Non-healing Wounds Research Articles

Contemporary Medical Management of Peripheral Arterial Disease.

Peripheral arterial disease (PAD) is characterized by atherosclerotic arterial occlusive disease of the lower extremities and is associated with an increased risk of major adverse cardiovascular events (MACE) in addition to disabling clinical sequelae, including intermittent claudication and chronic limb-threatening ischemia (CLTI). Given the growing burden of disease, knowledge of modern practices to prevent MACE and major adverse limb events (MALE) is essential. This review article examines evidence for medical management of PAD and its associated risk factors, as well as wound prevention and care. A thorough review of the literature was performed, with attention to evidence for the management of modifiable atherosclerotic risk factors, claudication symptoms, wound prevention, and wound care. Contemporary management of PAD requires a multi-faceted approach to care, with medical optimization of smoking, hypertension, hyperlipidemia, and diabetes mellitus. The use of supervised exercise therapy for intermittent claudication is highlighted. The anatomic disease patterns of smoking and diabetes mellitus are discussed further, and best practices for diabetic foot ulcer prevention, including offloading footwear, are described. Quality wound care is essential in this patient population and involves strategic use of debridement, wound-healing adjuncts, and skin substitutes, when appropriate. The objective of medical management of PAD is to reduce the risk of MACE and MALE. Atherosclerotic risk factor optimization, appropriate wound care, and management of diabetic foot ulcers, foot infections, gangrene, and chronic, non-healing wounds are critical components of PAD care. Interdisciplinary care is essential to coordinate care, leverage expertise, and improve outcomes.

Fetal bovine acellular dermal matrix in the management of chronic nonhealing lower extremity wounds.

The management of chronic nonhealing lower extremity wounds remains a problem that substantially affects patients and significantly burdens the health care system. Nonhealing wounds lead to increased hospitalization, decreased quality of life, minor and major amputations, and increased risk of mortality. Dermal matrices have advanced the science of wound healing. To evaluate fetal bovine acellular dermal matrix (FBADM), an acellular dermal collagen repair scaffold derived from fetal bovine dermis, in the management of chronic nonhealing lower extremity wounds. A single-center retrospective chart review was conducted to collect data on patients with chronic nonhealing lower extremity wounds treated with FBADM from January 2013 through December 2019. A total of 43 patients were enrolled, with a mean age of 68.5 years and a mean wound area of 27 cm2. Complete closure of the wound occurred in 53% of patients overall, with 28% of patients achieving healing within 12 weeks. Application of FBADM in the management of chronic nonhealing lower extremity wounds is safe, effective, and efficient.

Potential roles of circulating microRNAs in the healing of type 1 diabetic wounds treated with green tea extract: molecular and biochemical study

BackgroundCirculating miRNAs have been implicated in various aspects of diabetic wound healing, including inflammation, angiogenesis, and extracellular matrix remodeling. Thus, in alternative herbal medicine strategies, miRNAs will be potential therapeutic molecular targets in nonhealing wounds. These could be valuable elements for understanding the molecular basis of diabetic wound healing and could be used as good elements in bioinformatics. ObjectivesTo elucidate the molecular mechanisms of microRNAs in association with apoptosis-inducing genes in controlling skin wound healing in diabetic wounds treated with green tea polyphenols (GTPs). MethodsGreen tea hydro extract (GTE) at doses of100–200 mg/ml was topically applied to the skin tissues of rats with T1DM induced by a single dose of streptozotocin (STZ; 100 mg/kg, in 0.01 M sodium citrate, pH 4.3–4.5) injected intraperitoneally for seven consecutive days to induce T1DM. The rats were treated with green tea for three weeks. A sterile surgical blade was used to inflict a circular wound approximately 2 cm in diameter on the anterior-dorsal side of previously anesthetized rats by a combination of ketamine hydrochloride (50 mg/kg, i.e., body weight) and xylazine hydrochloride. Afterward, the molecular roles of the circulating miRNAs miR-21, miR-23a, miR-146a, and miR-29b and apoptotic genes were determined by quantitative real-time PCR to evaluate Bax, Caspase-3, and Bcl-2 in wound healing. In addition, HPLC analysis was also performed to estimate the active polyphenols (GTPs) present in the hydro extract of green tea leaves. ResultsWound healing was improved in diabetic skin wounds following treatment with GTE at doses of 100–200 mg/dl for three weeks. The wound parameters contraction, epithelialization, and scar formation significantly improved in a short time (14 days) compared to the longer periods identified in diabetic non-treated rats (20 days) and the standard control (15.5 days). Molecular analyses reported a significant increase in the levels of miR-21, miR-23a, and miR-146a and a decrease in the levels of miR-29b in green tea-treated diabetic rats compared to those in the standard control and STZ-diabetic non-treated rats. In addition, the molecular apoptotic genes Bax and caspase-3 significantly increased, and the BcL-2 gene significantly decreased following treatment with green tea polyphenols. ConclusionsThe data showed that active green tea polyphenols (GTPs) present in GTE significantly improved diabetic wound healing by controlling apoptotic genes and the circulating microRNAs miR-21, miR-23a, miR-146a, and miR-29b, which might be involved in cellular apoptosis and angiogenesis processes. Thus, to establish a future model for the treatment of diabetic wounds, further studies are needed to understand the potential association of these biological parameters with the wound-healing process in diabetic wounds.

16 The early transcriptional response of fibroblasts to non-healing wound exudates reveals roles for inflammation and unfolded protein response in the pathology of chronic wounds

16 The early transcriptional response of fibroblasts to non-healing wound exudates reveals roles for inflammation and unfolded protein response in the pathology of chronic wounds

Autologous Blood-Derived Products for Chronic Nonhealing Wounds: Journey to Successful Reimbursement.

Autologous Blood-Derived Products for Chronic Nonhealing Wounds: Journey to Successful Reimbursement.

Digital Twin in Healthcare: A Study for Chronic Wound Management.

Although the concept of digital twin technology has been in existence for nearly half a century, its application in healthcare is a relatively recent development. In healthcare, the utilization of digital twin and data-driven models has proven to enhance clinical decision support, particularly in the treatment and assessment of chronic wounds, leading to improved clinical outcomes. This paper proposes the implementation of a digital twin in the domain of healthcare, specifically in the management of chronic wounds, by leveraging artificial intelligence techniques. The digital twin is composed of data collection, data processing, and AI models dedicated to wound healing. A novel AI pipeline is utilized to track the healing of chronic wounds. The digital twin, serving as a virtual representation of the actual wound, simulates and replicates the healing process. Furthermore, the proposed wound-healing prediction model effectively guides the treatment of chronic wounds. Additionally, by comparing the actual wound with its digital twin, the system enables early identification of non-healing wounds, facilitating timely adjustments and modifications to the treatment plan. By incorporating a digital twin in healthcare, the proposed system enables personalized and tailored treatments, potentially playing a crucial role in proactive problem identification.

IMPACT OF HONEY DRESSING ON CHRONIC ULCER

Purpose: This study aims to highlight the significance of honey in wound treatment by focusing on its healing properties, main compounds responsible for healing capacity, its effectiveness in non-healing wounds, cost-effectiveness, and challenges coming its way. Background: Honey is an ancient treatment that is increasingly earning its place in modern wound care. Honey has been found to exert antioxidant, anticarcinogenic, anti-inflammatory, and antibacterial effects without antibiotic resistance, promote moist wound healing, and facilitate debridement. Composed of 80% sugar and 17% water, this supersaturated natural substance makes a splendid wound dressing. Its high osmolarity, phytochemicals, and enzymatic production of hydrogen peroxide inhibit bacterial growth, while its acidic pH and autolytic debridement, decrease inflammation and improve blood circulation to enhance epithelialization and healing with minimal scar tissue. Clinical observations suggest that honey holds significant promise as an effective treatment for several medical conditions, particularly in managing non-healing wounds. Large, contaminated wounds are difficult and expensive to treat. Thus, using honey can be an effective and economical approach to managing large wounds. Methods:A prospective observational study was conducted in the Department of General Surgery at Silchar Medical College and Hospital from August 2022 to April 2023, to evaluate the significance of honey dressing and related complications. This study included 25 cases with an average age of 38.18 (range 17-63) years, of these 19 were males and 6 were females. Result:In the results of the study, it was reported that honey in acute and chronic wounds provided rapid epithelization and wound contraction in wound healing, had anti-inflammatory and debridement effects, decreased pain, ensured infection control, shortened the time of wound healing, and was cost-effective.

Targeting estrogen signaling and biosynthesis for aged skin repair.

Non-healing skin wounds are disproportionally prevalent in older adults. Current treatments do not account for the particularities of aged skin and result in inadequate outcomes. Overall, healing chronic wounds in the elderly remains a major unmet clinical need. Estrogens play a critical role in reproduction but also have important actions in non-reproductive organs. Estrogen biosynthesis and signaling pathways are locally activated during physiological wound healing, processes that are inhibited in elderly estrogen-deprived skin. Estrogen deprivation has been shown to be a critical mediator of impaired wound healing in both postmenopausal women and aged men, and topical estrogen application reverses age-associated delayed wound healing in both elderly men and women. These data indicate that adequate estrogen biosynthesis and properly regulated estrogen signaling pathways are essential for normal wound healing and can be targeted to optimize tissue repair in the elderly. However, due to fundamental questions regarding how to safely restore estrogen signaling locally in skin wounds, there are currently no therapeutic strategies addressing estrogen deficiency in elderly chronic wounds. This review discusses established and recent literature in this area and proposes the hypothesis that estrogen plays a pleiotropic role in skin aging and that targeting estrogen signaling and biosynthesis could promote skin repair in older adults.

Investigating the effect of Polyherbal Ointment on Non-Healing Burn Wound: The Geriatric Approach

Investigating the effect of Polyherbal Ointment on Non-Healing Burn Wound: The Geriatric Approach

Investigating Diabetic Foot Pathophysiology and Amputation Prevention Strategies through Behavioral Modification

Diabetic foot complications stem from intricate interactions between macrovascular and microvascular changes, neuropathy, inflammation, immune responses, hyperglycemia, oxidative stress, and infection susceptibility. Macrovascular factors like atherosclerosis lead to tissue ischemia, while microvascular dysfunction worsens perfusion deficits. Neuropathy contributes significantly to such complications, causing sensory loss, motor problems, and autonomic dysfunction. This results in unnoticed injuries, muscle atrophy, deformities, and dry skin, elevating the risk of non-healing wounds and infections. Inflammation and immune responses amplify tissue damage and hinder healing. Chronic hyperglycemia generates advanced glycation end products, stiffening tissues, while oxidative stress exacerbates damage. Mitochondrial dysfunction further compromises cellular energy production, worsening tissue repair challenges. These multifaceted factors collectively contribute to diabetic foot complications. The impact of modifiable behavior factors such as smoking, heavy alcohol consumption, and exercise on the risk of lower extremity amputation (LEA) in diabetic patients is also not to be ignored. Substantial data had identified increased LEA risk from smoking and heavy alcohol intake and reduced risk from regular exercise. The cumulative impact of these behaviors underscores the significance of behavior modification in preventing LEA and enhancing the well-being of diabetic patients. Understanding these mechanisms is vital for developing effective preventive strategies, diagnostics, and treatments, addressing the impact of diabetic foot complications on individuals and healthcare systems.

Preadipocytes in human granulation tissue: role in wound healing and response to macrophage polarization

BackgroundChronic non-healing wounds pose a global health challenge. Under optimized conditions, skin wounds heal by the formation of scar tissue. However, deregulated cell activation leads to persistent inflammation and the formation of granulation tissue, a type of premature scar tissue without epithelialization. Regenerative cells from the wound periphery contribute to the healing process, but little is known about their cellular fate in an inflammatory, macrophage-dominated wound microenvironment.MethodsWe examined CD45−/CD31−/CD34+ preadipocytes and CD68+ macrophages in human granulation tissue from pressure ulcers (n=6) using immunofluorescence, immunohistochemistry, and flow cytometry. In vitro, we studied macrophage-preadipocyte interactions using primary human adipose-derived stem cells (ASCs) exposed to conditioned medium harvested from IFNG/LPS (M1)- or IL4/IL13 (M2)-activated macrophages. Macrophages were derived from THP1 cells or CD14+ monocytes. In addition to confocal microscopy and flow cytometry, ASCs were analyzed for metabolic (OXPHOS, glycolysis), morphological (cytoskeleton), and mitochondrial (ATP production, membrane potential) changes. Angiogenic properties of ASCs were determined by HUVEC-based angiogenesis assay. Protein and mRNA levels were assessed by immunoblotting and quantitative RT-PCR.ResultsCD45−/CD31−/CD34+ preadipocytes were observed with a prevalence of up to 1.5% of total viable cells in human granulation tissue. Immunofluorescence staining suggested a spatial proximity of these cells to CD68+ macrophages in vivo. In vitro, ASCs exposed to M1, but not to M2 macrophage secretome showed a pro-fibrotic response characterized by stress fiber formation, elevated alpha smooth muscle actin (SMA), and increased expression of integrins ITGA5 and ITGAV. Macrophage-secreted IL1B and TGFB1 mediated this response via the PI3K/AKT and p38-MAPK pathways. In addition, ASCs exposed to M1-inflammatory stress demonstrated reduced migration, switched to a glycolysis-dominated metabolism with reduced ATP production, and increased levels of inflammatory cytokines such as IL1B, IL8, and MCP1. Notably, M1 but not M2 macrophages enhanced the angiogenic potential of ASCs.ConclusionPreadipocyte fate in wound tissue is influenced by macrophage polarization. Pro-inflammatory M1 macrophages induce a pro-fibrotic response in ASCs through IL1B and TGFB1 signaling, while anti-inflammatory M2 macrophages have limited effects. These findings shed light on cellular interactions in chronic wounds and provide important information for the potential therapeutic use of ASCs in human wound healing.

The Model of an Ischemic Non-Healing Wound: Regeneration after Transplantation of a Living Skin Equivalent

The Model of an Ischemic Non-Healing Wound: Regeneration after Transplantation of a Living Skin Equivalent

Extracellular Vesicles: Emergent and Multiple Sources in Wound Healing Treatment.

Non-healing wound- and tissue-injury are commonly experienced worldwide by the aging population. The persistence of disease commonly leads to tissue infection, resulting in severe clinical complications. In the last decade, extracellular vesicles (EVs) have been considered promising and emergent therapeutic tools to improve the healing processes. Therefore, efforts have been directed to develop a cell-free therapeutic platform based on EV administration to orchestrate tissue repair. EVs derived from different cell types, including fibroblast, epithelial, and immune cells are recruited to the injured sites and in turn take part in scar formation. EVs are nano-sized particles containing a heterogeneous cargo consisting of lipids, proteins, and nucleic acids protected from degradation by their lipid bilayer. Noteworthy, since EVs have natural biocompatibility and low immunogenicity, they represent the ideal therapeutic candidates for regenerative purposes. Indeed, EVs are released by several cell types, and even if they possess unique biological properties, their functional capability can be further improved by engineering their content and functionalizing their surface, allowing a specific cell cargo delivery. Herein, we provide an overview of preclinical data supporting the contribution of EVs in the repair and regenerative processes, focusing on different naïve EV sources, as well as on their engineering, to offer a scalable and low-cost therapeutic option for tissue repair.

Next-generation of smart dressings: Integrating multiplexed sensors and theranostic functions

Non-healing wounds represent a significant burden for healthcare systems and society, giving rise to severe economic and human issues. Currently, the use of dressings and visual assessment represent the primary and standard care for wounds. Conventional dressings, like cotton gauze, provide only passive physical protection. Besides, they end up paradoxically hampering the wound-healing process by producing tissue damage and pain when removed during routine check-ups. In response to these limitations, researchers, engineers, and technologists are developing innovative dressings that incorporate advanced diagnostic and therapeutic functionalities, coined as “smart dressings”. Now, the maturation of smart dressing is bringing them closer to real-life applications, leading to an exciting new generation of these devices. The next generation of smart dressings is capable of monitoring in real-time multiple biomarkers while including pro-healing capabilities in a single platform. Such multiplexed and theranostic smart dressings are expected to offer a timely biomarker-directed diagnosis of non-healing wounds while enabling rapid, automated, and personalized treatments of infection and chronicity. Herein, we provide an insightful overview of these advantageous devices, delving into the diverse spectrum of possible engineering strategies. This encompasses the use of electrochemical and optical platforms with diverse multiplexing architectures, such as multi-zone sensing arrays and multi-layered devices. Open or closed-loop theranostic mechanisms using various stimuli-responsive materials that could be internally or externally controlled are also included. Finally, a critical discussion on the main challenges and future directions of smart dressings is also offered.

The Use of Active Coagulation Whole Blood-An Innovative Treatment Strategy for Hard-To-Heal Wounds.

Deep and tunneling wounds are a challenge to apply and maintain most advanced wound dressings to promote effective healing. An autologous whole blood clot is a topical treatment and has been found to be safe and effective in healing cutaneous wounds. The active coagulation whole blood (ACWB) clot treatment, using the patient's own blood, is used to treat deep and tunneling wounds, by mixing the blood with coagulation components and applying it into the wound cavity allowing the clot to re-form inside the wound. We aimed to explore ACWB treatment in hard-to-heal wounds. 5 patients with multiple comorbidities, exhibiting surgical abdominal wound, chronic pilonidal sinus, stage 4 sacral pressure ulcer with exposed bone, post-amputation surgical site wound, and non-healing wound dehiscence at the site of a prior hip replacement, were all treated with the ACWB clot treatment. Complete wound healing was observed in 4/5 cases. In the fifth case, there was a 70% reduction in the depth and surface area of the abdominal surgical wound. The ACWB treatment was found to be effective in deep wounds with cavities and exposed structures. ACWB, in its flowable form, can effectively provide coverage of the deepest interstices of the wound's cavities by virtue of its liquid properties, forming a fibrin matrix, mimicking the role of the extracellular matrix. The flowable formulation of ACWB treatment safely and efficiently provides coverage of the entirety of the wound surface to improve the time and process of complex wound surface healing.

Exosomes derived from platelet-rich plasma promote diabetic wound healing via the JAK2/STAT3 pathway

Diabetic non-healing wounds are bringing a heavy burden on patients and society. Platelet-rich plasma (PRP) has been widely applied in tissue regenerating for containing various growth factors. Recently, PRP-derived exosomes (PRP-Exos) have been proved to be more effective than PRP in tissue regeneration. However, few studies have investigated the therapeutic potential of PRP-Exos in diabetic wound healing to date. Therefore, we extracted and identified exosomes derived from PRP and tested its promoting effect on diabetic wound healing invivo and invitro. We found that high glucose (HG) inhibited cell proliferation and migration and induced apoptosis through ROS-dependent activation of the JNK and p38 MAPK signaling pathways. PRP-Exos can stimulate fibroblast functions and accelerate diabetic wound healing. The benefits of PRP-Exos may be attributed to its capability to prevent HG-induced ROS-dependent apoptosis via the PDGF-BB/JAK2/STAT3/Bcl-2 signaling pathway. This illustrates the therapeutic potential of PRP-Exos in diabetic wounds.

Combinatorial wound dressings loaded with synergistic antibiotics in the treatment of chronic infected wounds

Advanced medicated wound dressings fabricated by electrospinning and electrospraying were prepared for the eradication of topical bacterial infections potentially applied in the management of infected acute and chronic non-healing wounds. Two different antibiotics (ciprofloxacin and rifampicin), with different aqueous solubilities and different mechanisms of antimicrobial action, were loaded within electrosprayed polymer microparticles and within electrospun nanofibers, respectively, to provide the resulting wound dressing with dually controlled antibiotic release kinetics. Due to the large surface area per volume ratio of the electrosprayed microparticles containing ciprofloxacin, an initial burst release was obtained. Simultaneously, the reduced surface area per volume ratio for the electrospun nanofibers together with the reduced aqueous solubility of rifampicin produced an extended rifampicin release over time. More importantly, a synergistic antimicrobial effect against Gram-positive and Gram-negative bacteria was observed when both antibiotics were combined. Biofilm formation prevention and the elimination of already formed mature bacterial biofilms were also successfully achieved using our advanced dressings. The lack of cytotoxicity of the advanced wound dressings here reported against eukaryotic cells at antimicrobial doses was also demonstrated using three different mammalian cell lines. Moreover, the advanced wound dressings successfully eliminated a Staphylococcus aureus mediated experimental infection in a chronic wound murine model showing their efficacy for the treatment of these complicated non-healing wounds. The strategy of advanced medicated wound dressings developed here may be used as a potential methodology for the fabrication of functional combinatorial materials that offer the ability to eradicate bacterial infections.

Somatic evolution of Cancer: A new synthesis

Cancers have been interpreted either as somatic evolution of cheater cells that escape replication regulation or alternatively as non-healing wounds. Both the interpretations have substantial support as well as glaring anomalies but the two have not been put together to make a coherent synthesis. We argue here that mechanisms and pathways to escape the normal regulation of cell proliferation do not need to evolve de novo. Mechanisms to override the normal regulation have already evolved for wound healing and tissue regeneration. Almost all of the hallmarks of cancer are also seen in the wound healing process. This suggests that cancer develops not by any de novo gain of function but by exaptation of pre-evolved wound healing functions. Somatic evolution that makes the wound healing triggers constitutive is not mutation limited but selection limited and the selective forces are dependent on the tissue microenvironment. Some mechanisms for such selection have been suggested. Many more need to be investigated. A series of mechanisms have evolved to minimize the risk of cancers which may fail in an altered lifestyle context. We support our synthesis with multiple lines of evidence and also make differential testable predictions. This evolutionary perspective challenges multiple prevalent ideas, suggests novel lines of research and also has translatable implications for cancer prevention.

Synthesis and Characterization of a Biopolymer Pectin/Ethanolic Extract from Olive Mill Wastewater: In Vitro Safety and Efficacy Tests on Skin Wound Healing.

Wound-healing delay is one of the major problems of type 2 diabetes, representing also a clinical emergency in non-healing chronic wounds. Natural antioxidants show interesting wound-healing properties, including those extracted from waste derived from olive oil production. Olive mill wastewater is one of the main by-products of the olive oil-making process, and it is rich in high-value secondary metabolites, mainly hydroxytyrosol. We proposed an eco-friendly extraction method, employing both ultrasound-assisted and Soxhlet techniques and ethanol as a solvent, to recover valuable molecules from Roggianella cv (Olea europea L.) olive mill wastewater, which was further entrapped in a pectin polymer via an enzymatic reaction using porcine pancreatic lipase. Pectin, in combination with other substances, promoted and accelerated wound healing and demonstrated good potential to produce a biomedical conjugate for wound treatment. The antioxidant activity of the extracts and conjugate were evaluated against lipophilic (IC50 equal to 0.152 mg mL-1) and hydrophilic (IC50 equal to 0.0371 mg mL-1) radical species as well as the in vitro cytotoxicity via NRU, h-CLAT, and a wound-healing scratch assay and assessment. The pectin conjugate did not exert hemolytic effects on the peripheral blood, demonstrating interesting wound-healing properties due to its ability to stimulate cell proliferation in a dose-dependent manner.

Real-time in vivo monitoring of the antimicrobial action of combination therapies in the management of infected topical wounds

The increasing prevalence of non-healing infected wounds has become a serious concern in the clinical practice, being associated to population aging and to the rising prevalence of several chronic conditions such as diabetes. Herein, the evaluation of the bactericidal and antibiofilm effects of the natural antiseptic terpenes thymol and farnesol standing alone or in combination with the standard care antiseptic chlorhexidine was carried out both in vitro and in vivo. The in vitro combinatorial treatment of chlorhexidine associated with those terpenes against Staphylococcus aureus in its planktonic and sessile forms demonstrated a superior antibacterial activity than that of chlorhexidine alone. Real-time in vivo monitoring of infection progression and antimicrobial treatment outcomes were evaluated using the bioluminescent S. aureus strain Xen36. In vivo studies on infected wound splinting murine models corroborated the superior bactericidal effects of the combinatorial treatments here proposed. Moreover, the encapsulation of thymol in electrospun Eudragit® S100 (i.e., a synthetic anionic copolymer of methacrylic acid and ethyl acrylate)-based wound dressings was also carried out in order to design efficient antimicrobial wound dressings.