WHS guidelines for the treatment of pressure ulcers-2023 update.

The major populations at risk for developing pressure ulcers are older adults who have multiple risk factors that increase their vulnerability, people who are critically ill and those with spinal cord injury/disease. The reported prevalence of pressure ulcers in the United States is 2.5 million. However, this estimate is derived from acute care facilities and does not include people who are living at home or in nursing facilities. Despite the implementation of hospital and facility-based preventive measures, the incidence of pressure ulcers has not decreased in decades. In addition to the burden of pain, infection and death, it is estimated that hospital-acquired pressure ulcers cost the health system $26.8 billion annually with over 50% of the cost attributed to treating Stage 3 and 4 pressure injuries. Thus, it is critical to examine the literature and develop guidelines that will improve the outcomes of this complex and costly condition. This guideline update is a compendium of the best available evidence for the treatment of Pressure Ulcers published since the last update in 2015 and includes a new section based on changing demographics entitled 'Palliative wound care for seriously ill patients with pressure ulcers'. The overall goal of the Wound Healing Society Guideline project is to present clear, concise and commercial free guidelines that clinicians can use to guide care, that researchers can use to develop studies that will improve treatment and that both clinicians and researchers can use to understand the gaps in our knowledge base.

Role of quercetin and rutin in enhancing the therapeutic potential of mesenchymal stem cells for cold induced burn wound.

Introduction: Cold burn wounds differ in their pathophysiological spectrum as compared to other types of burn wounds. These wounds have prolonged devastating effects on the body including hypertrophic scars, contracture, and necrosis. Mesenchymal stem cells (MSCs) are considered promising candidates for the complete regeneration of burn wounds. However, transplanted MSCs face the challenge to survive under the harsh tissue conditions. Preconditioning of MSCs with bioactive compounds may enhance their survival and regenerative potential for use in clinical applications. Bioactive compounds of Melia azedarach are well known for their potential role in treating different types of skin wounds due to their anti-inflammatory, anti-viral, anti-cytotoxic, and anti-oxidative properties. This study aims to evaluate the synergistic effects of human umbilical cord derived MSCs (hUC-MSCs) after preconditioning them with bioactive compounds of M. azedarach (quercetin and rutin) for cold induced burn wounds. Method: Human umbilical cord MSCs (hUC-MSCs) were characterized based on their specific cell surface markers and treated with 20 µM of quercetin or rutin. In vitro scratch assay was performed to measure cell migration and wound closure. In vivo cold burn wound model was developed via direct exposure of the dorsal rat skin to liquid nitrogen. hUC-MSCs were subcutaneously transplanted next day of burn wound induction and wound was examined at different time points corresponding to the wound healing phases (days 3, 7, and 14). The regenerative potential of preconditioned hUC-MSCs was assessed in different groups; control (treated only with hUC-MSCs), and treated groups (quercetin or rutin treated hUC-MSCs). Healing potential and wound closure were evaluated by histological, gene expression, and immunohistochemical analyses of the wound tissues before and after treatment. Results: Scratch assay exhibited enhanced cell migration towards wound closure in the treated groups as compared to the control. Macroscopic examination of the wound revealed scab formation at day 14 in control, whereas scab was detached and the wound tissue was remarkably remodeled in the treated groups. Comparison between the treated groups showed that burn wound treated with quercetin significantly increased healing potential than the rutin treated MSCs. Histological findings showed enhanced regeneration of skin layers along with hair follicles in the quercetin group, while increased neovascularization was noted in both treatment groups. Gene profile of wound healing mediators illustrated significant upregulation of IL-5, IL-4, GPX-7, TXNRD-2, PRDX, VEGF, and FGF and downregulation of inflammatory cytokines IL-1ß and IL-6. Conclusion: In conclusion, synergistic effect of hUC-MSCs and bioactive compounds of M. azedarach enhances wound healing by reducing the inflammation, mitigating oxidative stress and enhancing neovascularization. The study findings will aid in designing more effective treatment options for cold burn wounds.

Lactate, with oxygen, incites angiogenesis.

Lactate has been reconsidered! As we now know, most is produced aerobically We report that lactate accumulation commonly occurs in the presence of oxygen and is sufficient to instigate signals for angiogenesis and connective tissue deposition. These include vascular endothelial growth factor (VEGF), transforming growth factor beta (TGF beta), interleukin-1 (IL-1), and hypoxia-inducible factor (hif-1alpha). This paper, a mini-review, is occasioned by new data showing increased presence of VEGF and angiogenesis in an oxygenated site by adding a slow-release source of lactate into Matrigel and implanting the Matrigel subcutaneously in mice.

Aerobically derived lactate stimulates revascularization and tissue repair via redox mechanisms.

Hypoxia serves as a physiologic cue to drive an angiogenic response via HIF-dependent mechanisms. Interestingly, minor elevation of lactate levels in the tissue produces the same effect under aerobic conditions. Aerobic glycolysis contributes to lactate accumulation in the presence of oxygen, especially under inflammatory conditions. We previously postulated that aerobic lactate accumulation, already known to stimulate collagen deposition, will also stimulate angiogenesis. If substantiated, this concept would advance understanding of wound healing and aerobic angiogenesis because lactate accumulation has many aerobic sources. In this study, Matrigel plugs containing a powdered, hydrolyzable lactate polymer were implanted into the subcutaneous space of mice. Lactate monomer concentrations in the implant were consistent with wound levels for more than 11 days. They induced little inflammation but considerable VEGF production and were highly angiogenic, as opposed to controls. Arterial hypoxia abrogated angiogenesis. Furthermore, inhibition of lactate dehydrogenase by using oxamate also prevented the angiogenic effects of lactate. Lactate monomer, at concentrations found in cutaneous wounds, stabilized HIF-1alpha and increased VEGF levels in aerobically cultured human endothelial cells. Accumulated lactate, therefore, appears to convey the impression of "metabolic need" for vascularization, even in well-oxygenated and pH-neutral conditions. Lactate and oxygen together stimulate angiogenesis and matrix deposition.

Lactate stimulates endothelial cell migration.

The significance of the high lactate levels that characterize healing wounds is not fully understood. Lactate has been shown to enhance collagen synthesis by fibroblasts and vascular endothelial growth factor (VEGF) production by macrophages and endothelial cells. VEGF has been shown to induce endothelial cell migration. However, it has not been shown whether accumulated lactate correlates with the biological activity of VEGF. Therefore, we investigated the effect of lactate on migration of endothelial cells. Human umbilical vein endothelial cells and human microvascular endothelial cells were cultured to subconfluent monolayers in standard six-well tissue culture plates. Following a 24-hour serum starvation, cells were treated with the indicated concentrations of l-lactate. Cell migration was assessed using a modified Boyden chamber. VEGF protein in the cell culture supernatant was measured by enzyme-linked immunoassay. Lactate-enhanced VEGF protein synthesis in a time- and dose-dependent manner. Lactate added into the bottom well did not stimulate cellular migration from the upper well. However, lactate when added together with endothelial cells to the bottom well of the Boyden chamber increased cellular migration in a dose-dependent manner. This effect was blocked by anti-VEGF and by cycloheximide. Lactate enhances VEGF production in endothelial cells, although lactate, itself, is not a chemoattractant. We conclude that the lactate-mediated increase in cellular migration is regulated by VEGF.

IGF-I-induced VEGF expression in HUVEC involves phosphorylation and inhibition of poly(ADP-ribose)polymerase.

Insulin-like growth factor-I (IGF-I) has been shown to promote angiogenesis by enhancing vascular endothelial growth factor (VEGF) expression. However, how IGF-I-induces VEGF expression is not yet fully understood. With this investigation, we propose a new possible mechanism involving downregulation of poly(ADP-ribosyl)ation (pADPR). We first demonstrated that IGF-I increased VEGF protein expression in endothelial cells. Inhibitors of mitogen activated kinase (PD 98059), phosphatidyl-3-inositol-kinase (LY 294002), and protein kinase C (staurosporine) diminished the IGF-I effect suggesting the involvement of signal transduction. Since there is an established link between pADPR and transcriptional activity, we focused on a possible role of poly(ADP-ribose)polymerase (PARP). The inhibition of PARP by 3-aminobenzamide or nicotinamide enhanced VEGF expression. Additionally, IGF-I markedly decreased PARP activity. Furthermore, the IGF-I-mediated inhibition of PARP could be demonstrated as a result of protein phosphorylation since phosphorylation of PARP decreased its activity in vitro and IGF-I treatment of endothelial cells induced PARP phosphorylation. The IGF-I-mediated phosphorylation and inhibition of PARP represent a novel mechanism of VEGF protein expression.