Co-release of nitric oxide and L-arginine from poly (β-amino ester)-based adhesive reprogram macrophages for accelerated wound healing and angiogenesis in vitro and in vivo

Recently, insufficient angiogenesis and prolonged inflammation are crucial challenges of chronic skin wound healing. The sustained release of L-Arginine (L-Arg) and nitric oxide (NO) production can control immune responses, improve angiogenesis, enhance re-epithelialization, and accelerate wound healing. Here, we aim to improve wound healing via the controlled release of NO and L-Arg from poly (β-amino ester) (PβAE). In this regard, PβAE is functionalized with methacrylate poly-L-Arg (PAMA), and the role of PAMA content (50, 66, and 75 wt%) on the adhesive properties, L-Arg, and NO release, as well as collagen deposition, inflammatory responses, and angiogenesis, is investigated in vitro and in vivo. Results show that the PAMA/ PβAE could provide suitable adhesive strength (~25 kPa) for wound healing application. In addition, increasing the PAMA content from 50 to 75 wt% results in an increased release of L-Arg (approximately 1.4-1.7 times) and enhanced NO production (approximately 2 times), promoting skin cell proliferation and migration. The in vitro studies also show that compared to PβAE hydrogel, incorporation of 66 wt% PAMA (PAMA 66 sample) reveals superior collagen I synthesis (~ 3-4 times) of fibroblasts, controlled pro-inflammatory and improved anti-inflammatory cytokines secretion of macrophages, and accelerated angiogenesis (~1.5-2 times). In vivo studies in a rat model with a full-thickness skin defect also demonstrate the PAMA66 sample could accelerate wound healing (~98 %) and angiogenesis, compared to control (untreated wound) and Tegaderm™ commercial wound dressing. In summary, the engineered multifunctional PAMA functionalized PβAE hydrogel with desired NO and L-Arg release, and adhesive properties can potentially reprogram macrophages and accelerate skin healing for chronic wound healing.

Microenvironment-responsive smart hydrogels with antibacterial activity and immune regulation for accelerating chronic wound healing

Current therapeutic strategies for chronic refractory wounds remain challenge owing to their unfavorable wound microenvironment and poor skin regeneration ability. Thus far, a regimen for effective chronic refractory wounds management involves bacterial elimination, alleviation of oxidative stress, inhibition of inflammatory response, and promotion of angiogenesis. In this work, an injectable glycopeptide hydrogel based on phenylboronic acid-grafted ϵ-polylysine (EPBA) and poly (vinyl alcohol) (PVA) with pH/reactive oxygen species (ROS) dual-responsive properties was prepared, which exerted intrinsic antibacterial and antioxidant properties. ROS-responsive micelles (MIC) loaded with herb-derived Astragaloside IV (AST) are introduced into the hydrogel before gelation. Attributed to the acidic condition and oxidative stress microenvironment of wound bed, the hydrogel gradually disintegrates, and the released EPBA could help to eliminate bacterial. Meanwhile, the subsequential release of AST could help to achieve anti-oxidation, anti-inflammatory, proangiogenic effects, and regulation of macrophage polarization to accelerate chronic wound healing. In addition, the wound repair mechanism of composite hydrogel accelerating skin regeneration was assessed by RNA-sequencing, exploring a range of potential targets and pathway for further study. Collectively, this multifunctional hydrogel dressing, matching different healing stages of tissue remodeling, holds a great potential for the treatment of chronic refractory wounds.

Zinc-mineralized diatom biosilica/hydroxybutyl chitosan composite hydrogel for diabetic chronic wound healing

For sustained and stable improvement of the diabetic wound microenvironment, a temperature-sensitive composite hydrogel (ZnDBs/HBC) composed of inorganic zinc mineralized diatom biosilica (ZnDBs) and hydroxybutyl chitosan (HBC) was developed. The interfacial anchoring effect between ZnDBs and HBC enhanced the mechanical strength of the hydrogel. The mechanical strength of the composite hydrogel containing 3 wt% ZnDBs was increased by nearly 2.3times. The hydrogel can be used as a carrier for sustained release of Zn2+ for at least 72 h. In diabetic rats models, ZnDBs/HBC composite hydrogel could accelerate the inflammatory process by regulating the expression of pro-inflammatory factor IL-6 and anti-inflammatory factor IL-10, and also promote tissue cell proliferation and collagen deposition, thereby restoring the normal healing process and accelerating wound healing. The wound contraction rate of the composite hydrogel group was more than 2 times that of the control group. Therefore, ZnDBs/HBC composite hydrogel has the potential to be used as a therapeutic dressing for diabetic chronic wounds.

A multifunctional chitosan composite aerogel based on high density amidation for chronic wound healing

The management of chronic wounds remains a challenging clinical problem worldwide, mainly because of secondary infections, excessive oxidative stress, and blocked angiogenesis. Aerogel is a novel material with high porosity and specific surface area that allows gas exchange and rapid absorption of a large amount of exudate as well as loading bioactive molecules. Therefore, functional aerogel can be an ideal material for chronic wound treatment. The multifunctional aerogel (CG-DA-VEGF) was prepared by a simple and eco-friendly freeze-drying process combined with harmless EDC/NHS as crosslinking agents using chitosan and dopamine-grafted gelatin as raw materials. The physicochemical characterization revealed that the CG-DA-VEGF aerogel had excellent water absorption, water retention, and mechanical properties, and could release VEGF continuously and stably. In vitro experiments demonstrated that the CG-DA-VEGF aerogel exhibited effective antioxidant and antibacterial properties, as well as superb cytocompatibility. In vivo experiments further confirmed that the CG-DA-VEGF aerogel could significantly improve angiogenesis and re-epithelialization, and promote collagen deposition, thus accelerating wound healing with excellent biosafety. These results suggest that the as-prepared CG-DA-VEGF aerogel may be adopted as a promising multifunctional graft for the treatment of chronic wounds.

Multi-functional conductive hydrogels based on heparin-polydopamine complex reduced graphene oxide for epidermal sensing and chronic wound healing

Flexible hydrogel sensors have expanded the applications of electronic devices due to their suitable mechanical properties and excellent biocompatibility. However, conventionally synthesized reduced graphene oxide (rGO) encounters limitations in reduction degree and dispersion, restricting the conductivity of graphene hydrogels and impeding the development of high-sensitivity flexible sensors. Moreover, hydrogels are susceptible to inflammation and bacterial infections, jeopardizing sensor stability over time. Thus, the challenge persists in designing conductive hydrogels that encompass high sensitivity, antibacterial efficacy, and anti-oxidative capabilities. In this study, GO was modified and reduced via a heparin-polydopamine (Hep-PDA) complex, yielding well-reduced and uniformly dispersed Hep-PDA-rGO nanosheets. Consequently, a hydrogel utilizing Hep-PDA-rGO was synthesized, showcasing commendable conductivity (3.63 S/m) and sensor performance, effectively applied in real-time motion monitoring. Notably, the hydrogel's attributes extend to facilitating chronic diabetic wound healing. It maintained a suitable inflammatory environment credited to its potent antibacterial and antioxidative properties, while its inherent conductivity promoted angiogenesis. The multifunctional nature of this hydrogel highlight its potential not only as an epidermal sensor but also as a promising dressing candidate for chronic wound treatment.

Therapeutic Potential of Extracellular Vesicles from Different Stem Cells in Chronic Wound Healing

Wound healing has long been a complex problem, especially in chronic wounds. Although debridement, skin grafting, and antimicrobial dressings have been used to treat chronic wounds, their treatment period is long, expensive, and has specific rejection reactions. The poor treatment results of traditional methods have caused psychological stress to patients and a substantial economic burden to society. Extracellular vesicles (EVs) are nanoscale vesicles secreted by cells. They play an essential role in intercellular communication. Numerous studies have confirmed that stem cell-derived extracellular vesicles (SC-EVs) can inhibit overactive inflammation, induce angiogenesis, promote re-epithelization, and reduce scar formation. Therefore, SC-EVs are expected to be a novel cell-free strategy for chronic wound treatment. We first summarize the pathological factors that hinder wound healing and discuss how SC-EVs accelerate chronic wound repair. And then, we also compare the advantages and disadvantages of different SC-EVs for chronic wound treatment. Finally, we discuss the limitations of SC-EVs usage and provide new thoughts for future SC-EVs research in chronic wound treatment.

A pH/enzyme dual responsive PMB spatiotemporal release hydrogel promoting chronic wound repair

Suppressing persistent multidrug-resistant (MDR) bacterial infections and excessive inflammation is the key for treating chronic wounds. Therefore, developing a microenvironment-responsive material with good biodegradability, drug-loading, anti-infection, and anti-inflammatory properties is desired to boost the chronic wounds healing process; however, using ordinary assembly remains a defect. Herein, we propose a pH/enzyme dual-responsive polymyxin B (PMB) spatiotemporal-release hydrogel (GelMA/OSSA/PMB), namely, the amount of OSSA and PMB released from GelMA/OSSA/PMB was closely related the wound pH and the enzyme concentration changing. The GelMA/OSSA/PMB showed better biosafety than equivalent free PMB, owing to the controlled release of PMB, which helped kill planktonic bacteria and inhibit biofilm activity in vitro. In addition, the GelMA/OSSA/PMB exhibited excellent antibacterial and anti-inflammatory properties. A MDR Pseudomonas aeruginosa caused infection was effectively resolved by the GelMA/OSSA/PMB hydrogel in vivo, thereby significantly boosting wound closure during the inflammatory phase. Furthermore, GelMA/OSSA/PMB accelerated the sequential phases of wound repair.

Bilayer hydrogel dressing with lysozyme-enhanced photothermal therapy for biofilm eradication and accelerated chronic wound repair

Biofilms are closely associated with the tough healing and dysfunctional inflammation of chronic wounds. Photothermal therapy (PTT) emerged as a suitable alternative which could destroy the structure of biofilms with local physical heat. However, the efficacy of PTT is limited because the excessive hyperthermia could damage surrounding tissues. Besides, the difficult reserve and delivery of photothermal agents makes PTT hard to eradicate biofilms as expectation. Herein, we present a GelMA-EGF/Gelatin-MPDA-LZM bilayer hydrogel dressing to perform lysozyme-enhanced PTT for biofilms eradication and a further acceleration to the repair of chronic wounds. Gelatin was used as inner layer hydrogel to reserve lysozyme (LZM) loaded mesoporous polydopamine (MPDA) (MPDA-LZM) nanoparticles, which could rapidly liquefy while temperature rising so as to achieve a bulk release of nanoparticles. MPDA-LZM nanoparticles serve as photothermal agents with antibacterial capability, could deeply penetrate and destroy biofilms. In addition, the outer layer hydrogel consisted of gelatin methacryloyl (GelMA) and epidermal growth factor (EGF) promoted wound healing and tissue regeneration. It displayed remarkable efficacy on alleviating infection and accelerating wound healing in vivo. Overall, the innovative therapeutic strategy we came up with has significant effect on biofilms eradication and shows promising application in promoting the repair of clinical chronic wounds.

Photothermal Hydrogel Encapsulating Intelligently Bacteria-Capturing Bio-MOF for Infectious Wound Healing

Chronic wounds are characterized by long-term inflammation and persistent infection, which make them difficult to heal. Therefore, an urgent desire is to develop a multifunctional wound dressing that can prevent wound infection and promote wound healing by creating a favorable microenvironment. In this study, a curcumin-based metal-organic framework (QCSMOF-Van), loaded with vancomycin and coated with quaternary ammonium salt chitosan (QCS), was prepared. Multifunctional composite hydrogels were conveniently synthesized by combining methacrylic anhydride modified gelatin and methacrylic anhydride modified oxidized sodium alginate with QCSMOF-Van through radical polymerization and Schiff base reaction. It is important to note that the QCSMOF-Van could capture bacteria through the positive charges on the surface of QCS. In this process, due to the synergistic effect of broad-spectrum antibacterial Zn²⁺ and vancomycin, the metabolism of bacteria was well inhibited, and the efficient capturing and rapid killing of bacteria were achieved. The QCSMOF-Van hydrogels could precisely regulate the balance of M1/M2 phenotypes of macrophages, thereby promoting the regeneration of nerves and blood vessels, which promotes the rapid healing of chronic wounds. This advanced cascade management strategy for tissue regeneration highlights the potential of multifunctional composite hydrogels in chronic wound dressings.

Novel dopamine-modified oxidized sodium alginate hydrogels promote angiogenesis and accelerate healing of chronic diabetic wounds

Herein, the dopamine (DA) was grafted with oxidized sodium alginate (OSA) via Schiff base reduction reaction, aiming to fabricate novel DA-grafted OSA (OSA-DA) hydrogels with enhanced biocompatibility and suitable adhesion for clinical applications. The chemical structures of OSA-DA were characterized via UV-Vis, FTIR and ¹H NMR spectroscopy analysis. The hydrogel characteristics, biocompatibility, as well as the chronic diabetic wound healing efficacy were investigated. Our results demonstrated that DA was grafted with OSA successfully with highest grafting rate of 7.50%. Besides, OSA-DA hydrogels possessed suitable swelling ratio and appropriate adhesion characteristics. Additionally, OSA-DA exhibited satisfactory cytocompatibility and cell affinity in L-929 cells, and superior biocompatibility in SD rats. Moreover, OSA-DA exerted remarkable promoting effects on migration and tube formation of human umbilical vein endothelial cells (HUVECs). Studies on full-thickness excision chronic diabetic wounds further revealed that OSA-DA hydrogels could accelerate healing via promoting angiogenesis, reducing inflammation response, and stimulating collagen deposition. Overall, our studies would provide basis for SA-based hydrogels as clinical wound dressings.

Photoactive electrospun cellulose acetate/polyethylene oxide/methylene blue and trilayered cellulose acetate/polyethylene oxide/silk fibroin/ciprofloxacin nanofibers for chronic wound healing

This study aimed to synthesize cellulose acetate (CA)-based electrospun nanofibers as drug delivery dressings for chronic wound healing. For the first time, CA was blended with polyethylene oxide (PEO) using acetone and formic acid. Methylene blue (MB) was incorporated into monolayered random CA/PEO nanofibers. They had a diameter of 400-600 nm, were hydrophilic, and generated reactive oxygen species upon irradiation. Thus, they mediated antimicrobial photodynamic inactivation (aPDI) against isolated biofilm-forming Staphylococcus aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Bacterial survival, biofilm mass, and produced pyocyanin of the treated groups declined by 90%, 80%, and 3 folds, respectively. On the other hand, ciprofloxacin (Cipro) was loaded into an innovative trilayered aligned nanofiber consisting of CA/PEO surrounding a blank layer of silk fibroin. Cipro and MB release followed the Korsmeyer-Peppas model. An infected diabetic wound mouse model was established and treated with either MB-aPDI or Cipro. A combined therapy group of MB-aPDI followed by Cipro was included. The combined therapy showed significantly better results than monotherapies delineated by elevation in re-epithelization, collagen deposition, CD34, and TGF-β expression, along with a decline in CD95+ cells. This study deduced that drug-loaded CA electrospun nanofibers might be exploited in multimodal chronic wound healing.

Soft apoptotic-cell-inspired nanoparticles persistently bind to macrophage membranes and promote anti-inflammatory and pro-healing effects

Macrophages play a key role in inflammation, infection, cancer, and repairing damaged tissues. Thus, modulating macrophages with engineered nanomaterials is an important therapeutic strategy for healing chronic inflammatory injuries. However, designing and manufacturing therapeutic nanomaterials remains challenging. Therefore, in this study, apoptotic-cell-inspired deformable phosphatidylserine (PS)- containing nanoliposomes (D-PSLs) with a Young's modulus (E) of approximately 0.5 kPa were constructed via a facile and scalable method. Compared with similar-sized conventional PSLs with an E of approximately 80 kPa, the d-PSLs had a lower uptake efficacy, a much longer binding time to the cell surface, and induced enhanced anti-inflammatory and pro-healing effects via the synergistic effects of their mechanical stimulus and PS-receptor mediation after recognition by macrophages. In particular, chronic wound healing in diabetic rats showed that d-PSLs can efficiently promote M2-like macrophage polarization, increase the expression of the vascular endothelial marker CD31 and accelerate wound closure. Our findings suggest that soft d-PSLs represent a promising biomimetic nano-therapeutic approach for macrophage immunotherapy for chronic inflammatory injury, and that the mechanical stimulus of nanomaterials significantly affects the receptor-mediated biological responses, which will inspire the design of engineered nanomaterials for biomedical applications. STATEMENT OF SIGNIFICANCE: Macrophages play a significant role in restoring tissue homeostasis by modulating inflammation and wound healing. Specifically, an M1/M2 macrophage imbalance contributes to various inflammatory disorders. However, modulating macrophages with engineered nanomaterials remains a challenge. In this study, apoptotic-cell-inspired deformable phosphatidylserine (PS)- containing nanoliposomes (D-PSLs) were constructed to explore their interactions with macrophages, and evaluate their anti-inflammatory and pro-healing effects on chronic wounds in diabetic rats. We found that soft d-PSLs can persistently bind to macrophage membranes and enhance the anti-inflammatory and pro-healing responses of macrophages, which not only sheds new light on the design of therapeutic biomaterials based on regulating macrophages but also provide a promising biomimetic nano-therapeutic approach for chronic inflammatory injury.

Nanofibers reinforced injectable hydrogel with self-healing, antibacterial, and hemostatic properties for chronic wound healing

The chronic wounds often hinder wound healing resulting from infection; thus, an ideal wound dressing should be able to maintain a healthy wound microenvironment. Herein, peptide modified nanofibers reinforced hydrogel has been designed by Schiff base dynamic crosslinking. The incorporation of the nanofibers into the hydrogel extremely enhances the stability and mechanical strength of the hydrogel. Taking advantage of the feature, the reinforced hydrogel can restore its original shape while suffering the various external forces on the hydrogel-covered irregular shape wounds. The peptide modified nanofibers reinforced hydrogel (NFRH) not only possesses injectable and self-healing properties, but also inherent antibacterial and hemostatic properties, which can eradicate the bacterial biofilms and induce blood cells and platelets aggregation and finally accelerate the chronic wound healing process. The peptide modified nanofibers reinforced hydrogel has enormous potential to be novel dressing for chronic wounds healing clinically.

Deformable liposomes for skin therapy with human epidermal growth factor: The effect of liposomal surface charge

The topical administration of exogenous human epidermal growth factor (hEGF) is a promising approach for improved chronic wound therapy. To develop therapeutically superior hEGF formulation, we prepared hEGF-containing neutral (NDLs), cationic (CDLs) and anionic (ADLs) deformable liposomes (DLs), respectively, since it is expected that the liposomal surface charge can affect both the liposomal physicochemical properties, their skin penetration potential and therapeutic efficacy of liposome-associated drug. All prepared liposomes were of similar size (300-350 nm) with high hEGF load (~80% entrapment efficacy). Among the studied DLs, ADLs were found to be most promising for sustained release of hEGF, as assessed in vitro using the polyamide membrane. Ex vivo studies revealed that all DLs were excellent systems for skin therapy with hEGF and no penetration of hEGF through the full thickness human skin was detected. ADLs provided a depot exhibiting the highest hEGF retention onto the human skin surface. ADLs also revealed enhanced mitogenic activities in human fibroblasts compared to both NDLs and CDLs after 48 hrs treatment. Moreover, hEGF-containing ADLs significantly enhanced mitogenic activity in fibroblast as compared to activity of hEGF solution (positive control). Similar trends were observed in human keratinocytes after 24 hrs of treatment. We proved that the liposomal surface charge affects the therapeutic potential of hEGF-containing liposomes. hEGF-containing ADLs can be a promising nanosystem-based formulation for localized therapy of chronic wounds.

Randomized, Prospective, Blinded-Enrollment, Head-To-Head Venous Leg Ulcer Healing Trial Comparing Living, Bioengineered Skin Graft Substitute (Apligraf) with Living, Cryopreserved, Human Skin Allograft (TheraSkin)

Chronic venous leg ulcers are responsible for significant morbidity and health care costs worldwide. This pilot study evaluated the effectiveness 2 biologically active grafts, TheraSkin and Apligraf, in conjunction with compression therapy. The study, not industry-sponsored, was designed and conducted as a prospective, head-to-head, single-site, randomized clinical trial to assess differences in healing rates, adverse outcomes, and treatment costs. The healing rates were different but not statistically significant, there were no adverse outcomes, and TheraSkin averaged $2495.33 and Apligraf averaged $4316.67 per subject. This suggests that TheraSkin may provide equivalent or superior outcomes to Apligraf while reducing costs.

In vitro assessment of a novel, hypothermically stored amniotic membrane for use in a chronic wound environment

Chronic wounds require extensive healing time and place patients at risk of infection and amputation. Recently, a fresh hypothermically stored amniotic membrane (HSAM) was developed and has subsequently shown promise in its ability to effectively heal chronic wounds. The purpose of this study is to investigate the mechanisms of action that contribute to wound-healing responses observed with HSAM. A proteomic analysis was conducted on HSAM, measuring 25 growth factors specific to wound healing within the grafts. The rate of release of these cytokines from HSAMs was also measured. To model the effect of these cytokines and their role in wound healing, proliferation and migration assays with human fibroblasts and keratinocytes were conducted, along with tube formation assays measuring angiogenesis using media conditioned from HSAM. Additionally, the cell-matrix interactions between fibroblasts and HSAM were investigated. Conditioned media from HSAM significantly increased both fibroblast and keratinocyte proliferation and migration and induced more robust tube formation in angiogenesis assays. Fibroblasts cultured on HSAMs were found to migrate into and deposit matrix molecules within the HSAM graft. These collective results suggest that HSAM positively affects various critical pathways in chronic wound healing, lending further support to promising qualitative results seen clinically and providing further validation for ongoing clinical trials.

Structural and functional insights into the interaction of sulfated glycosaminoglycans with tissue inhibitor of metalloproteinase-3 - A possible regulatory role on extracellular matrix homeostasis

An imbalance between tissue-degrading matrix metalloproteinases (MMPs) and their counterparts' tissue inhibitors of metalloproteinases (TIMPs) causes pathologic extracellular matrix (ECM) degradation in chronic wounds and requires new adaptive biomaterials that interact with these regulators to re-establish their balance. Sulfated glycosaminoglycans (GAGs) and TIMP-3 are key modulators of tissue formation and remodeling. However, little is known about their molecular interplay. GAG/TIMP-3 interactions were characterized combining surface plasmon resonance, ELISA, molecular modeling and hydrogen/deuterium exchange mass spectrometry. We demonstrate the potential of solute and surface-bound sulfated hyaluronan (sHA) and chondroitin sulfate (sCS) derivatives to manipulate GAG/TIMP-3 interactions by varying GAG concentration, sulfation degree and chain length. Three GAG binding sites in the N- and C-terminal domains of TIMP-3 were identified. We reveal no overlap with the matrix metalloproteinases (MMP)-binding site, elucidating why GAGs did not change MMP-1/-2 inhibition by TIMP-3 in enzyme kinetics. Since we prove that GAGs alone have a low impact on MMP activity, sHA and sCS offer a promising strategy to possibly control ECM remodeling via stabilizing and accumulating TIMP-3 by maintaining its MMP inhibitory activity under GAG-bound conditions. Whether GAG-based functional biomaterials can be applied to foster chronic wound healing by shifting the MMP/TIMP balance to a healing promoting state needs to be evaluated in vivo.

STATEMENT OF SIGNIFICANCE

Increased levels of tissue-degrading matrix metalloproteinases (MMPs) lead to pathologic matrix degradation in chronic wounds. Therefor functional biomaterials that restore the balance between MMPs and tissue inhibitors of metalloproteinases (TIMPs) are required to promote wound healing. Since sulfated glycosaminoglycan (GAG) derivatives demonstrated already to be e.g. anti-inflammatory and immunomodulatory, and native GAGs interact with TIMP-3 the former are promising candidates for functionalizing biomaterials. We identified the GAG binding sites of TIMP-3 by combining experimental and molecular modeling approaches and revealed that GAG derivatives have a higher capacity to sequester TIMP-3 than native GAGs without altering its inhibitory potential towards MMPs. Thus GAG derivative-containing biomaterials could protect tissue from excessive proteolytic degradation e.g. in chronic wounds by re-establishing the MMP/TIMP balance.

Amniotic membrane is a potential regenerative option for chronic non-healing wounds: a report of five cases receiving dehydrated human amnion/chorion membrane allograft

A case series of five patients with a total of six chronic non-healing wounds (>30 day duration) were non-randomly selected to evaluate the performance, safety and handling properties of dehydrated human amnion/chorion membrane allograft, an amniotic membrane scaffolding product. The patients had lower extremity wounds that had previously failed standard of care within a university outpatient/inpatient wound healing programme. Five wounds treated with dehydrated amnion/chorion membrane allograft showed a mean 43% area reduction from baseline (51% median) at 3 weeks into treatment and completely healed with a 64-day median time to closure (SD ±27·6 days). One wound worsened at 3 weeks and was found to have a complete central vein obstruction that was treated with long-term mild compression but still eventually healed at 6 months. Removing this outlier, the four responding wounds had a 72% mean and 69% median change in area from baseline, at the 3 week point. All five patients received only one application of dehydrated human amnion/chorion membrane allograft, and there were no adverse events. The product was easy to use, administer and handle. In summary, dehydrated human amnion/chorion membrane allograft appears to be a safe, effective and easy to use therapy for chronic non-healing wounds. This study describes the details of these clinical cases and provides an overview of the current evidence on the use of amniotic tissue in clinical practice.

Tadalafil therapy and severe chronic foot wound resolution

We report an unanticipated medication effect resulting in near-complete wound healing in a patient after beginning tadalafil therapy of 20 mg thrice daily. This patient was treated for 50 years with state-of-the art acute and then chronic wound interventions after a traumatic farm machinery accident which resulted in a devascularised foot wound. This infection was both life- and limb-threatening. The patient had undergone multiple vascular and plastic surgeries and antimicrobial therapies in addition to hospitalisations for sepsis. Limb amputation was being considered, when his urologist placed him on daily phosphodiesterase-5 inhibitor therapy, prior to unrelated urologic surgery. Remarkably, his foot wound underwent near-complete resolution and has been stable for 2 years.

Povidone Iodine Dressing in Chronic Wound Healing

To compare the healing of chronic wounds with honey dressing vs. Povidone iodine dressing in adult subjects with chronic wounds of ≥6 weeks of duration, attending wound care clinic in Surgical Out Patient Department of All India Institute of Medical Sciences, Surgical Out Patient Department of Jai Prakash Narayan Apex Trauma center, New Delhi. Forty five subjects were randomized into two groups i.e., Honey & Povidone iodine dressing group. Dressing was done on alternate day basis for 6 weeks of followup period. Main outcome measure was complete healing at 6 weeks. Wound healing status was assessed at 2 weekly intervals till 6 weeks. Seven out of 22 subjects in honey treated group achieved complete healing as compared to none out of 20 subjects in Povidone iodine treated group. There was a significant decrease in the wound surface area, pain score & increase in comfort score in Honey dressing group in comparison to the Povidone Iodine group at 0.05 level of significance. Honey dressing is highly effective in achieving healing in chronic wounds as compared to Povidone iodine dressing.