Treatment of severe pressure ulcers with protein-enriched filtered platelet-rich plasma (PEFPRP): a possible management.

Background: Biological dressings with non-transfusion blood components are among the treatments available for pressure ulcers (PUs). Biological dressings contain active concentrated pro-regenerative molecules that can modify and switch off local inflammatory pathways. This re-establishes the physiological homing, which results in healing. In our study, we used a biological component obtained by ultrafiltration of plasma-platelet concentrate: protein-enriched filtered platelet-rich plasma (PEFPRP) with a higher platelet and higher plasma protein concentration. We tested whether treatment with PEFPRP could improve healing in advanced-stage pressure ulcers with a large surface area. All the patients in this study had a surgical indication but were not able to undergo surgery for various reasons. Materials and methods: Ten patients with severe neurological disability and advanced-stage sacral pressure ulcers were treated with allogenic PEFPRP. The mean lesion surface area at T0 was 13.4 cm2 ( ± 9.8 SD). PEFPRP was derived from allogenic plasma-platelet apheresis that had been pre-ultrafiltered with a ProSmart™ filter (Medica, Italy) to obtain a concentration after filtration of the plasma protein (12-16 g/dL) and platelet (1-1.2 x 106 microL). Results and Conclusion: All cases showed a reduction in the surface area of the pressure ulcer and in the Pressure Ulcer Scale for Healing (PUSH) score. The mean reduction values at week 6 were as follows: -52% for surface area and -21% for PUSH. Rapid wound healing is fundamental to avoid infections and improve patients' quality of life. This blood component builds new tissue by creating a new extracellular matrix. This, in turn, promotes rapid restoration of the three-dimensional structure of the tissue necessary for healing deeper wounds. PEFPRP shrinks the PU and improves its morphological features (reducing undermining and boosting granulation tissue). PEFPRP also promotes tissue restoration, obtaining an optimal scar. It is a safe and feasible treatment, and these preliminary results support the use of PEFPRP in the treatment of pressure ulcers. PEFPRP dressings could be integrated in the standard treatment of advanced-stage PU.

Perinatal asphyxia partly affects presepsin urine levels in non-infected term infants.

OBJECTIVES: Standard of care sepsis biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) can be affected by several perinatal factors, among which perinatal asphyxia (PA) has a significant role. In this light, new early sepsis biomarkers such as presepsin (P-SEP) are needed to enact therapeutic strategies at a stage when clinical and laboratory patterns are still silent or unavailable. We aimed at investigating the potential effects of PA on longitudinal P-SEP urine levels. METHODS: We conducted an observational case-control study in 76 term infants, 38 with PA and 38 controls. Standard clinical, laboratory, radiological monitoring procedures and P-SEP urine measurement were performed at four time-points (first void, 24, 48, 96 h) after birth. RESULTS: Higher (p<0.05) CRP and PCT blood levels at T1-T3 were observed in PA than control infants whilst no differences (p>0.05, for all) at T0 were observed between groups. P-SEP urine levels were higher (p<0.05) in PA at first void and at 24 h while no differences (p>0.05) at 48 and 96 h were observed. No significant correlations were found (p>0.05) between P-SEP and urea (R=0.11) and creatinine (R=0.02) blood levels, respectively. CONCLUSIONS: The present results, showed that PA effects on P-SEP were limited up to the first 24 h following birth in absence of any kidney function bias. Data open the way to further investigations aimed at validating P-SEP assessment in non-invasive biological fluids as a reliable tool for early EOS and LOS detection in high-risk infants.

A Single-Center Pilot Prospective Study of Topical Application of Platelet-Derived Eye Drops for Patients with Ocular Chronic Graft-versus-Host Disease.

Ocular involvement of chronic graft-versus-host disease (cGVHD) is a complication that occurs in up to 60% of patients after allogeneic hematopoietic stem cell transplantation. Conventional therapeutic options include medical and surgical procedures that are administered depending on the severity of the condition, but most of them have provided unsatisfactory results and, to date, there is no consensus about treatment. We considered that topical application of a platelet lysate, administered as eye drops, might be considered an alternative worthwhile of investigation to treat ocular surface disorders in patients suffering from cGVHD. Therefore, we conducted a single-center prospective pilot study to assess the efficacy and safety of using eye drops made from reconstituted lysed platelet concentrate. Twenty-six patients with ocular cGVHD were eligible for the study; all but 2 completed their scheduled 1-year treatment and complied with the hematologic and ophthalmic regimen. At their first assessment interviews, after 30 days of treatment, 91% of patients reported an improvement in their symptoms and for 32%, substantive objective differences were measured. Remission of corneal damage was seen for 86% of our cohort, and improved National Institutes of Health scores for 73%, of whom 8% achieved the best score of 0 (ie, non-dry eye). Similar results were seen at later time points. Comparing outcomes for our patient cohort to those determined retrospectively for patients in our institutional database revealed a 5-year overall survival (OS) of 65%. This OS is comparable to patients with limited cGVHD (75%) and is superior to that of patients with nonocular extensive cGVHD or without cGVHD (30% and 59%, respectively) (P = .013). Our results suggest that platelet-derived eye drops are a safe, practical, and well-tolerated therapeutic option that offers substantial benefits for most patients affected by ocular cGVHD at onset. The favorable OS of our patient cohort suggests that this topical therapy, rather than systemic immunosuppression, may be the treatment of choice.

Non-Hematopoietic Essential Functions of Bone Marrow Cells: A Review of Scientific and Clinical Literature and Rationale for Treating Bone Defects.

Hematopoiesis as the only essential function of bone marrow cells has been challenged for several decades through basic science (in vitro and in vivo) and clinical data. Such work has shed light on two other essential functions of bone marrow cells: osteopoiesis and angio-genesis/vasculogenesis. Clinical utility of autologous concentrated bone marrow aspirate (CBMA) has demonstrated both safety and efficacy in treating bone defects. Moreover, CBMA has been shown to be comparable to the gold standard of iliac crest bone graft (ICBG), or autograft, with regard to being osteogenic and osteoinductive. ICBG is not considered an advanced therapy medicinal product (ATMP), but CBMA may become regulated as an ATMP. The European Medicines Agency Committee for Advanced Therapies (EMA:CAT) has issued a reflection paper (20 June 2014) in which reversal of the 2013 ruling that CBMA is a non-ATMP has been proposed. We review bone marrow cell involvement in osteopoiesis and angiogenesis/vasculogenesis to examine EMA:CAT 2013 decision to use CBMA for treatment of osteonecrosis (e.g, of the femoral head) should be considered a non-ATMP. This paper is intended to provide discussion on the 20 June 2014 reflection paper by reviewing two non-hematopoietic essential functions of bone marrow cells. Additionally, we provide clinical and scientific rationale for treating osteonecrosis with CBMA.

Platelet-rich plasma induces mixed osteogenic/osteoclastogenic phenotype in osteosarcoma SaOS-2 cells: role of TGF-beta.

Platelet-rich plasma (PRP) is widely used to promote tissue repair and accelerate osteogenesis, but there is no agreement about its mechanism of action. We characterized the modulatory effect of PRP on the in vitro osteoblast model SaOS-2, by using cell motility/chemoattraction and osteogenesis/mineralization assays, and a series of osteogenic/ osteoclastogenic genomic markers. Scratch wound assay showed that PRP stimulates cell motility, while transwell assay revealed a strong chemoattraction. Alkaline phosphatase (ALP) and alizarin red-S assays showed that PRP induces slight, but significant, stimulations of ALP activity and mineralization. The TGF-ß inhibitor SB431542 reversed these effects, showing a main role for TGF-ß1 released by PRP. Analyses of gene expression by qRT-PCR, showed the upregulation of osteocalcin, osteopontin, osteoprotegerin, receptor activator of NFκB (RANK), and runt-related transcription factor 2 (RUNX2) genes, with a total reversion by SB431542 for osteoprotegerin and RANK, and a partial reversion for ostecalcin, osteopontin, and RUNX2. The use of PCR array technique revealed the upregulation of the cathepsin K gene. These data show that PRP induces the development of mixed osteogenic/osteoclastogenic traits in the SaOS-2 model. Such a behavior may favour in vivo bone resorption and reconstitution at post-surgery or post-traumatic sites.

"Reasonable compromise" to define the quality standards of platelet concentrate for non-transfusion use (CPunT).

Platelets concentrate for non-transfusion use (CPunT) is a blood component specific for regenerative medicine. This blood component has found regenerative applications in many clinical fields (orthopedic, plastic surgery, maxillofacial surgery) since platelets contain growth factors, cytokines and bioactive molecules. Plasticity and ease of preparation of this blood component has often led the user to prepare it without using standardized procedures and references to quality product standards, but to evaluate the effectiveness of treatments and to standardize clinical protocols, is essential. The complexity of establish functional and non-functional parameters to define CPunT properties is linked to three fundamental steps: variability and bioavailability of biomolecules content in platelets, variability in product preparation. Then it is very difficult to understand which are the real parameters to evaluate, but it seems a "reasonable compromise" to establish content of platelets×ml (1×10(9)ml) as reference realistic parameter for CPunT qualification.

One-Step Cartilage Repair with Bone Marrow Aspirate Concentrated Cells and Collagen Matrix in Full-Thickness Knee Cartilage Lesions: Results at 2-Year Follow-up.

OBJECTIVE: The purpose of our study was to determine the effectiveness of cartilage repair utilizing 1-step surgery with bone marrow aspirate concentrate (BMAC) and a collagen I/III matrix (Chondro-Gide, Geistlich, Wolhusen, Switzerland). MATERIALS AND METHODS: We prospectively followed up for 2 years 15 patients (mean age, 48 years) who were operated for grade IV cartilage lesions of the knee. Six of the patients had multiple chondral lesions; the average size of the lesions was 9.2 cm(2). All patients underwent a mini-arthrotomy and concomitant transplantation with BMAC covered with the collagen matrix. Coexisting pathologies were treated before or during the same surgery. X-rays and MRI were collected preoperatively and at 1 and 2 years' follow-up. Visual analog scale (VAS), International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Marx, SF-36 (physical/mental), and Tegner scores were collected preoperatively and at 6, 12, and 24 months' follow-up. Four patients gave their consent for second-look arthroscopy and 3 of them for a concomitant biopsy. RESULTS: Patients showed significant improvement in all scores at final follow-up (P < 0.005). Patients presenting single lesions and patients with small lesions showed higher improvement. MRI showed coverage of the lesion with hyaline-like tissue in all patients in accordance with clinical results. Hyaline-like histological findings were also reported for all the specimens analyzed. No adverse reactions or postoperative complications were noted. CONCLUSION: This study showed that 1-step surgery with BMAC and collagen I/III matrix could be a viable technique in the treatment of grade IV knee chondral lesions.

Platelet lysate promotes in vitro wound scratch closure of human dermal fibroblasts: different roles of cell calcium, P38, ERK and PI3K/AKT.

There is a growing interest for the clinical use of platelet derivates in wound dressing. Platelet beneficial effect is attributed to the release of growth factors and other bioactive substances, though mechanisms are mostly unknown. We studied wound-healing processes of human primary fibroblasts, by exposing cells to a platelet lysate (PL) obtained from blood samples. Crystal violet and tetrazolium salt (MTS) assays showed dose-response increase of cell proliferation and metabolism. In scratch wound and transwell assays, a dose of 20% PL induced a significant increase of wound closure rate at 6 and 24 hrs, and had a strong chemotactic effect. BAPTA-AM, SB203580 and PD98059 caused 100% inhibition of PL effects, whereas wortmannin reduced to about one third the effect of PL on wound healing and abolished the chemotactic response. Confocal imaging showed the induction by PL of serial Ca2(+) oscillations in fibroblasts. Data indicate that cell Ca2(+) plays a fundamental role in wound healing even without PL, p38 and ERK1/2 are essential for PL effects but are also activated by wounding per se, PI3K is essential for PL effects and its downstream effector Akt is activated only in the presence of PL. In conclusion, PL stimulates fibroblast wound healing through the activation of cell proliferation and motility with different patterns of involvement of different signalling pathways.

The use of autologous platelet gel to treat difficult-to-heal wounds: a pilot study.

BACKGROUND: Chronic ulcers can benefit from topical treatment with growth factors (GFs). PLT gel provides tissue regeneration-inducing GFs. The aim of this study was to verify the effectiveness of autologous PLT gel in the treatment of nonhealing skin lesions. STUDY DESIGN AND METHODS: PLT gel was produced by treating PLTs with autologous thrombin. Two groups of patients were investigated: patients with dehiscent sternal wounds and patients with necrotic skin ulcers. Patients treated with PLT gel were retrospectively compared with patients having similar lesions but undergoing conventional treatment. The clinical endpoints of the study were the healing rate, the length of hospital stay, and/or the time required to bring about adequate tissue regeneration in order to undergo reconstructive plastic surgery. RESULTS: In patients with treated dehiscent sternal wounds the healing rate (3.5 vs. 6.0 wks, p = 0.0002) and hospital stay (31.5 vs. 52.5 days, p < 0.0001) were significantly reduced. Patients with treated necrotic skin ulcers required a notably shorter time to have surgery (median 15.0 vs. 35.5 wks, p < 0.0001). Neither adverse reactions nor in-situ recurrences were observed. CONCLUSIONS: Patients with chronic unhealing wounds showed substantial improvement when treated with PLT gel lesion dressings.