Combined insulin-like growth factor-1 and growth hormone improves weight loss and wound healing in burned rats

The anabolic effects of growth hormone (GH) in burned patients appear to act both directly and through insulin-like growth factor-1 (IGF-1). We, therefore, hypothesize that exogenous GH plus IGF-1 will attenuate increases in metabolism and lean muscle wasting while promoting wound healing. MATERIALS AND METHODS: Rats, each weighing 440-470 g, were given a 35% total body surface area, full-thickness scald burn and divided into four groups to receive placebo (burned controls), bovine GH (2.5 mg/kg/day), IGF-1 (2.0 mg/kg/day), or bovine GH plus rhIGF-1 (2.5 + 2.0 mg/kg/day), respectively, for 8 weeks. RESULTS: Total body weight gain after 8 weeks averaged 110 g for GH plus IGF-1 compared with gains of 49 and 11 g for GH or IGF-1 alone, respectively. Burned controls lost 24 g. Metabolic rates were significantly reduced in all groups receiving growth hormones. Gastrocnemius muscle dry weight was significantly increased in those receiving GH plus IGF-1 compared with GH and IGF-1 alone or burned controls (p < .01). CONCLUSIONS: Data show that GH plus IGF-1 synergistically increased lean muscle weight, total body weight, and was more effective in re-epithelialization of the burn wound than either GH or IGF-1 alone.     

Pretreatment of photoaged forearm skin with topical tretinoin accelerates healing of full-thickness wounds

Pretreatment of skin with all-trans retinoic acid (tretinoin) has been shown to enhance wound healing. Previous studies have mainly used animal models to demonstrate this effect. We wanted to determine whether pretreatment could promote wound healing in severely photoaged dorsal forearm skin. Four elderly men with severely actinically damaged forearms were treated daily for 16 weeks. One arm was treated with 0.05-0.1% tretinoin cream (Retin A, Ortho), and the other with Purpose cream (Ortho) as a vehicle control. Four-millimetre punch biopsies were taken from both dorsal forearms prior to treatment. After 16 weeks, full-thickness 2-mm punch biopsies were taken from both sides. Serial photographs were taken, and healing of the wounds quantitatively assessed by image analysis. On the 11th day, the wounds were excised using a 4-mm biopsy punch. Biopsies were processed for light microscopy. After 16 weeks, the tretinoin-treated forearms showed moderate erythema and scaling. Polarized light photographs revealed multiple, red, vascularized foci and/or a diffuse network of small vessels. The histological effects were typical for tretinoin, i.e. compaction of the stratum corneum, epidermal acanthosis with correction of atypia, an increase in small vessels, and increased cellularity in the upper dermis. Purpose cream had no effect, either clinically or histologically. On the tretinoin-treated side, the wound areas were 35-37% smaller on days 1 and 4, and 47-50% smaller on days 6, 8, 11, compared with the controls. Clinically and histologically, reepithelialization occurred more rapidly. Thus tretinoin dramatically accelerated wound healing in photodamaged skin.     

Human albumin solder supplemented with TGF-beta 1 accelerates healing following laser welded wound closure

BACKGROUND AND OBJECTIVE: We examined the possibility that human albumin solder can be used as a vehicle for site specific delivery of growth factors for the purpose of accelerating tissue repair following laser welded wound closure. Certain human recombinant growth factors have been shown to accelerate wound healing in model systems. Pilot in vitro studies have established that several growth factors, including TGF-beta 1, maintain bioactivity following exposure to temperatures achieved during laser tissue welding. Using a temperature controlled laser delivery system (TCL) to precisely maintain welding temperatures, it is now possible to avoid thermal denaturation of exogenous bioactive molecules such as growth factors. STUDY DESIGN/MATERIALS AND METHODS: HB-EGF, bFGF, and TGF-beta 1 were tested in vitro for maintenance of bioactivity after exposure to 80 degrees C. In vivo experiments using porcine skin determined the efficacy of solders augmented with growth factors. Incisions were repaired using human albumin alone or supplemented with HB-EGF (2 micrograms), bFGF (10 micrograms), or TGF-beta 1 (1 microgram). Wounds were excised at 3, 5, and 7 days post-operatively. Tensile strength, total collagen content, and histology were performed. RESULTS: At 3 days, tensile strength (TS) of TGF-beta 1 wounds were 36% (P < 0.05) and 20% (n.s.) stronger than laser alone and suture closures, respectively. By 5 days the TS of the TGF-beta 1 group increased by 50% (P < 0.05) and 59% (P < 0.02) over laser alone and suture groups, respectively. At 7 days the TGF-beta 1 group was 50% (P < 0.05) and 79% (P < 0.01) stronger than laser solder alone or suture, respectively. The HB-EGF and bFGF groups were equivalent to the laser solder group at all time points. Total collagen TGF-beta 1 Accelerates Healing Following Laser Welding content at 7 days increased in the TGF-beta 1 group by 7% (n.s.) over the suture group and 21% (P < 0.05) in the laser group. CONCLUSION: Human albumin solder supplemented with TGF-beta 1 increases the early post-operative strength of laser welded wounds. This novel application of laser tissue soldering augmented with a growth factor has the potential to bring about immediate fluid tight seals while providing site specific delivery of biological modifiers. This may lead to an overall improvement in post-operative convalescence, wound infections, and hospital costs.     

Acute surgical wound care. 2: The wound healing process

The first article in this series on acute surgical wound care traced the history of surgical wound care from primitive dressings and techniques of closure used in the past to the present-day approaches. It also outlined the classification of acute surgical wounds (Vol 7(18): 1101-6). This second article describes the four stages of wound healing in acute surgical wounds, using clinical slides to illustrate the wound healing process. General factors, such as age, nutrition and medication, and local factors, including a moist environment, blood supply and wound infection, will be discussed to demonstrate their importance in promoting optimum wound healing.     

Single local injection of recombinant fibroblast growth factor-2 stimulates healing of segmental bone defects in rabbits

One type of maturity-onset diabetes of the young (MODY2) is caused by mutations in the glucokinase gene, a key glycolytic enzyme in the beta cell and liver. Glucose fails to stimulate insulin secretion in mice in which the glucokinase gene has been selectively knocked out in the beta cell. We tested the hypothesis that this effect results from defective metabolic regulation of beta cell ATP-sensitive potassium (K(ATP)) channels. Glucose had little effect on K(ATP) currents in homozygous (-/-) mice but inhibited K(ATP) currents in wild-type (+/+) and heterozygous (+/-) mice with EC50 of 3.2 mM and 5.5 mM, respectively, in newborn animals, and of 4.7 mM and 9.9 mM, respectively, in 1.5-year-old mice. Glucose (20 mmol/l) did not affect the resting membrane potential of -/- beta cells but depolarised wild-type and + /- beta cells and induced electrical activity. In contrast, 20 mmol/l ketoisocaproic acid or 0.5 mmol/ l tolbutamide depolarised all three types of beta-cell. These results support the idea that defective glycolytic metabolism, produced by a loss (-/- mice) or reduction (+/- mice) of glucokinase activity, leads to defective K(ATP) channel regulation and thereby to the selective loss, or reduction, of glucose-induced insulin secretion.     

Influence of methylprednisolone and transforming growth factor-beta on wound healing

This study was aimed at evaluating the influence of transforming growth factor-beta (TGF-beta) on methylprednisolone induced inhibition of wound healing. C57BL/6 mice underwent a standardized dorsal incision. At regular intervals after wounding the mice were sacrificed and their pelts were excised. The fresh breaking strength (FBS) of the pelts was then measured with a constant-speed tension meter. 1) In the first experiment, designed to determine if methylprednisolone did in fact have any inhibiting effect on wound healing, mice received methylprednisolone and a control group received saline. Both methylprednisolone and saline were administered for a four day period. In this experiment the FBS of methylprednisolone treated mice was weaker than that of the control group on the 14th and the 21st day. 2) In the second experiment, designed to determine when the administration of methylprednisolone most noticeably inhibited wound healing, mice were divided into three groups which received methylprednisolone in the following manner: for three days prior to wounding, on the day of wounding, and for three days immediately following wounding. The fourth group received no methylprednisolone at all. The FBS of mice treated with methylprednisolone for three days prior to wounding was weaker than that of the control group on the 14th day after wounding, but showed no significant difference on the 21st day after wounding. The FBS of mice treated on the operative day was weaker on both the 14th and the 21st day after wounding. The FBS of mice treated three days after wounding showed no significant difference on the 14th day after wounding, but was weaker than the control group on the 21st day after wounding. 3) In the third experiment, designed to determine at what time the administration of TGF-beta most accelerated wound healing, mice were divided into three groups which received TGF-beta at different intervals. The first group received TGF-beta on the day of wounding, the second group received TGF-beta on the third day after wounding, and the third group received TGF-beta on the 7th day after wounding. A control group received no treatment. In this experiment the FBS of mice treated with TGF-beta on the third day after wounding was stronger than that of the control group when measured on the 7th and 11th day after wounding, but there was no significant difference on the 14th day. The FBS of mice treated on the day of wounding and mice treated on the 7th day after wounding was not significantly different from that of the control group. 4) In the fourth experiment, designed to determine if TGF-beta can prevent methylprednisolone-induced inhibition of wound healing, mice were divided into three groups. The first group received methylprednisolone for four days prior to wounding. On the third day after wounding they were given saline. The second group also received methylprednisolone for four days prior to wounding, but was treated with TGF-beta on the third day after wounding. The third group received no methylprednisolone, and was given saline three days after wounding. In this experiment the FBS of mice which received only methylprednisolone and saline was weaker than that of the control group on both the 14th and the 21st day after wounding. However, there was no significant difference between the FBS of methylprednisolone treated mice which received TGF-beta and the control group on both the 14th and the 21st day after wounding. From these results the following conclusions were drawn: 1) Methylprednisolone does inhibit wound healing. 2) The influence of methylprednisolone on wound healing is stronger if it is received on operative day. 3) TGF-beta can accelerate wound healing. 4) TGF-beta can prevent methylprednisolone induced inhibition of wound healing.     

Transforming growth factor-beta in GI neoplasia, wound healing and immune response

The last decade has been marked by tremendous advances in the biochemical and functional characterization of TGF-betas and their receptors in normal and transformed cells. TGF-betas have been shown to modulate proliferation, differentiation and motility of different cell types in a number of in vitro model systems and in some cases with some intriguing results. It is obvious that there is no simple pattern that explains the TGF-betas biological activity in vitro and their effects on cell behaviour need to be assessed in the context of an appropriate physiological cellular environment. Cell-cell and cell-matrix interactions, the differentiating status of the cell together with the functional activity of other soluble growth factors can influence how TGF-betas modulate cell behaviour. However, the overwhelming interest in this field shown by clinicians and basic scientists is rapidly increasing our understanding of how growth factors such as TGF-betas regulate the homeostasis of the GI mucosa and their role in gastrointestinal carcinogenesis.     

The role of selected cell growth factors in the wound healing process

Growth factors, naturally occurring proteins secreted by different cells or tissues, play very important role in accelerating the wound healing process. Growth factors are mainly released from macrophages, neutrophils, lymphocytes, platelets and fibroblasts and induce cells to migrate, divide or produce other factors required for wound healing. These factors bind to target cells via specific cell-surface receptors and may elicit inhibitory or stimulatory responses, depending on interactions with other factors and the cellular environment into which they are liberated. Systemic growth factors, such as growth hormone and local epidermal growth factor, fibroblast growth factor, platelet-derived growth factor, transforming growth factor i and insulin-like growth factor show to enhance wound healing. Growth factors stimulate fibroblasts proliferation and chemotaxis, collagen synthesis, reepithelialization and angiogenesis. Although growth factors are not widely available for clinical use, many are studied actively to determine their role in the acceleration of wound healing. Results of animal experiments and preliminary clinical trials demonstrate that specific uses growth factors may become the new mode of therapy in wound healing process.     

Influence of biosynthetic human growth hormone on the biomechanical strength development in skin incisional wounds of diabetic rats

The influence of biosynthetic human growth hormone (b-hGH) on the mechanical strength development of skin incisional wounds in diabetic rats has been investigated after 4, 7 and 21 days of healing. Diabetes caused decreased mechanical strength of the wounds. After 21 days of healing, the diabetic animals treated with b-hGH from 7 days before wound infliction had an increased maximum load (14%) compared with the untreated diabetic animals. After 4 and 7 days of healing, no differences in the biomechanical strength of diabetic wounds with and without b-hGH treatment were found. The diabetic animals receiving b-hGH showed a significant increase in body weight compared with the untreated diabetic animals. In the diabetic animals, the blood glucose concentration was increased by treatment with b-hGH. In conclusion, treatment with b-hGH from 7 days before operation can counteract the reduced mechanical strength of skin wounds in diabetic rats on day 21.     

Specific nutritional factors in wound healing

Provision of a nutritionally complete diet provides the optimum environment for recovery and healing. Clinical research and experience suggest that several nutritional factors may be associated with impaired wound healing, including vitamin C, vitamin A, vitamin E, zinc, protein, and individual amino acids. Studies have shown that supplementing specific nutrients to patients who are not clinically deficient has little effect on pressure ulcer healing. Inexpensive, nontoxic nutritional supplements may not harm the patient, however, some nutritional supplements are expensive or potentially toxic. Before routine use of these nutrients can be justified, further research is required.     

Phosphatidylcholine-associated aspirin accelerates healing of gastric ulcers in rats

In this double-blind study, we administered lumbar epidural bupivacaine or bupivacaine plus verapamil to investigate the possible role of the calcium channel blocker, verapamil, in postoperative pain. One hundred patients (ASA physical class I or II) scheduled for lower abdominal surgery were randomly assigned to one of four groups. Group 1 received 10 mL of 0.5% epidural bupivacaine injected 15 min before incision, followed by 10 mL of epidural normal saline 30 min after incision. Group 2 received 10 mL of epidural normal saline injected before incision, followed by 10 mL of 0.5% epidural bupivacaine 30 min after incision. Group 3 received 10 mL of 0.5% epidural bupivacaine plus 5 mg of verapamil injected before incision, followed by 10 mL of epidural normal saline 30 min after incision. Group 4 received the same drugs as Group 3, in the reverse order. Pain and mood numeric rating scores, sedation scores, Prince Henry scores, patient-controlled cumulative postoperative analgesic consumption, and the incidence of side effects were assessed 2, 6, 12, 24, and 48 h after the operation in each group. Cumulative postoperative analgesic consumption in Groups 3 and 4 was significantly lower (P < 0.05) than that in Groups 1 and 2 24 and 48 h after surgery. There were no differences in the pain, mood, and sedation scores and the incidence of side effects among the four groups. We conclude that epidural verapamil decreases postoperative pain, possibly by interfering with normal sensory processing and by preventing the establishment of central sensitization. Implications: Calcium plays an important role in pain physiology at the spinal cord level. We examined the effect of bupivacaine plus verapamil (calcium channel blocker) and of bupivacaine alone. We demonstrated that the combination, administered epidurally, resulted in less postoperative analgesic consumption than bupivacaine alone.     

OCI-5/rat glypican-3 binds to fibroblast growth factor-2 but not to insulin-like growth factor-2

OCI-5 encodes the rat homologue of glypican-3, a membrane-bound heparan sulfate proteoglycan that is mutated in the Simpson-Golabi-Behmel overgrowth syndrome. OCI-5 and glypican-3 are 95% identical. It has been recently suggested that glypican-3 interacts with insulin-like growth factor-2 (IGF-2) and that this interaction regulates IGF-2 activity. We report here that we have transfected OCI-5 into two different cell lines, and we have not been able to detect an interaction between the OCI-5 proteoglycan produced by the transfected cells and IGF-2. On the other hand, we have found that OCI-5 interacts with FGF-2, as has already been shown for glypican-1. This interaction is mediated by the heparan sulfate chains of OCI-5 because it can be inhibited by heparin or by heparitinase.     

Effects of growth factors on wound healing in serum-deprived kitten corneal endothelial cell cultures

The influence of epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), and insulin-like growth factor (IGF) I and II on wound healing was investigated in a corneal endothelial system with minimal mitotic activity, using serum-deprived kitten corneal endothelial-cell cultures. After wounding, growth factors were added and wound diameter was evaluated. The DNA synthesis was determined by 3H-thymidine labeling. Wounds did not close in the control cultures grown in serum-free medium without growth factors. The IGF I or II, alone (10 and 100 ng/ml) or added (10 ng/ml) to EGF or bFGF, had no significant effect on wound closure or thymidine uptake. With EGF or bFGF (10 ng/ml), wounds closed after 15 days. Wounds closed after 10 days with EGF or bFGF (100 ng/ml) alone or with the combination of EGF and bFGF (each at 10 ng/ml). Combined EGF and bFGF (each at 100 ng/ml) did not enhance wound closure further. Thymidine uptake was significantly higher in cultures treated with EGF or bFGF (10 ng/ml) than in controls. The uptake could be increased, if both growth factors were combined, but only to the same level achieved with a single factor at 100 ng/ml. This study showed that EGF and bFGF, but not IGF I or II, enhanced wound closure and DNA synthesis in a corneal endothelial cell system that had minimal mitotic activity.     

Effects of fibroblast growth factor-2 on longitudinal bone growth

In vivo, fibroblast growth factor-2 (FGF-2) inhibits longitudinal bone growth. Similarly, activating FGF receptor 3 mutations impair growth in achondroplasia and thanatophoric dysplasia. To investigate the underlying mechanisms, we chose a fetal rat metatarsal organ culture system that would maintain growth plate histological architecture. Addition of FGF-2 to the serum-free medium inhibited longitudinal growth. We next assessed each major component of longitudinal growth: proliferation, cellular hypertrophy, and cartilage matrix synthesis. Surprisingly, FGF-2 stimulated proliferation, as assessed by [3H]thymidine incorporation. However, autoradiographic studies demonstrated that this increased proliferation occurred only in the perichondrium, whereas decreased labeling was seen in the proliferative and epiphyseal chondrocytes. FGF-2 also caused a marked decrease in the number of hypertrophic chondrocytes. To assess cartilage matrix synthesis, we measured 35SO4 incorporation into newly synthesized glycosaminoglycans. Low concentrations (10 ng/ml) of FGF-2 stimulated cartilage matrix production, but high concentrations (1000 ng/ml) inhibited matrix production. We conclude that FGF-2 inhibits longitudinal bone growth by three mechanisms: decreased growth plate chondrocyte proliferation, decreased cellular hypertrophy, and, at high concentrations, decreased cartilage matrix production. These effects may explain the impaired growth seen in patients with achondroplasia and related skeletal dysplasias.     

Angiogenesis in wound healing and tumor metastasis

Formation of new blood vessels is essential for several physiological and pathological events, e.g. embryogenesis, wound healing and tumor growth and metastasis. In order to increase the insight into the mechanisms of angiogenesis we have visualized the different components of the microvasculature in human wounds and tumors by immunohistochemistry on the light and electronmicroscopic level. For this purpose, antibodies recognizing distinct markers for human endothelial cells, pericytes and basal lamina were used on freshly frozen or paraformaldehyde-fixed tissue samples. In terms of efficacy, the PAL-E antigen is highly specific for blood vessel endothelium. Its sensitivity is less than other endothelial markers, such as von Willebrand factor and CD 31, as it is not expressed in arterioles. Within the context of the microvasculature alpha-smooth muscle actin and the HMW-MAA chondroitin sulphate proteoglycan are useful markers for pericytes. Type IV Collagen and Laminin can be visualized consistently in the microvascular basal lamina. During the formation of granulation tissue in wound healing a heterogeneity of the expression of endothelial and pericyte markers is found. In the least matured zone in granulation tissue of decubitus lesions and experimental skin wounds microvessels already contained both endothelial cells and pericytes, suggesting a role for both cell types in the early steps of angiogenesis. Regarding the tumor microvasculature, antibodies to von Willebrand factor often failed to stain capillaries, that did show expression of the other endothelial markers studied. Broad staining in pericytes was found for the HMW-MAA chondroitin sulphate proteoglycan. In contrast, these cells only locally expressed alpha-smooth muscle actin. Staining of the basal lamina components Type IV Collagen and Laminin within tumors was not restricted to the microvasculature. Therefore, antibodies recognizing endothelial markers, particularly PAL-E and BMA 120, are preferable as tools to visualize the tumor microvasculature. In accordance with the situation in granulation tissue of wound healing the broad presence of pericytes in the microvasculature of human tumor suggests an involvement of this cell type in tumor angiogenesis. Recent immunohistochemical studies on human tumor lesions indicated that a high number of microvessels adjacent to the tumor as a measure of tumor angiogenesis is an unfavorable prognostic factor in cutaneous melanoma, mammary carcinoma and non-small cell pulmonary carcinoma. This new application of immunohistochemistry represents a valuable, clinically relevant adjunct to the repertoire of the surgical pathologist.     

The conjunctiva in corneal epithelial wound healing

BACKGROUND/AIMS: During the healing of corneal epithelial wounds with limbal involvement, conjunctival epithelium often migrates across the denuded limbus to cover the corneal surface. It is believed that, over a period of time, conjunctival epithelium covering the cornea assumes characteristics of corneal epithelium by a process referred to as conjunctival transdifferentiation. The purpose of this study was to examine, clinically, the fate of conjunctival epithelial cells covering the cornea and to assess the healing of corneal epithelial wounds when the conjunctival epithelium was removed or actively prevented from crossing the limbus and extending onto the cornea. METHODS: 10 patients with conjunctivalisation of the cornea were followed for an average of 7.5 months. Five patients in this group had their conjunctival epithelium removed from the corneal surface and allowed to heal from the remaining intact corneal epithelium. In another four patients with corneal epithelial defects, the conjunctival epithelium was actively prevented from crossing the limbus by mechanically scraping it off. RESULTS: The area of cornea covered by conjunctival epithelium appeared thin, irregular, attracted new vessels and was prone to recurrent erosions. Conjunctivalisation of the visual axis affected vision. Removal of conjunctival epithelium from the cornea allowed cells of corneal epithelial phenotype to cover the denuded area with alleviation of symptoms and improvement of vision. It was also established that migration of conjunctival epithelium onto corneal surface could be anticipated by close monitoring of the healing of corneal epithelial wounds, and prevented by scraping off conjunctival epithelium before it reached the limbus. CONCLUSION: This study shows that there is little clinical evidence to support the concept that conjunctival transdifferentiation per se, occurs in humans. "Replacement" of conjunctival epithelium by corneal epithelial cells may be an important mechanism by which conjunctival "transdifferentiation" may occur. In patients with partial stem cell deficiency this approach can be a useful and effective alternative to partial limbal transplantation, as is currently practised.     

The importance of nutrition in wound healing

Nursing Standards recent Focus on Nutrition campaign raised some uncomfortable issues about nurses' knowledge of wound healing. We continue the theme here, with a review of the importance of good nutrition for effective wound healing.