Elevated UTI Biomarkers in Symptomatic Patients with Urine Microbial Densities of 10,000 CFU/mL Indicate a Lower Threshold for Diagnosing UTIs.

The literature lacks consensus on the minimum microbial density required for diagnosing urinary tract infections (UTIs). This study categorized the microbial densities of urine specimens from symptomatic UTI patients aged ≥ 60 years and correlated them with detected levels of the immune response biomarkers neutrophil gelatinase-associated lipocalin (NGAL), interleukin-8 (IL-8), and interleukin-1-beta (IL-1ß). The objective was to identify the microbial densities associated with significant elevation of these biomarkers in order to determine an optimal threshold for diagnosing symptomatic UTIs. Biobanked midstream voided urine samples were analyzed for microbial identification and quantification using standard urine culture (SUC) and multiplex-polymerase chain reaction (M-PCR) testing, while NGAL, IL-8, and IL-1ß levels were measured via enzyme-linked immunosorbent assay (ELISA). NGAL, IL-8, and IL-1ß levels were all significantly elevated at microbial densities ≥ 10,000 cells/mL when measured via M-PCR (p < 0.0069) or equivalent colony-forming units (CFUs)/mL via SUC (p < 0.0104) compared to samples with no detectable microbes. With both PCR and SUC, a consensus of two or more elevated biomarkers correlated well with microbial densities > 10,000 cells/mL or CFU/mL, respectively. The association between ≥10,000 cells and CFU per mL with elevated biomarkers in symptomatic patients suggests that this lower threshold may be more suitable than 100,000 CFU/mL for diagnosing UTIs.

Quantitative multiplex polymerase chain reaction in copies ml-1 linearly correlates with standard urine culture in colonies ml-1 for urinary tract infection (UTI) pathogens.

Standard urine culture (SUC) is the current standard method for confirmation of a urinary tract infection (UTI). SUC identifies microorganisms in urine samples and semi-quantifies these as colony-forming units (CFUs) ml-1. In contrast, quantitative multiplex polymerase chain reaction (q-MPCR) is a culture-independent assay in which the microbes are quantified by targeting genomic sequences and reported as cells ml-1, calculated from copies ml-1. Using serial dilutions within the 104-105 cells ml-1 range, the usual reporting range of SUC, this study compared the quantification results based on SUC and q-MPCR for four uropathogens with the control hemocytometer counts. The results revealed a linear relationship and a 1:1 correlation between the q-MPCR and SUC results. Additional q-MPCR quantification of 36 uropathogenic non-fastidious and fastidious bacteria and yeast indicated a reproducible linear correlation in a 1:1 manner with the control counts over a range of cell densities (103-106 cells ml-1). The results confirm that the quantifications by q-MPCR in cells ml-1 and by SUC in CFUs ml-1 are comparable and answer to the lingering question of how the results of these two methods correlate. Moreover, q-MPCR provided accurate quantification of various microorganisms over wider cell density ranges without the time required for microbial growth.

The Evolution of Animal Models in Wound Healing Research: 1993-2017.

Significance: Wound healing is a complex and dynamic series of events influenced by a variety of intrinsic and extrinsic factors. Problematic wounds, particularly chronic wounds and pathologic scars, remain clinically significant burdens. Modeling physiologic and aberrant wound repair processes using in vitro or in vivo models have contributed to Advances in Wound Care (AWC); however, the fidelity of each model used, particularly with respect to its species-specific limitations, must be taken into account for extrapolation to human patients. Twenty-five years of wound healing models published in Wound Repair and Regeneration (1993-2017) and AWC (2012-2017) were collected and analyzed to determine trends in species utilization and models used. Recent Advances: In 25 years, 1,521 original research articles utilizing one or more wound models were published (total of 1,665 models). Although 20 different species were used over the course of 25 years, 5 species were most commonly utilized: human, mouse, rat, pig, and rabbit. In vivo modeling was used most frequently, followed by in vitro, ex vivo, and in silico modeling of wound healing processes. Critical Issues: A comparison of articles from 1993 to 1997 and 2013 to 2017 periods showed notable differences in model and species usage. Experiments utilizing mouse and human models increased, while the usage of pig models remained constant, rabbit and rat models declined in the more recent time period examined compared to the time period two decades before. Future Directions: This analysis shows notable changes in types of models and species used over time which may be attributed to new knowledge, techniques, technology, and/or reagents. Explorations into mechanisms of limb regeneration and wound healing of noncutaneous tissues have also contributed to a shift in modeling over time. Changes within the journals (i.e., page expansion and increased rejection rates), research funding, and model expense may also influence the observed shifts.

The Origin and Evolution of the HARMONIC® Scalpel.

When Jacques and Pierre Curie first researched ultrasonic energy and piezoelectric effects in the 1880s, they likely had no idea of the profound impact it would eventually have on surgical patients. Today in operating rooms around the world, ultrasonic energy is used for tissue manipulation, dissection, cutting, and coagulation. Surgeons including but not limited to the specialties of gynecology, general surgery, colorectal, thoracic, breast, and bariatric have activated ultrasonic energy in thousands of patients. As a mainstay surgical energy device, patients have benefited from the ultrasonic versatility of its cutting and coagulating effects. The ability of ultrasonic energy to be used near vital organs with precision by adjusting for tissue tension, power settings, and activation time has accounted for its safety and clinical outcomes. This overview of the mechanics of ultrasonic energy and the evolution of the HARMONIC® (UltraCision, Providence, Rhode Island, now owned by Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) surgical tools since 1988 provides readers an understanding of this energy platform and its distinct advantages. Clinical implications of key research and clinical studies are explored and discussed with a focus on patient and surgical outcomes. Research in a variety of fields and tissues is presented with a special emphasis on the gynecological patient.

Itching for Knowledge About Wound and Scar Pruritus.

Chronic itch continues to be a problem that plagues millions of humans and animals. Pruritus has a negative impact on patient quality of life and many patients experience sleep deprivation, anxiety, and depression, similar to patients with chronic pain. This review provides an overview of clinical pruritus research with special emphasis on itch that wound care providers may see. In addition, the need for using multifactorial questionnaires for better research in pruritus is summarized. Similarities and differences in itch characteristics, triggers, and relievers in various patient populations are discussed. A brief overview of itch receptors and pathways is provided to help the reader better understand the complexity of the resultant itch sensation. Also, some nonpharmacological and pharmacological antipruritic therapies and their mechanisms of action are included.

Equine exuberant granulation tissue and human keloids: a comparative histopathologic study.

OBJECTIVE: To compare histopathologic features of a fibroproliferative disorder in horses (exuberant granulation tissue-EGT) and people (keloid). SAMPLE POPULATION: Archival tissue samples of EGT (n = 8) and keloid (12). METHODS: After automated hematoxylin and eosin, histochemical (Gomori trichrome, Verhoeff-van Gieson elastin) and immunohistochemical (vimentin, α-smooth muscle actin, CD34, CD68, CD117) stainings, tissue sections were evaluated using a semi-quantitative grading scale for presence or absence of ulceration, keloidal collagen, myofibroblasts, and elastic fibers as well as degree of inflammation, fibrosis, vascularity, and orientation of collagen fibers. RESULTS: Superficial dermis and deep dermis of both horses and people had increased numbers of haphazardly oriented thickened collagen fibers; however, only keloids contained "keloidal" collagen. Fibroblast numbers were markedly increased in both groups but only EGT had myofibroblasts. Minimal vascularity was observed in the deep dermis of both groups. The superficial dermis in EGT was characterized by small vessels within immature granulation tissue. Macrophages and mast cells were infrequently found in both groups but polymorphonuclear cells were markedly increased in EGT. CONCLUSIONS: Humans and horses are the only mammals known to naturally develop excessive granulation during wound healing; however, similarities and differences between fibroblast populations and associated collagen have not been reported. Inflammatory response may contribute to observed differences in the cellular populations, with EGT possessing markedly increased myofibroblasts, small vessels, and acute inflammatory cells compared with keloids. Further work is warranted to develop common treatment strategies for these fibroproliferative conditions.

Preclinical Models of Wound Healing: Is Man the Model? Proceedings of the Wound Healing Society Symposium.

SIGNIFICANCE: A review of therapeutic effects in preclinical and clinical studies suggests that concordance between large animal (pig=78%), small laboratory animal (53%) and in vitro (57%) results with those observed in humans is only partial. Pig models of wound healing provide major advantages over other animal models. Since the vast majority of wound-healing research is done in rodents and in vitro, the low concordance rate is a significant impediment to research that will have any clinical impact. CRITICAL ISSUES: To generate clinically relevant experimental data, hypothesis generation should begin, or at least involve human wound tissue samples. Such tissue could be used to test a predetermined hypothesis generated based on, say, murine data. Alternatively, such tissue could be analyzed using high-throughput cell biology techniques (e.g., genomics, proteomics, or metabolomics) to identify novel mechanisms involved in human wounds. Once the hypothesis has been formulated and confirmed using human samples, identification of these same mechanisms in animals represents a valid approach that could be used for more in-depth investigations and experimental manipulations not feasible with humans. FUTURE DIRECTIONS: This consensus statement issued by the Wound Healing Society symposium strongly encourages all wound researchers to involve human wound tissue validation studies to make their animal and cell biology studies more translationally and clinically significant.

Assessment of pruritus characteristics and impact on burn survivors.

The goal of this cross-sectional study was to characterize and describe persistent postburn pruritus. Cause and treatment of postburn itch is elusive. It has been suggested that burn survivors with persistent pruritus should be divided into acute itch (≤6 months postinjury) and chronic itch (>6 months postinjury) because the cause of itch may be different. Cross-sectional data of itch characteristics reported here are from the baseline data of a prospective, randomized, double-blind, controlled pilot study of 23 subjects with frequent and bothersome postburn pruritus. Subjects self-completed validated scales for variables of itch sensation, affect of itch, and severity. Variables of quality of life, frequency, pain and itch intensity, skin condition, scar, and medication were also recorded. Itch frequency revealed that 87% of subjects experienced itching daily, 96% experienced three or more episodes a day, and 52% had episode durations lasting 5 to 30 minutes per incidence. Itch was reported as unbearable by 94% of subjects with chronic itch and by 86% of subjects with acute itch, whereas bothersome was 88 and 100%, respectively. Itch sensation dimension of stinging was 74% in both acute and chronic itch subjects. Crawling and burning sensations were often severe. Potential itch triggers and relief activities were identified. Differences in sensory and affective itch components were detected between acute and chronic itch subjects. Combinations of itch mechanisms probably contribute to the development of and changes in pruritus. Characterizing the sensation and affective itch dimensions in conjunction with inflammation, burn injury, recovery, scar maturation, medication, and psychological status should better elucidate postburn itch.

Double-blind, randomized, pilot study assessing the resolution of postburn pruritus.

The objective of this study was to evaluate whether Provase®, a nonprescription moisturizer with a blend of protease enzymes, would reduce postburn itching in adult burn survivors relative to a control moisturizer. This was a prospective, single-center, double-blinded, pilot study where 23 burn survivors were randomized to either the treatment group, who applied Provase, or the control group, who applied the base moisturizer used in Provase every 8 hours for 4 weeks. Twelve were randomized to the treatment and 11 to the control groups with 9 participants in each group completing the study. There was no difference between groups with respect to gender, ethnicity, causative factor, TBSA burned, or time postinjury. Participant's pruritus and scar were reevaluated on a weekly basis for 4 consecutive weeks. Relative to baseline, there was a significant reduction of itch duration in minutes at weeks 3 and 4, the number of days per week that itch was experienced at weeks 2, 3, and 4, and the number of itch episodes per day at week 2 for the treatment group. The itch TBSA reduced significantly relative to baseline for the treatment group at week 1, 2, and 3. The affective itch characteristics were significantly reduced for the treatment group for bothersome at weeks 1, 2, 3, and 4; for annoying at week 4; and for unbearable at weeks 2, 3, and 4. Although this was a pilot study and not powered for statistical differences, there were statistically significant differences for itch duration, weekly frequency, itch episodes per day, itch TBSA, and reported affective burden of itch after treatment. Further investigation is recommended with a larger sample size treated for a longer period of time where participants are stratified based on acute or chronic itch.

Use of platelet rich plasma gel on wound healing: a systematic review and meta-analysis.

OBJECTIVE: Autologous platelet rich plasma is an advanced wound therapy used in hard-to-heal acute and chronic wounds. To better understand the use and clinical outcomes of the therapy, a systematic review of the published literature in cutaneous wounds was performed. METHODS: Electronic and hand searches for randomized controlled trials and comparative group studies using platelet rich plasma therapy in cutaneous wounds and published over the last 10 years was conducted. Eligible studies compared the treatment to standard care or other interventions. All citations were screened and eligible studies were assessed for validity, quality, and bias using accepted scoring methods. The primary outcomes were effect of platelet rich plasma and control wound care on wound healing and related healing measurements. Secondary outcomes related to healing such as infection, pain, exudate, adverse events, and quality of life were also considered. The meta-analysis utilized appropriate statistical methods to determine the overall treatment effect on chronic and acute wound healing and infection. RESULTS: The search terms resulted in 8577 citations and after removing duplicates and screening for protocol eligibility, a total of 24 papers were used. The meta-analysis of chronic wound studies revealed platelet rich plasma therapy is significantly favored for complete healing. The meta-analysis of acute wounds with primary closure studies demonstrated that presence of infection was reduced in platelet rich plasma treated wounds. CONCLUSIONS: This systematic review and meta-analysis of platelet rich plasma therapy in cutaneous wounds showed complete and partial wound healing was improved compared to control wound care.

Protein degradation and protection observed in the presence of novel wound dressing components.

Chronic wounds typically have excessive levels of matrix metalloproteinases (MMPs) and proinflammatory cytokines that impair healing. Reducing these detrimental proteins may be key to healing chronic wounds. Proprietary protease blends were formulated specifically to degrade excessive amounts of proinflammatory factors that could prevent wound healing. Applications of protease-containing wound dressings to acute and chronic wounds have been observed clinically to resolve inflammation and appear to aid healing. The purpose of this study was to test in vitro a deliberate blend of proteases for the ability to deactivate or activate known proteins associated with inflammation or healing. Purified human target proteins were incubated with test and control solutions and samples removed at various time points. Blinded samples were tested using a novel infrared protein multiplex sandwich-ELISA-type array technique. Many proinflammatory proteins such as MMPs, cytokines and chemokines were susceptible to degradation. Many proteins such as growth factors, cytokines and TIMP1 were resistant to degradation. Not all proinflammatory proteins were deactivated. Family protein structure did not appear to affect susceptibility to degradation or deactivation. These results suggest that specific protease containing wound dressings appear to reduce multiple detrimental components which may disrupt their deleterious effects on the wound bed and microenvironment. By improving the wound microenvironment through the use of definitive proteases, these novel wound dressings may help transition wounds into the subsequent phase of healing.

Wound dressing components degrade proteins detrimental to wound healing.

Excessive levels of matrix metalloproteinases (MMPs) are present in chronic wounds preventing wound closure. Reducing detrimental components may be key in healing chronic wounds. Elta Protease-containing wound dressings have been observed clinically to resolve inflammation and appear to aid healing in acute and chronic recalcitrant wounds. To investigate possible mechanisms of action, in vitro tests, zymography, collagenase assays and enzyme-linked immunosorbent assays (ELISAs), were performed to evaluate the effect of the dressing proteases on detrimental and beneficial wound healing components such as MMPs, Tissue Inhibitor of Matrix Metalloproteinases (TIMPs), cytokines and growth factors. Standards of pro- and active MMP-2, MMP-9 and chronic wound fluid (CWF) were prepared. Degradation of target proteins was enhanced by increased Elta Protease concentration, temperature and incubation time. Incubation with serial dilutions of the Elta Proteases resulted in nearly complete degradation of all MMP standards. After a 30-minute incubation, twofold diluted Elta Proteases degraded >90% of the gelatinases in CWF. ELISAs showed that Elta Proteases effectively degraded MMP-9 and tumour necrosis factor (TNF-alpha). In contrast, Platelet Derived Growth Factor (PDGF) and interleukin 1 beta were resistant to degradation by Elta Proteases. These results suggest that Elta Protease dressings appear to deactivate detrimental components in CWF, which may reduce wound bed contact with harmful proteins.

Up close and personal with deep vein thrombosis.

Deep vein thrombosis - the formation of clots in one of the body's deep veins (usually in the lower extremities) - develops as a result of vascular damage to the vein wall, venous stasis, and hypercoagulability (Virchow's triad). Among the many problems it can cause, the condition can escalate the challenge of healing a chronic wound. If a patient presents with pain, swelling, warmth, muscle cramps, and/or redness, the clinician should consider deep vein thrombosis, even if the patient does not initially appear to be at risk. Because approximately 2 million Americans have deep vein thrombosis every year (including otherwise healthy adults, the elderly, and persons with and without a history of venous insufficiency), prompt attention to symptoms is warranted. Diagnosis takes into consideration risk factors such as hypercoagulability, estrogen contraception, and Factor V Leiden mutation and is confirmed via compression ultrasonography and duplex ultrasound. Management includes anticoagulation therapy and thrombolytic therapy; prevention focuses on avoiding long periods of sitting, wearing compression hose when necessary and, for persons at risk, prophylactic anticoagulant therapy. Prescribed bedrest as a result of deep vein thrombosis provided one clinician/patient who did not consider herself to be at risk the opportunity to explore the condition in depth.