure ulcer wound model in diabetic (db/db) mice to explore their potential as novel wound dressing. Results: This dressing exhibits a controlled ion release and a good in vitro bioactivity. The polymeric composite dressing treatment stimulates angiogenesis, collagen synthesis, granulation tissue formation, and accelerates wound closure of ischemic wounds created in diabetic mice. In addition, the performance of the newly designed composite is remarkably better than a commercially available dressing frequently used for the treatment of low-exuding chronic wounds. Innovation: The developed nanoplatforms are cell- and growth factor free and control the host microenvironment resulting in enhanced wound healing. These nanoplatforms are available by cost-effective synthesis with a defined composition, offering an additional advantage in potential clinical application. Conclusion: Based on the obtained results, these polymeric composites offer an optimum approach for chronic wound healing without adding cells or external biological factors.

Impact of resolvin mediators in the immunopathology of diabetes and wound healing

Introduction: Wound healing in diabetes may be delayed by persistent wound infection due to deficient immune and cellular response to tissue injury. Hyperglycemia due to decreased insulin availability and increased insulin resistance affects the immune response of the body. Accumulation of inflammatory immune cells and pro-inflammatory cytokines results in chronic inflammation and an altered resolution and remodeling phase of wound healing.Areas covered: Pro-resolving mediators called 'resolvins' target the resolution phase of wound healing and are becoming an area of increased interest. Resolvins stimulate self-limited innate immune responses and enhance innate microbial killing and clearance. Resolvins resolve inflammation by decreasing neutrophil infiltration and transmigration, increasing the phagocytic activity of macrophages, decreasing adipose tissue macrophages, downregulating platelet activation, suppressing nuclear factor-kappa beta activation, promoting the apoptosis of polymorphonuclear leukocytes, and improving insulin sensitivity. This review discusses the role of resolvins in diabetic wound healing and potential therapeutic strategies. The review is based on a literature search of PubMed and the Web of Science restricted to publications between January 2001 and October 2020.Expert opinion: There is increasing support for the use of resolvins in clinical applications related to diabetes and wound healing. Further research will help clarify this potential.

Predictors of wound leakage in patients undergoing surgery for neck of femur fractures

AIMS

Persistent wound leakage following joint arthroplasty is a known risk for periprosthetic joint infection. Little is known of the predictors of wound leakage, particularly in patients with a fractured neck of femur. We aimed to determine patient and surgical risk factors for wound leakage in this cohort.

MATERIALS AND METHODS

All patients undergoing surgery for a fractured neck of femur at Leicester Royal Infirmary between May and August 2017 were included. Patients were identified from a prospective database and placed into two groups: those with wound leakage later than three days postoperatively and those without leakage. All previously reported potential risk factors for wound leakage were compared between groups using a chi-square test and logistic regression. A Kattan-style nomogram was also created to allow probabilities output for the regression predictive models in a visual representation.

RESULTS

Two hundred patients underwent surgery for a fractured neck of femur. Overall, 17% of patients (33/200) developed a persistent leaky wound. A multivariable model highlighted increased age (p = 0.01), raised body mass index (BMI; > 25 kg/m²; p = 0.047), diabetes (p = 0.03) and intramedullary hip screw fixation (p = 0.03) as significant risk factors for wound leakage. Patients with persistent wound leakage had significantly longer hospital admission than those without (p = 0.001).

DISCUSSION

Our analysis identified four perioperative risk factors for wound leakage following fractured neck of femur surgery. We also developed a novel tool to identify those patients at highest risk of leakage. Once identified, the aggressive management of certain medical comorbidities in these patients may help to reduce their incidence of wound issues and the prolonged admissions that result.

Wound fluid under occlusive dressings from diabetic patients show an increased angiogenic response and fibroblast migration

INTRODUCTION

Metabolic diseases like diabetes mellitus often show prolonged healing and chronic wounds. Occlusive wound dressings are known to support wound closure by creating a moist environment which supports collagen synthesis, epithelialization and angiogenesis. We aimed to assess the effect of occlusion on diabetic wound fluid on the cellular level regarding fibroblast activity and angiogenetic response.

MATERIAL AND METHODS

22 split skin donor sites from 22 patients (11 patients with diabetes mellitus) were treated with occlusive dressings intraoperatively. On day 3, fluid and blood serum samples were harvested while changing the dressings. The influence of wound fluid on fibroblasts was assessed by measuring metabolic activity (Alamar Blue assay, Casey Counter), cell stress/death (LDH assay) and migration (in vitro wound healing assay) of fibroblasts. Angiogenesis of endothelial cells (HUVEC) was analyzed with the tube formation assay. Furthermore, a Magnetic Luminex Assay for multi-cytokines detection was performed focusing on inflammatory and pro-angiogenetic cytokines.

RESULTS

The influence of wound fluid under occlusive dressings from diabetic patients showed a significantly increased angiogenic response and fibroblast migration compared to the non-diabetic patient group. Additionally, cell stress was increased in the diabetic group. Cytokine analysis showed an increase in VEGF-A in the diabetic group.

CONCLUSION

Occlusive dressings may stimulate regenerative effects in diabetic wounds. Our in-vitro study shows the influence of wound fluid under occlusive dressings from diabetic patients on angiogenesis, migration and proliferation of fibroblasts, which are essential modulators of wound healing and scar modulation.

Endothelial Cell Glucose Metabolism and Angiogenesis

Angiogenesis, a process of new blood vessel formation from the pre-existing vascular bed, is a critical event in various physiological and pathological settings. Over the last few years, the role of endothelial cell (EC) metabolism in angiogenesis has received considerable attention. Accumulating studies suggest that ECs rely on aerobic glycolysis, rather than the oxidative phosphorylation pathway, to produce ATP during angiogenesis. To date, numerous critical regulators of glucose metabolism, fatty acid oxidation, and glutamine metabolism have been identified to modulate the EC angiogenic switch and pathological angiogenesis. The unique glycolytic feature of ECs is critical for cell proliferation, migration, and responses to environmental changes. In this review, we provide an overview of recent EC glucose metabolism studies, particularly glycolysis, in quiescent and angiogenic ECs. We also summarize and discuss potential therapeutic strategies that take advantage of EC metabolism. The elucidation of metabolic regulation and the precise underlying mechanisms could facilitate drug development targeting EC metabolism to treat angiogenesis-related diseases.

Outcome analysis of lumbar endoscopic unilateral laminotomy for bilateral decompression in patients with degenerative lumbar central canal stenosis

BACKGROUND CONTEXT

Lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has been reported as an alternative treatment for degenerative lumbar central canal stenosis (DLCS).

PURPOSE

To investigate the outcomes of LE-ULBD for different types of DLCS, including simple DLCS, DLCS with degenerative spondylolisthesis (DSL), and DLCS with degenerative scoliosis (DSC).

STUDY DESIGN/SETTING

Prospective cohort study.

PATIENT SAMPLE

One-hundred sixteen patients with DLCS who underwent LE-ULBD at a spine center from April 2015 to June 2017 were enrolled in this study.

OUTCOME MEASURES

Operative time, postoperative duration of hospitalization, and clinical outcomes (Oswestry disability index [ODI], visual analog scale [VAS], and modified Macnab outcome scale), and adverse events.

METHODS

A comparative analysis was performed evaluating medical records, radiological studies, and patient reported outcomes including ODI score, VAS scores and modified Macnab outcome scales in patients who underwent LE-ULBD. Data were prospectively collected at preoperative, postoperative 3-, 6-, 12-, 24-month to assess clinical and radiological outcomes and complications.

RESULTS

The study analyzed 106 patients (45 men and 61 women, with a mean age of 69.5 years); 40 (37.8%) had simple DLCS, 41 (38.7%) had DLCS with DSL, and 25 (23.5%) had DLCS with DSC. The mean follow-up period was 33.3 months. The mean preoperative and postoperative follow-up ODI score and VAS scores for leg and back pain showed significant improvement in all time points. No significant difference was found among different pathologies in terms of VAS scores for back and leg pain, ODI scores and modified Macnab outcome scales at all follow-up periods.

CONCLUSIONS

LE-ULBD is a feasible treatment method for DLCS. It did not result in worse outcomes in cases with DLCS with DSL or DLCS with DSC as compared with cases with simple DLCS.

Advances of hydrogel dressings in diabetic wounds

The hydrogel dressings with various functions for diabetic wound treatment.

Videocapillaroscopy of the Oral Mucosa in Patients with Diabetic Foot: Possible Diagnostic Role of Microangiopathic Damage?

INTRODUCTION

Diabetic foot represents one of the most serious and expensive complications of diabetes and is subject to a high percentage of amputations that are almost always preceded by ulcers ascribable to neuropathy and/or vasculopathy. Videocapillaroscopy (VCS) can be a valuable aid in order to uncover morpho-structural anomalies in the vascular bed, both at the level of the oral mucosa and at the level of the terminal vessels of the lower limb.

MATERIALS AND METHODS

Sixty subjects divided into 4 groups were enrolled: 15 healthy subjects; 15 patients with diabetes for more than 10 years without ulcerative foot lesions; 15 patients with neuropathic diabetic foot (clinical diagnosis, MDNS); 15 patients with ischemic diabetic foot (clinical diagnosis, ABI, lower limb doppler). A complete videocapillaroscopic mapping of the oral mucosa was carried out on each patient. The areas investigated were: labial mucosa, the retro-commissural region of the buccal mucosa, and the vestibular masticatory mucosa (II and V sextant).

RESULTS

The analysis of the morphological and densitometric characteristics of the capillaries revealed the following: a significant reduction in capillary density in neuropathic (mean ± SD 7.32 ± 2.1) and ischemic patients (mean ± SD 4.32 ± 3.2) compared to the control group of patients (both diabetic mean ± SD 12.98 ± 3.1 and healthy mean ± SD 19.04 ± 3.16) (ANOVA test and Bonferroni t test p < 0.05); a reduction in the average length of the capillaries and a significant increase in tortuosity (ANOVA test and Bonferroni t test p < 0.05). In the neuropathic patients, a recurrent capillaroscopic pattern that we defined as "sun" was found, with capillaries arranged radially around an avascular area.

CONCLUSIONS

The data obtained from this preliminary study suggest a potential diagnostic role of oral capillaroscopy in the early and subclinical identification of microangiopathic damage in patients with diabetic foot.

Promote anti-inflammatory and angiogenesis using a hyaluronic acid-based hydrogel with miRNA-laden nanoparticles for chronic diabetic wound treatment

Chronic diabetic wound causes serious threat to human health due to its long inflammatory phase and the reduced vascularization. Herein, we develop a hydrogel system for the treatment of diabetic wound, which can short the inflammatory stage (through the use of ori) and promote the angiogenesis (through the addition of siRNA-29a gene). Based on the Schiff base bonds, the Gel/Alg@ori/HA-PEI@siRNA-29a hydrogel was prepared by mixing oxidized hydroxymethyl propyl cellulose (OHMPC), adipic dihydrazide-modified hyaluronic acid (HA-ADH), oridonin (ori) loaded alginate microspheres (Alg@ori) and siRNA-29a gene-loading hyaluronic acid-polyethyleneimine complex HA-PEI@siRNA-29a (HA-PEI@siRNA-29a) under physiological conditions, which had moderate mechanical strength, appropriate swelling property, impressive stability, and slow release ability of ori and siRNA-29a. Excellent biocompatibility of the prepared hydrogel was also confirmed by in vitro mouse fibroblasts L929 cells culture study. Moreover, in vivo experiments further demonstrated that the prepared Gel/Alg@ori/HA-PEI@siRNA-29a hydrogel not only significantly accelerated the diabetic wound healing, angiogenesis factors (α-SMA and CD31) production, but also inhibited pro-inflammatory factors (IL-6 and TNF-α). In summary, we believe that the prepared hydrogels exhibit great potential for the treatment of chronic diabetic wound.

Determinants of Bone Material Strength and Cortical Porosity in Patients with Type 2 Diabetes Mellitus

CONTEXT

Reduced bone material strength index (BMSi) and increased cortical porosity (CtPo) have emerged as potentially contributing to fracture risk in type 2 diabetes mellitus (T2DM) patients.

OBJECTIVE

To determine whether BMSi or CtPo are related to other diabetic complications.

DESIGN

Cross-sectional observational study.

SETTING

Subjects recruited from a random sample of southeast Minnesota residents.

PARTICIPANTS

A total of 171 T2DM patients (mean age, 68.8 years) and 108 age-matched nondiabetic controls (mean age, 67.3 years).

MAIN MEASURES

Bone material strength index was measured using microindentation, skin advanced glycation end-products (AGEs) measured using autofluorescence, high-resolution peripheral quantitative computed tomography at the distal radius and tibia, assessment of diabetic microvascular complications including urine microalbuminuria, retinopathy, neuropathy, and vascular disease (ankle brachial index and transcutaneous oxygen tension [TcPO2]). All analyses were adjusted for age, sex, and body mass index.

RESULTS

Skin AGEs were negatively correlated with the BMSi in both T2DM (r = -0.30, P < 0.001) and control (r = -0.23, P = 0.020) subjects. In relating diabetic complications to CtPo, we found that T2DM patients with clinically significant peripheral vascular disease (TcPO2 ≤ 40 mm Hg) had higher (+21.0%, P = 0.031) CtPo at the distal tibia as compared to controls; in these subjects, CtPo was negatively correlated with TcPO2 at both the distal tibia (r = -0.39, P = 0.041) and radius (r = -0.41, P = 0.029).

CONCLUSIONS

Our findings demonstrate that bone material properties are related to AGE accumulation regardless of diabetes status, while CtPo in T2DM patients is linked to TcPO2, a measure of microvascular blood flow.

Use of Oral Anticoagulation and Diabetes Do Not Inhibit the Angiogenic Potential of Hypoxia Preconditioned Blood-Derived Secretomes

Patients suffering from tissue ischemia, who would greatly benefit from angiogenesis-promoting therapies such as hypoxia preconditioned blood-derived secretomes commonly receive oral anticoagulation (OA) and/or have diabetes mellitus (DM). In this study, we investigated the effect of OA administration on the in vitro angiogenic potential of hypoxia preconditioned plasma (HPP) and serum (HPS), prepared from nondiabetic/diabetic subjects who did not receive OA (n = 5) or were treated with acetylsalicylic acid (ASA, n = 8), ASA + clopidogrel (n = 10), or nonvitamin K antagonist oral anticoagulants (n = 7) for longer than six months. The effect of DM was differentially assessed by comparing HPP/HPS obtained from nondiabetic (n = 8) and diabetic (n = 16) subjects who had not received OA in the past six months. The concentration of key proangiogenic (vascular endothelial growth factor or VEGF) and antiangiogenic (thrombospondin-1 or TSP-1 and platelet factor-4 or PF-4) protein factors in HPP/HPS was analyzed via ELISA, while their ability to induce microvessel formations was examined in endothelial cell cultures. We found that OA use significantly reduced VEGF levels in HPP, but not HPS, compared to non-OA controls. While HPP and HPS TSP-1 levels remained largely unchanged as a result of OA usage, HPS PF-4 levels were significantly reduced in samples obtained from OA-treated subjects. Neither OA administration nor DM appeared to significantly reduce the ability of HPP or HPS to induce microvessel formations in vitro. These findings indicate that OA administration does not limit the angiogenic potential of hypoxia preconditioned blood-derived secretomes, and therefore, it does not prohibit the application of these therapies for supporting tissue vascularization and wound healing in healthy or diabetic subjects.

A Dual-Acting Nitric Oxide Donor and Phosphodiesterase 5 Inhibitor Promotes Wound Healing in Normal Mice and Mice with Diabetes

Chronic wounds affect a large percentage of the population worldwide and cause significant morbidity. Unfortunately, efficient compounds for the treatment of chronic wounds are yet not available. Endothelial dysfunction, which is at least in part a result of compromised nitric oxide production and concomitant reduction in cGMP levels, is a major pathologic feature of chronic wounds. Therefore, we designed and synthesized a compound with a unique dual-acting activity (TOP-N53), acting as a nitric oxide donor and phosphodiesterase 5 inhibitor, and applied it locally to full-thickness skin wounds in healthy and healing-impaired mice with diabetes. TOP-N53 promoted keratinocyte proliferation, angiogenesis, and collagen maturation in healthy mice without accelerating the wound inflammatory response or scar formation. Most importantly, it partially rescued the healing impairment of mice with genetically determined type II diabetes (db/db) by stimulating re-epithelialization and granulation tissue formation, including angiogenesis. In vitro studies with human and murine primary cells showed a positive effect of TOP-N53 on keratinocyte and fibroblast migration, keratinocyte proliferation, and endothelial cell migration and tube formation. These results demonstrate a remarkable healing-promoting activity of TOP-N53 by targeting the major resident cells in the wound tissue.

Dissolved oxygen from microalgae-gel patch promotes chronic wound healing in diabetes

Chronic wounds in diabetes undergo a lifetime risk of developing into diabetic foot ulcers. Oxygen is crucial to wound healing by regulating cell proliferation, migration, and neovascularization. However, current oxygen therapies, including hyperbaric oxygen (HBO) and topical gaseous oxygen (TGO), mainly employ gaseous oxygen delivery, which is much less effective in penetrating the skin. Here, we introduce an oxygen-producing patch, made of living microalgae hydrogel, which can produce dissolved oxygen. The superior performance of the patch that results from its dissolved oxygen delivery is >100-fold much more efficient than TGO penetrating the skin. Further experiments indicate that the patch could promote cell proliferation, migration, and tube formation in vitro, and improve chronic wound healing and the survival of skin grafts in diabetic mice. We believe that the microalgae-gel patch can provide continuous dissolved oxygen to improve chronic wound healing.

Compromised angiogenesis and vascular Integrity in impaired diabetic wound healing

Vascular deficits are a fundamental contributing factor of diabetes-associated diseases. Although previous studies have demonstrated that the pro-angiogenic phase of wound healing is blunted in diabetes, a comprehensive understanding of the mechanisms that regulate skin revascularization and capillary stabilization in diabetic wounds is lacking. Using a mouse model of diabetic wound healing, we performed microCT analysis of the 3-dimensional architecture of the capillary bed. As compared to wild type, vessel surface area, branch junction number, total vessel length, and total branch number were significantly decreased in wounds of diabetic mice as compared to WT mice. Diabetic mouse wounds also had significantly increased capillary permeability and decreased pericyte coverage of capillaries. Diabetic wounds exhibited significant perturbations in the expression of factors that affect vascular regrowth, maturation and stability. Specifically, the expression of VEGF-A, Sprouty2, PEDF, LRP6, Thrombospondin 1, CXCL10, CXCR3, PDGFR-β, HB-EGF, EGFR, TGF-β1, Semaphorin3a, Neuropilin 1, angiopoietin 2, NG2, and RGS5 were down-regulated in diabetic wounds. Together, these studies provide novel information about the complexity of the perturbation of angiogenesis in diabetic wounds. Targeting factors responsible for wound resolution and vascular pruning, as well those that affect pericyte recruitment, maturation, and stability may have the potential to improve diabetic skin wound healing.

The Impact of Extracorporeal Shock Wave Therapy on Microcirculation in Diabetic Feet: A Pilot Study

BACKGROUND

Patients with diabetic foot commonly experience vascular insufficiency and compromised tissue perfusion. Extracorporeal shockwave therapy (ESWT) reportedly promotes wound healing and angiogenesis, but clinical studies on the effect of ESWT on angiogenesis are scarce and the exact mechanism remains unclear.

OBJECTIVE

To investigate the effect of ESWT on cutaneous microcirculation in diabetic feet.

METHODS

Ten patients with diabetic feet received ESWT twice weekly for a total of six sessions. Transcutaneous partial oxygen pressure (TcPO2) and cutaneous blood flow were measured before and after ESWT.

MAIN RESULTS

The treated feet showed statistically significant improvements in the mean TcPO2 (P < .01) and cutaneous blood flow level (P < .05) compared with control feet. In treated feet, TcPO2 increased by 19.6%, from 41.4 ± 9.9 to 49.5 ± 8.7 mm Hg (P < .05). In control feet, TcPO2 decreased by 11.6%, from 39.5 ± 14.0 to 34.9 ± 14.5 mm Hg (P = .059). The average cutaneous blood flow level of treated feet before ESWT was 36.9 ± 25.6, which increased to 48.3 ± 32.4 AU after ESWT (30.9% increase; P = .646). In control feet, the cutaneous blood flow level decreased from 80.5 ± 36.7 to 60.4 ± 38.8 AU, a decrease of 25.0% (P = .241).

CONCLUSIONS

These results demonstrate that ESWT may have beneficial effects on microcirculation in diabetic feet.

Vaccarin Regulates Diabetic Chronic Wound Healing through FOXP2/AGGF1 Pathways

Background: Diabetes mellitus is a growing global health issue nearly across the world. Diabetic patients who are prone to develop diabetes-related complications often exhibit progressive neuropathy (painless and sensory loss). It is usual for small wounds to progress to ulceration, which especially worsens with peripheral arterial disease and in the presence of anaerobic bacteria, culminating into gangrene. In our study, vaccarin (VAC), the main active monomer extracted from Chinese herb vaccariae semen, is proven to have a role in promoting diabetic chronic wound healing through a cytoprotective role under high glucose conditions. Materials and methods: We constructed a pressure ulcer on both VAC-treated and control mice based on a type 1 diabetes (T1DM) model. The wound healing index was evaluated by an experimental wound assessment tool (EWAT). We also determined the effect of VAC on the proliferation and cell migration of human microvascular endothelial cells (HMEC-1) by a cell counting kit (CCK-8), a scratch and transwell assay. Results: The results demonstrated that VAC could promote the proliferation and migration of high glucose-stimulated HMEC-1 cells, which depend on the activation of FOXP2/AGGF1. Activation of the angiogenic factor with G patch and FHA domains 1 (AGGF1) caused enhanced phosphorylation of serine/threonine kinase (Akt) and extracellular regulated protein kinases (Erk1/2). By silencing the expression of forkhead box p2 (FOXP2) protein by siRNA, both mRNA and protein expression of AGGF1 were downregulated, leading to a decreased proliferation and migration of HMEC-1 cells. In addition, a diabetic chronic wound model in vivo unveiled that VAC had a positive effect on chronic wound healing, which involved the activation of the above-mentioned pathways. Conclusions: In summary, our study found that VAC promoted chronic wound healing in T1DM mice by activating the FOXP2/AGGF1 pathway, indicating that VAC may be a promising candidate for the treatment of the chronic wounds of diabetic patients.

High glucose environment induces M1 macrophage polarization that impairs keratinocyte migration via TNF-α: An important mechanism to delay the diabetic wound healing

BACKGROUND

Macrophages play important roles during wound healing, and delayed healing in diabetics is associated with sustained inflammation. M1 type macrophage is recognized to secrete excessive amount of tumor necrosis factor-alpha (TNF-α) as compared to its M2 counterpart.

OBJECTIVES

We hypothesized that macrophage polarization is different between diabetic and normal rats during skin wounding and has direct impact on keratinocyte function in the context of re-epithelialization.

METHODS

Skin wounds were created in diabetic and control rats. The phenotypes of infiltrating macrophages, the levels of TNF-α, and the rate of wound closure were determined. Using cell model, the effects of M1 type macrophage on keratinocyte migration were evaluated, and the potential regulatory pathways were determined.

RESULTS

The percentage of M1 macrophages and the levels of TNF-α expression were significantly higher in the perilesional area of diabetic rats as compared to control. The condition media (CM) from M1 type macrophage upregulated tissue inhibitor metalloproteinases (TIMP)-1 expression in keratinocytes and significantly reduced keratinocyte migratory capacity. Addition of neutralizing TNF-α antibody to the CM or gene-silencing of TIMP1 in keratinocytes restored the keratinocyte migratory capacity. Treating wounds of diabetic rats with TNF-α antagonist improved the wound healing process.

CONCLUSIONS

In summary, high glucose wound environment harbored more M1 macrophages infiltration, an event that created excess TNF-α micro-environment. TNF-α upregulated TIMP1 expression in keratinocytes and resulted in impaired keratinocyte migration. Taken together, these events contributed to impaired wound healing during diabetic condition, and targeting TNF-α is a potential therapeutic option to improve diabetic wound healing.

Sodium-Glucose Cotransporter 2 Inhibitors: A Case Study in Translational Research

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are the most recently approved class of diabetes drugs. Unlike other agents, SGLT2 inhibitors act on the kidney to promote urinary glucose excretion. SGLT2 inhibitors provide multiple benefits, including decreased HbA_1c, body weight, and blood pressure. These drugs have received special attention because they decrease the risk of major adverse cardiovascular events and slow progression of diabetic kidney disease (1-3). Balanced against these impressive benefits, the U.S. Food and Drug Administration-approved prescribing information describes a long list of side effects: genitourinary infections, ketoacidosis, bone fractures, amputations, acute kidney injury, perineal necrotizing fasciitis, and hyperkalemia. This review provides a physiological perspective to understanding the multiple actions of these drugs complemented by a clinical perspective toward balancing benefits and risks.

The association of diabetic microvascular and macrovascular disease with cutaneous circulation in patients with type 2 diabetes mellitus

AIMS

To study the impact of diabetic neuropathy, both peripheral sensorimotor (DPN) and cardiac autonomic neuropathy (CAN), on transcutaneous oxygen tension (TcPO₂) in patients with type 2 diabetes mellitus (T2DM).

METHODS

A total of 163 participants were recruited; 100 with T2DM and 63 healthy individuals. Peripheral arterial disease (PAD) was defined as ankle-brachial index (ABI) values ≤0.90. Diagnosis of DPN was based on neuropathy symptom score and neuropathy disability score (NDS), while diagnosis of CAN on the battery of the cardiovascular autonomic function tests. TcPO₂ was measured using a TCM30 system.

RESULTS

Patients with T2DM had lower TcPO₂ levels when compared with healthy individuals. Among the diabetic cohort, those who had either PAD, DPN or CAN had significantly lower TcPO₂ values than participants without these complications. Multivariate linear regression analysis, after controlling for diabetes duration, diastolic blood pressure, HbA1c, albumin to creatinine ratio and CAN score, demonstrated that TcPO₂ levels were significantly and independently associated with current smoking (p = 0.013), ABI (p = 0.003), and NDS (p = 0.013).

CONCLUSION

Presence of DPN is independently associated with impaired cutaneous perfusion. Low TcPO₂ in subjects with DPN may contribute to delay in healing of diabetic foot ulcers, irrespectively of PAD.

Gangliosides in Diabetic Wound Healing

An organized series of complicated biological and molecular phenomena is required for normal skin wound healing. These processes depend on normal cellular responses to cytokines, growth factors, and other mediators, such as clotting factors, prostaglandins, free radicals, and nitric oxide. In diabetic ulcers, impaired responses to these molecules lead to abnormalities in vascularization, innervation, matrix reconstruction, and reepithelialization of wounds. keratinocyte migration and proliferation on an extracellular matrix is critical in reepithelialization, but the response to growth factors is blunted in diabetes, including the insulin/IGF-1signaling axis. Ganglioside GM3, a sialylated epidermal glycosphingolipid, has been identified as a key mediator of the inhibition of insulin/IGF-1 signaling in response to factors, such as tumor necrosis factor-alpha (TNF-α) and hyperglycemia. Decreased expression of GM3 and the enzyme required for its synthesis, GM3 synthase (GM3S), leads to increased insulin/IGF-1 receptor signaling and accelerated keratinocyte migration, even in the presence of high glucose levels. GM3 depletion in GM3S knockout diabetic mice and diet-induced diabetic mice treated topically with nanoconstruct-mediated GM3S-targeting gene regulation also accelerates wound healing. These recent observations, coupled with evidence that GM3 depletion reverses distal innervation abnormalities in diabetic mice, suggest that GM3-depleting strategies are a promising new approach for human diabetic wounds.

Dysfunctional Wound Healing in Diabetic Foot Ulcers: New Crossroads

PURPOSE OF REVIEW

Diabetic foot ulcerations (DFU) affect 25% of patients with diabetes mellitus during their lifetime and constitute a major health problem as they are often recalcitrant to healing due to a constellation of both intrinsic and extrinsic factors. The purpose of this review is to (1) detail the current mechanistic understanding of DFU formation and (2) highlight future therapeutic targets.

RECENT FINDINGS

From a molecular perspective, DFUs exhibit a chronic inflammatory predisposition. In addition, increased local hypoxic conditions and impaired cellular responses to hypoxia are pathogenic factors that contribute to delayed wound healing. Finally, recent evidence suggests a role for epigenetic alterations, including microRNAs, in delayed DFU healing due to the complex interplay between genes and the environment. In this regard, notable progress has been made in the molecular and genetic understanding of DFU formation. However, further studies are needed to translate preclinical investigations into clinical therapies.

Diabetes and Wound Angiogenesis

Diabetes Mellitus Type II (DM2) is a growing international health concern with no end in sight. Complications of DM2 involve a myriad of comorbidities including the serious complications of poor wound healing, chronic ulceration, and resultant limb amputation. In skin wound healing, which has definite, orderly phases, diabetes leads to improper function at all stages. While the etiology of chronic, non-healing diabetic wounds is multi-faceted, the progression to a non-healing phenotype is closely linked to poor vascular networks. This review focuses on diabetic wound healing, paying special attention to the aberrations that have been described in the proliferative, remodeling, and maturation phases of wound angiogenesis. Additionally, this review considers therapeutics that may offer promise to better wound healing outcomes.