Parafricta bootees compared with standard care to prevent heel pressure ulcers: a multicentre pragmatic randomised controlled trial

Background: Parafricta bootees are made of low friction material intended to prevent heel pressure ulcers (PU).

Aims: To compare, in hospitalised patients, whether the bootees, added to standard care (SC), prevent heel PU compared with SC alone.

Methods: Patients with Waterlow score ≥20 and no heel PUs at baseline were randomly allocated to either bootees plus SC, or SC alone. Target sample size was 450 patients. Patients’ heels were clinically assessed for heel PUs at day 3 and day 14. 

Results: Slow recruitment stopped the study early. In 31 recruited patients there were zero incident heel PUs (intervention group, 0%) versus 1 (SC group, 6%) at day 3 and no new heel pressure ulcers at Day 14.

Conclusion: This study failed to reach sufficient statistical power to assess the efficacy of the bootees in preventing heel PUs. No adverse events were related to the bootees. Only 1 patient in the SC group developed a heel PU.

KEY WORDS Pressure ulcer Bootees Friction Medical device-related pressure ulcers Shear

ANDREW CLEVES, Researcher, Cedar, Cardiff and Vale University Health Board, Cardiff Medicentre, University Hospital of Wales, Cardiff

NICOLA IVINS, Clinical Research Director, Welsh Wound Innovation Centre, Rhodfa Marics, Ynysmaerdy, Pontyclun

MICHAEL CLARK, Commercial Director, Welsh Wound Innovation Centre, Rhodfa Marics, Ynysmaerdy, Pontyclun

GRACE CAROLAN-REES, Cedar Director (Retired), Cedar, Cardiff and Vale University Health Board, Cardiff Medicentre, University Hospital of Wales, Cardiff

NIA JONES, Advanced Clinical Podiatrist, seconded to the Welsh Would Innovation Centre, Rhodfa Marics, Ynysmaerdy, Pontyclun.

JUDITH WHITE, Researcher, Cedar, Cardiff and Vale University Health Board, Cardiff Medicentre, University Hospital of Wales, Cardiff.

RHYS MORRIS,Cedar Director, Cedar, Cardiff and Vale University Health Board, Cardiff Medicentre, University Hospital of Wales, Cardiff

原位交联含氧化石墨烯的甲基丙烯酸酐化 明胶水凝胶对小鼠全层皮肤缺损创面 血管化的影响

本文亮点：

(1) 制备了含氧化石墨烯（GO）的甲基丙烯酸酐化明胶（GelMA）水凝胶，进一步观察到原位光聚合含0.1 μg/mL GO的GelMA水凝胶能促进小鼠全层皮肤缺损创面血管新生，且新生血管富集于GO附近。

(2) 证实 GO 的促血管新生作用与创面细胞分泌的 VEGF 增加相关。

梁莉婷 1   宋薇 2    张超 2    李曌 2    姚斌 2    张孟德 2    袁星宇 2     恩和吉日嘎拉 2    付小兵 2    黄沙 2    朱平 3   

1 华南理工大学医学院，广州 510006； 2 解放军总医院医学创新研究部创伤修复与组织 再生研究中心，北京 100048；3 广东省医学科学院 广东省人民医院心外科 广东省心血管病研究所，广州 510080

通信作者：黄沙，Email：该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。；朱平，Email：该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。

【摘要】

      目的 制备含氧化石墨烯（GO）的甲基丙烯酸酐化明胶（GelMA）水凝胶并探讨原位光 聚合 GO-GelMA 复合水凝胶对小鼠全层皮肤缺损创面血管化的影响。 方法 采用实验研究方法。 将 0.2 mg/mL 的 GO 溶液 50 μL 均匀涂抹于导电胶上，烘干后于场发射扫描电子显微镜下观察 GO 的结构和大小。将人皮肤成纤维细胞（HSF）分为采用相应终质量浓度 GO 处理的 0 μg/mL GO（不加 GO 溶液，下同）组、0.1 μg/mL GO 组、1.0 μg/mL GO 组、5.0 μg/mL GO 组、10.0 μg/mL GO 组，用酶标仪检测细胞培养 48 h 的吸光度值，以此表示细胞增殖活性（样本数为 6）。将 HSF 和人脐静脉血管内皮细胞（HUVEC）分别分为采用相应终质量浓度 GO 处理的 0 μg/mL GO 组、0.1 μg/mL GO 组、1.0 μg/mL GO组、5.0 μg/mL GO 组，采用划痕试验检测划痕后 24、36 h HSF 的迁移率（样本数为 5）及划痕后 12 h HUVEC 的迁移率（样本数为 3），采用酶联免疫吸附测定法检测培养 4、6、8 h 后 HSF 分泌的血管内皮生长因子（VEGF）水平（样本数为 3）。将配制的含相应终质量浓度 GO 的 GO-GelMA 复合水凝胶设为0 μg/mL GO 复合水凝胶组、 0.1 μg/mL GO 复合水凝胶组、1.0 μg/mL GO 复合水凝胶组、5.0 μg/mL GO 复合水凝胶组，观察其交联前后的性状，检测用磷酸盐缓冲液浸泡 3、7 d 后 GO 的释放情况（样本数为 3）。在 16 只 6 周龄雌性 C57BL/6 小鼠背部制作全层皮肤缺损创面，将采用原位交联的含相应终质量浓 度 GO 的 GO-GelMA 复 合 水 凝 胶 处 理 的 小 鼠 按 随 机 数 字 表 法 分 为 0 μg/mL GO 复 合 水 凝 胶 组 、0.1 μg/mL GO 复合水凝胶组、1.0 μg/mL GO 复合水凝胶组、5.0 μg/mL GO 复合水凝胶组，每组 4 只，观察治疗 3、7、14 d 创面大体情况并计算创面愈合率，采用激光多普勒血流仪检测治疗 3、7、14 d 创面血流灌注并计算平均灌注单位（MPU）比值，采用苏木精-伊红染色观察治疗 7 d 创面血管新生情况并计算血管密度（样本数均为 3）。取 0 μg/mL GO 复合水凝胶组和 0.1 μg/mL GO 复合水凝胶组治疗 7 d 的创面组织，采用苏木精-伊红染色观察 GO 分布与血管新生的关系（样本数为 3），行免疫组织化学染色后观察 VEGF 的表达。对数据行重复测量方差分析、单因素方差分析、Tukey 法。 结果 GO 为多层片状结构，宽度约为 20 μm、长度约为 50 μm。培养 48 h，10.0 μg/mL GO 组 HSF 的吸光度值明显低于0 μg/mL GO 组（q=7.64，P<0.01）。划痕后 24 h，4 组 HSF 迁移率相近（P>0.05）；划痕后 36 h，0.1 μg/mLGO 组 HSF 迁移率明显高于 0 μg/mL GO 组、1.0 μg/mL GO 组、5.0 μg/mL GO 组（q 值分别为 7.48、10.81、10.20，P 值 均 <0.01）。 划 痕 后 12 h，0.1 μg/mL GO 组 HUVEC 迁 移 率 明 显 高 于 0 μg/mL GO 组 、1.0 μg/mL GO 组、5.0 μg/mL GO 组（q 值分别为 7.11、8.99、14.92，P 值均<0.01），5.0 μg/mL GO 组 HUVEC迁移率明显低于 0 μg/mL GO 组和 1.0 μg/mL GO 组（q 值分别为 7.81、5.33，P<0.05 或 P<0.01）。培养 4、6 h，4 组 HSF 的 VEGF 表达均相近（P>0.05）；培养 8 h，0.1 μg/mL GO 组 HSF 的 VEGF 表达明显高于0 μg/mL GO 组和 5.0 μg/mL GO 组（q 值分别为 4.75、4.48，P 值均<0.05）。4 组 GO-GelMA 复合水凝胶在交联前均呈红色液体状，交联后呈微黄色凝胶状且流动性无明显差异。0 μg/mL GO 复合水凝胶组复合水凝胶各时间点均无 GO 释放，其余 3 组 GO-GelMA 复合水凝胶中的 GO 于浸泡 3 d 部分释放，至浸泡 7 d 全部释放。治疗 3~14 d，4 组小鼠创面可见水凝胶敷料覆盖在位并保持湿润，创面逐渐愈合。治疗 3、7、14 d，4 组小鼠创面愈合率均相近（P>0.05）。治疗 3 d，0.1 μg/mL GO 复合水凝胶组小鼠创面MPU 比值明显高于 0 μg/mL GO 复合水凝胶组、1.0 μg/mL GO 复合水凝胶组、5.0 μg/mL GO 复合水凝胶组（q 值分别为 10.70、11.83、10.65，P<0.05 或 P<0.01）。治疗 7、14 d，4 组小鼠创面 MPU 比值均相近（P>0.05）。0.1 μg/mL GO 复合水凝胶组小鼠创面治疗 7 d 的 MPU 比值明显低于治疗 3 d（q=14.38，P<0.05），治疗 14 d 的 MPU 比值明显低于治疗 7 d（q=27.78，P<0.01）。治疗 7 d，0.1 μg/mL GO 复合水凝胶组小鼠创面新生血管密度为每 200 倍视野下（120.7±4.1）根，明显高于 0 μg/mL GO 复合水凝胶组、1.0 μg/mL GO 复合水凝胶组、5.0 μg/mL GO 复合水凝胶组的每 200 倍视野下（61.7±1.3）、（77.7±10.2）、（99.0±7.9）根（q 值分别为 12.88、7.79、6.70，P 值均<0.01）；1.0 μg/mL GO 复合水凝胶组和 5.0 μg/mL GO复合水凝胶组小鼠创面新生血管密度均明显高于 0 μg/mL GO 复合水凝胶组（q 值分别为 5.10、6.19，P<0.05）。治疗 7 d，相较于 0 μg/mL GO 复合水凝胶组，0.1 μg/mL GO 复合水凝胶组小鼠创面中成簇新生血管更多，且聚集于 GO 附近；0.1 μg/mL GO 复合水凝胶组小鼠创面中 GO 和新生血管分布区域有大量 VEGF 表达。 结论 GO 质量浓度低于 10.0 μg/mL 对 HSF 增殖活性无明显影响，0.1 μg/mL 的 GO能够促进 HSF 和 HUVEC 迁移，能促进 HSF 分泌 VEGF。原位光聚合 GO-GelMA 复合水凝胶敷料能够通过促进小鼠全层皮肤缺损创面血管新生，增加创面早期血流灌注，且 GO 对新生血管有富集作用，其机制可能与 GO 促进创面细胞分泌 VEGF 相关。

【关键词】 伤口愈合； 水凝胶； 血管内皮生长因子 A； 血管新生； 甲基丙烯酸酐化明胶； 氧化石墨烯

基金项目：国家自然科学基金青年科学基金项目（32000969、82002056）；中国医学科学院医学与健康科技创新工程项目（2019-I2M-5-059）；解放军总医院军事医学创新研究项目（CX19026）；王正国创 伤 医 学 发 展 基 金 会 生 长 因 子 复 兴 计 划（SZYZ-TR-03）；广 州 市 科 学 研 究 计 划 重 点 项 目（201904020047）；广东省人民医院登峰计划专项（DFJH201812、KJ012019119、KJ012019423）

Effects of in situ cross-linked graphene oxide-containing gelatin methacrylate anhydride hydrogel on wound vascularization of full-thickness skin defect in mice

Liang Liting1, Song Wei2, Zhang Chao2, Li Zhao2, Yao Bin2, Zhang Mengde2, Yuan Xingyu2, Enhejirigala 2, Fu Xiaobing2, Huang Sha2, Zhu Ping3

1 School of Medicine, South China University of Technology, Guangzhou 510006, China; 2 Research Center for Wound Repair and Tissue Regeneration, Medical Innovation Research Department, the PLA General Hospital, Beijing 100048, China; 3 Guangdong Cardiovascular Institute, Department of Cardiac Surgery of Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China

Corresponding authors:Huang Sha, Email : 该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。; Zhu Ping , Email: 该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。

【Abstract】

      Objective To prepare graphene oxide (GO) -containing gelatin methacrylate anhydride (GelMA) hydrogel and to investigate the effects of in situ photopolymerized GO-GelMA composite hydrogel in wound vascularization of full-thickness skin defect in mice.

      Methods The experimental study method was used. The 50 μL of 0.2 mg/mL GO solution was evenly applied onto the conductive gel, and the structure and size of GO were observed under field emission scanning electron microscope after drying. Human skin fibroblasts (HSFs) were divided into 0 μg/mL GO (without GO solution, the same as below) group, 0.1 μg/mL GO group, 1.0 μg/mL GO group, 5.0 μg/mL GO group, and 10.0 μg/mL GO group treated with GO of the corresponding final mass concentration, and the absorbance value was detected using a microplate analyzer after 48 h of culture to reflect the proliferation activity of cells (n=6). HSFs and human umbilical vein vascular endothelial cells (HUVECs) were divided into 0 μg/mL GO group, 0.1 μg/mL GO group, 1.0 μg/mL GO group, and 5.0 μg/mL GO group treated with GO of the corresponding final mass concentration, and the migration rates of HSFs at 24 and 36 h after scratching ( n=5) and HUVECs at 12 h after scratching ( n=3) were detected by scratch test , and the level of vascular endothelial growth factor (VEGF) secreted by HSFs after 4, 6, and 8 h of culture was detected by enzyme-linked immunosorbent assay method ( n=3). The prepared GO-GelMA composite hydrogels containing GO of the corresponding final mass concentration were set as 0 μg/mL GO composite hydrogel group, 0.1 μg/mL GO composite hydrogel group, 1.0 μg/mL GO composite hydrogel group, and 5.0 μg/mL GO composite hydrogel group to observe their properties before and after cross -linking , and to detect the release of GO after soaking with phosphate buffer solution for 3 and 7 d (n=3). The full -thickness skin defect wounds were made on the back of 16 6-week-old female C57BL/6 mice. The mice treated with in situ cross-linked GO-GelMA composite hydrogel containing GO of the corresponding final mass concentration were divided into 0 μg/mL GO composite hydrogel group, 0.1 μg/mL GO composite hydrogel group, 1.0 μg/mL GO composite hydrogel group, and 5.0 μg/mL GO composite hydrogel group according to the random number table, with 4 mice in each group. The general condition of wound was observed and the wound healing rate was calculated on 3, 7, and 14 d of treatment, the wound blood perfusion was detected by laser Doppler flowmetry on 3, 7, and 14 d of treatment and the mean perfusion unit (MPU) ratio was calculated, and the wound vascularization on 7 d of treatment was observed after hematoxylin-eosin staining and the vascular density was calculated (n=3). The wound tissue of mice in 0 μg/mL GO composite hydrogel group and 0.1 μg/mL GO composite hydrogel group on 7 d of treatment was collected to observe the relationship between the distribution of GO and neovascularization by hematoxylin -eosin staining (n=3) and the expression of VEGF by immunohistochemical staining . Data were statistically analyzed with analysis of variance for repeated measurement, one -way analysis of variance , and Tukey's method.

      Results GO had a multilayered lamellar structure with the width of about 20 μm and the length of about 50 μm. The absorbance value of HSFs in 10. 0 μg/mL GO group was significantly lower than that in 0 μg/mL GO group after 48 h of culture (q=7.64, P<0.01). At 24 h after scratching, the migration rates of HSFs were similar in the four groups ( P>0.05); at 36 h after scratching, the migration rate of HSFs in 0.1 μg/mL GO group was significantly higher than that in 0 μg/mL GO group, 1 .0 μg/mL GO group , and 5.0 μg/mL GO group (with q values of 7.48, 10.81, and 10 .20, respectively , P<0.01). At 12 h after scratching, the migration rate of HUVECs in 0.1 μg/mL GO group was significantly higher than that in 0 μg/mL GO group, 1.0 μg/mL GO group, and 5.0 μg/mL GO group (with q values of 7.11, 8.99, and 14.92, respectively, P<0.01), and the migration rate of HUVECs in 5.0 μg/mL GO group was significantly lower than that in 0μg/mL GO group and 1.0 μg/mL GO group (with q values of 7.81 and 5.33, respectively, P<0.05 or P<0.01).At 4 and 6 h of culture,the VEGF expressions of HSFs in the four groups were similar(P>0.05); at 8 h of culture, the VEGF expression of HSFs in 0.1 μg/mL GO group was significantly higher than that in 0 μg/mL GO group and 5.0 μg/mL GO group (with q values of 4.75 and 4.48, respectively, P<0.05). The GO-GelMA composite hydrogels in the four groups were all red liquid before cross -linking, which turned to light yellow gel after cross -linking, with no significant difference in fluidity. The GO in the GO -GelMA composite hydrogel of 0 μg/mL GO composite hydrogel group had no release of GO at all time points; the GO in the GO -GelMA composite hydrogels of the other 3 groups was partially released on 3 d of soaking, and all the GO was released on 7 d of soaking. From 3 to 14 d of treatment, the wounds of mice in the 4 groups were covered with hydrogel dressings, kept moist, and gradually healed. On 3, 7, and 14 d of treatment, the wound healing rates of mice in the four groups were similar (P>0.05). On 3 d of treatment, the MPU ratio of wound of mice in 0.1 μg/mL GO composite hydrogel group was significantly higher than that in 0 μg/mL GO composite hydrogel group , 1.0 μg/mL GO composite hydrogel group , and 5 .0 μg/mL GO composite hydrogel group (with q values of 10.70 , 11.83, and 10.65, respectively, P<0.05 or P<0.01). On 7and 14 d of treatment, the MPU ratios of wound of mice in the four groups were similar (P>0.05).The MPU ratio of wound of mice in 0.1 μg/mL GO composite hydrogel group on 7 d of treatment was significantly lower than that on 3 d of treatment (q=14.38 ,P<0.05), and that on 14 d of treatment was significantly lower than that on 7 d of treatment ( q=27.78, P<01). On 7 d of treatment , the neovascular density of wound of mice on 7 d of treatment was 120.7±4.1 per 200 times of visual field, which was significantly higher than 61.7±1.3, 77.7±10.2, and 99.0±7.9 per 200 times of visual field in 0 μg/mL GO composite hydrogel group , 1. 0 μg/mL GO composite hydrogel group, and 5.0 μg/mL GO composite hydrogel group (with q values of 12 . 88 , 7.79, and 6.70, respectively, P<0.01), and the neovascular density of wound of mice in 1.0 μg/mL GO composite hydrogel group and 5.0 μg/mL GO composite hydrogel group was significantly higher than that in 0 μg/mL GO composite hydrogel group (with q values of 5.10 and 6.19, respectively, P<0.05). On 7 d of treatment, cluster of new blood vessels in wound of mice in 0.1 μg/mL GO composite hydrogel group was significantly more than that in 0 μg/mL GO composite hydrogel group, and the new blood vessels were clustered near the GO; a large amount of VEGF was expressed in wound of mice in 0.1 μg/mL GO composite hydrogel group in the distribution area of GO and new blood vessels.

      Conclusions GO with mass concentration lower than 10.0 μg/mL had no adverse effect on proliferation activity of HSFs, and GO of 0.1 μg/mL can promote the migration of HSFs and HUVECs , and can promote the secretion of VEGF in HSFs. In situ photopolymerized of GO -GelMA composite hydrogel dressing can promote the wound neovascularization of full -thickness skin defect in mice and increase wound blood perfusion in the early stage, with GO showing an enrichment effect on angiogenesis, and the mechanism may be related to the role of GO in promoting the secretion of VEGF by wound cells.

    【Key words】 Wound healing; Hydrogel; Vascular endothelial growth factor A; Neovascularization ; Gelatin methacrylate anhydride ; Graphene oxide

      Fund program: Youth Science Foundation of National Natural Science Foundation of China (32000969 , 82002056); Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (2019 -I2M-5-059); Military Medical Innovation Research Project of PLA General Hospital (CX 19026 ); Wang Zhengguo Foundation for Traumatic Medicine Growth Factor Rejuvenation Plan (SZYZ -TR-03); Key Program of Guangzhou Science Research Plan (201904020047); Special Project of Dengfeng Program of Guangdong Provincial People's Hospital (DFJH201812, KJ012019119, KJ012019423)

Limb salvage surgery in diabetic foot infection: encouraging early results with a local antibiotic carrier

NL Vasukutty, S Mordecai, A Tarik, M Subramaniam and B Srinivasan

Citation: Vasukutty NL, Mordecai S, Tarik A et al (2022) Limb salvage surgery in diabetic foot infection: encouraging early results with a local antibiotic carrier. The Diabetic Foot Journal 25(2): 1–5

Key words - CERAMENT® injection - Diabetic foot ulcers - Osteomyelitis

Article points

1. The use of a local antibiotic is an attractive option for diabetic foot infection.

2. The authors present early results of a cohort of patients where a local antibiotic carrier was used in conjunction with other aspects of multidisciplinary care.

3. The uthors report a limb salvage rate of 94% and infection control of 88%.

Authors

      NL Vasukutty is Consultant Orthopaedic Surgeon, United Lincolnshire Hospitals NHS Trust, Boston, UK; S Mordecai is Consultant Orthopaedic Surgeon, East and North Hertfordshire Hospitals NHS Trust, Stevenage, UK; A Tarik is Consultant Diabetes Physician, United Lincolnshire Hospitals NHS Trust, Lincoln, UK; M Subramaniam is Consultant Vascular Surgeon, United Lincolnshire Hospitals NHS Trust, Boston, UK; B Srinivasan is Consultant Diabetes Physician, United Lincolnshire Hospitals NHS Trust, Lincoln, UK.

      Diabetic foot disease is associated with high morbidity and is one of the leading causes of lower limb amputation. The use of a local antibiotic carrier to augment debridement and reconstructive procedures is presented. Methods: The authors present early results of 48 feet in 47 patients from two centres in the UK. Their multidisciplinary protocol involved pre-operative assessment, debridement, culture-specific antibiotics and local antimicrobial management with an antibiotic-loaded biocomposite (CERAMENT G®, BONESUPPORT, Lund, Sweden). Of the 48 feet, 22 (46%) had various foot reconstructive procedures. Six patients had pre-operative revascularisation procedures. All patients were graded as either University of Texas 3B or 3D ulcers. Results: At a mean follow-up of 33 months (range 13–49 months), 42 feet (88%) were free of infection and 39 patients (83%) were mobilising. There were 28 wounds healed by secondary intention, 17 with primary closure and three required skin grafting. Three patients had non-healing and persisting ulcers at the most recent follow-up. Three patients had undergone below–knee amputation. The average time to wound healing was 16 weeks (range 3–24 weeks). A limb salvage rate of 94% was achieved. Conclusion: These are encouraging early results in a cohort of diabetic foot patients where CERAMENT G was used as a local antibiotic vehicle in conjunction with other aspects of multidisciplinary care. This is effective in preventing reinfection and avoiding multiple theatre visits.

生长因子调控创面修复的进展与思考

本文亮点：

(1) 总结了关于生长因子通过调控皮肤创面的微环境，从而促进创面愈合的国内研究进展。

(2) 总结了生长因子与免疫系统、神经系统以及脂肪组织的相互作用对创面愈合进程的影响。

肖健 张凡 温州医科大学附属第一医院创面修复科 温州医科大学创伤修复与再生医学中心 温州 医科大学药学院，温州 325035

通信作者：肖健，Email：该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。

【摘要】 生长因子在创面愈合中起重要调控作用，其主要通过激活相关信号通路加速创面愈合。中国科学家对生长因子的基础、临床研究至今已有 30 年历史，研发的生长因子系列药物被广泛应用于烧创伤及慢性难愈合溃疡的治疗。该文从免疫、神经、脂肪等多个角度阐述了生长因子对创面修复的前沿进展，并提出了该研究团队对生长因子调控创面修复的进一步思考。

【关键词】 伤口愈合； 皮肤； 生长因子； 调控

基金项目：国家自然科学基金优秀青年科学基金项目

（81722028）；温州市重大科技创新攻关项目（ZY2020023）

Progress and thoughts on the regulation of wound repair by growth factors

Xiao Jian, Zhang Fan. Department of Wound Repair, the First Affiliated Hospital of Wenzhou Medical University, Wound Repair and Regenerative Medicine Center, Wenzhou Medical University, School of Pharmaceutical Science, Wenzhou Medical University, Wenzhou 325035, China

Corresponding author: Xiao Jian, Email: 该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。

【Abstract】 Growth factors play an important role in wound healing, and they mainly accelerate wound healing by activating the related signal pathways. Chinese scientists have been conducting basic and clinical researches on growth factors for 30 years, with a series of growth factor drugs being developed and widely used in the treatment of burns and trauma and chronic refractory ulcers. This paper expounds the frontier progress of growth factors on wound healing from the perspectives of immunity, nerve, fat, and so on, and puts forward the further thoughts of the research team on the regulation of wound healing by growth factors.

【Key words】 Wound healing； Skin； Growth factor ； Regulation

Fund program: Natural Science Foundation of China Excellent Young Program of National (81722028); Wenzhou Science and Technology Innovation Project (ZY2020023)

Barriers and facilitators to reporting medical device-related pressure ulcers: A qualitative exploration of international practice

Ewa A. Crunden a,⁎, Peter R. Worsley a, Susanne B. Coleman c, Lisette Schoonhoven a,b a School of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK b University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands c University of Leeds, Leeds Institute of Clinical Trials Research, Leeds LS2 9JT, UK

ARTICLE INFO

Article history: Received 25 February 2022 Received in revised form 13 June 2022 Accepted 11 July 2022 Available online xxxx

Keywords: Medical device-related pressure ulcers. Reporting. Barriers and facilitators. Determinants of practice

abstract

Background: Pressure ulcers are a complex healthcare issue. Hospital-acquired pressure ulcers are used as proxy measurements for the quality and safety of nursing care. Medical device-related pressure ulcers are mostly facility acquired, but their reporting has only recently been widely adopted. Consequently, we do not yet know what factors impact their reporting by registered nurses.

Objectives: To identify and systematically report determinants of the practice of medical device-related pressure ulcers reporting using the Tailored Implementation for Chronic Diseases checklist.

Design: Descriptive, explorative design using semi-structured interviews to explore barriers and facilitators to reporting medical device-related pressure ulcers.

Setting: We undertook online, telephone, and face-to-face interviews with participants from 11 different countries.

Participants:We interviewed 17 participants who represented acute care (Adult, Paediatrics), academia, and industry. Eleven participants were healthcare professionals with more than 10 years' experience in wound care.

Methods: The interview recordings were transcribed and coded by the lead researcher. Data were analysed thematically using the codebook approach, and themes were developed inductively and deductively.

Results: Participants identified determinants of practice which clustered around four domains of the Tailored Implementation for Chronic Diseases checklist i) individual health professional factors, ii) professional interactions, iii) incentives and resources, and iv) capacity for organisational change. Knowledge, attitudes, workload, time, staffing, and perception of consequences, including financial, were identified as the main barriers to reporting. Factors supporting the practice were education, openness, and teamwork. Device procurement could take on characteristics of a barrier or facilitator depending on the organisation.

Conclusions: Reporting medical device-related pressure ulcers has been adopted in healthcare institutions worldwide. Understanding what drives the reporting practice enables improvements in incident reporting, which consequently can lead to improvements in the quality of nursing care and patient safety.

© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

基于单细胞 RNA 测序探讨小鼠全层皮肤 缺损创面中真皮成纤维细胞的 生长因子调控网络

本文亮点：

(1) 通过建立小鼠全层皮肤缺损创面模型并进行伤后 7 d 创面组织的单细胞 RNA 测序，定义了多个Fb 亚群，明确了创面愈合过程中的真皮 Fb 存在高异质性，了解到真皮 Fb 是创面愈合过程中细胞因子网络调控的主要靶点。

(2) 通过生物信息学及组织多重染色技术，了解到 FGF7 主要由间质祖细胞表达，并作用于多个真皮Fb 亚群，揭示了 FGF 信号通路在创面修复中新的调控途径。

孙礼祥 吴帅 张小薇 刘文杰 张凌娟

厦门大学药学院，细胞应激生物学国家重点实验室，厦门 361102   通信作者：张凌娟，Email：该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。

【摘要】

目的 基于单细胞 RNA 测序探讨小鼠全层皮肤缺损创面中真皮成纤维细胞（dFb）的异质性与生长因子调控网络。

方法 采用实验研究方法。取 5 只 8 周龄雄性健康 C57BL/6 小鼠（鼠龄、性别、品系下同）正常皮肤组织，另取 5 只背部全层皮肤缺损小鼠伤后 7 d 创面组织，用胶原酶 D 和 DNA 酶Ⅰ消化组织获得细胞悬液，用 10x Genomics 平台构建测序文库，用 Illumina Novaseq6000 测序仪进行单细胞 RNA 测序。采用 R4.1.1 软件的 Seurat 3.0 程序分析获得 2 种组织细胞的基因表达矩阵，采用按细胞群、细胞来源、标记皮肤中主要细胞基因分类的二维 tSNE 云图进行可视化展示。根据已有文献报道和 CellMarker 数据库检索情况，分析 2 种组织细胞的基因表达矩阵中标志基因表达情况，对各细胞群进行编号和定义。将基因表达矩阵和细胞分群信息导入 R4.1.1 软件的 CellChat 1.1.3 程序，分析 2 种组织中细胞间通信以及创面组织血管内皮生长因子（VEGF）、血小板衍生生长因子（PDGF）、表皮生长因子（EGF）、成纤维细胞生长因子（FGF）信号通路中的细胞间通信，2 种组织中FGF 的各亚型与 FGF 受体（FGFR）各亚型的两两配对（以下简称 FGF 配受体对）对 FGF 信号网络的相对贡献，2 种组织中相对贡献排名前 2 的 FGF 配受体对信号通路中的细胞间通信。取 1 只健康小鼠正常皮肤组织和 1 只全层皮肤缺损小鼠伤后 7 d 创面组织，行多重免疫荧光染色，检测 FGF7 蛋白的表达与分布及其与二肽基肽酶 4（DPP4）、干细胞抗原 1（SCA1）、平滑肌肌动蛋白（SMA）和 PDGF 受体 α（PDGFRα）的蛋白共定位表达。

结果 健康小鼠正常皮肤组织和全层皮肤缺损小鼠伤后 7 d 创面组织中均包含 25 个细胞群，但 2 种组织中各细胞群中细胞数不一致。PDGFRα、血小板内皮细胞黏附分子 1、淋巴管内皮透明质酸受体 1、受体型蛋白酪氨酸磷酸酶 C、角蛋白 10 和角蛋白 79 基因在二维tSNE 云图上均有各自明确的分布，分别指示特定的细胞群。将 25 个细胞群按 C0~C24 编号，分为 9 个dFb 亚群和 16 个非 dFb 群，dFb 亚群包括 C0 间质祖细胞、C5 脂肪前体细胞、C13 具有收缩能力的肌肉细胞相关成纤维细胞等，非 dFb 群包括 C3 中性粒细胞、C8 T 细胞、C18 红细胞等。与健康小鼠正常皮肤组织比较，全层皮肤缺损小鼠伤后 7 d 创面组织中细胞间通信更多更密集，其中细胞间通信强度排前 3 位的细胞群为 dFb 亚群 C0、C1、C2，这 3 个 dFb 亚群与创面组织中其他细胞群之间均有通信。在全层皮肤缺损小鼠伤后 7 d 创面组织中，VEGF 信号主要由 dFb 亚群 C0 发送、脉管相关细胞群 C19 和C21 接收，PDGF 信号主要由周细胞 C14 发送、多个 dFb 亚群接收，EGF 信号主要由角质形成细胞亚群C9 和 C11 发送、dFb 亚群 C0 接收，FGF 信号的主要发送者和接收者均为 dFb 亚群 C6。健康小鼠正常皮肤组织和全层皮肤缺损小鼠伤后 7 d 创面组织 FGF 信号网络中的 FGF 配受体对相对贡献，均是FGF7-FGFR1 排在首位，排名第 2 的分别是 FGF7-FGFR2、FGF10-FGFR1；与正常皮肤组织比较，创面组织 FGF7-FGFR1 信号通路中的细胞间通信更多，而 FGF7-FGFR2 和 FGF10-FGFR1 信号通路中的细胞间通信稍有减少或无明显变化 ；创面组织 FGF7-FGFR1 信号通路中的细胞间通信强于FGF7-FGFR2、FGF10-FGFR1 信号通路；在 2 种组织中，FGF7 信号均主要由 dFb 亚群 C0 与 C1 和 C2 发送、dFb 亚群 C6 和 C7 接收。与健康小鼠正常皮肤组织比较，全层皮肤缺损小鼠伤后 7 d 创面组织中FGF7 蛋白表达更多；在正常皮肤组织中，FGF7 蛋白主要表达于皮肤间质层且在靠近真皮白色脂肪组织 附 近 也 有 表 达 ；在 2 种 组 织 中 ，FGF7 蛋 白 与 DPP4、SCA1 蛋 白 共 定 位 表 达 于 皮 肤 间 质 层 中 ，与PDGFRα 蛋白共定位表达于 dFb 中，与 SMA 蛋白无共定位表达，其中创面组织中的共定位表达多于正常皮肤组织。

结论 小鼠全层皮肤缺损创面愈合过程中的 dFb 存在高异质性，为多种生长因子潜在的主要分泌或接收细胞群落，与生长因子信号通路之间存在紧密、复杂的联系；FGF7-FGFR1 信号通路是创面愈合过程中的主要 FGF 信号通路，靶向调控多个 dFb 亚群。

【关键词】 伤口愈合； 皮肤； 真皮； 成纤维细胞； 成纤维细胞生长因子； 单细胞 RNA 测序； 生长因子； 细胞间通信

基金项目：国家重点研发计划（2020YFA0112901）；国家自然科学基金面上项目（81971551）；国家自然科学基金青年科学基金项目（82103702）；中国博士后科学基金（2020M682095）

Investigation on the growth factor regulatory network of dermal fibroblasts in mouse full-thickness skin defect wounds based on single-cell RNA sequencing

Sun Lixiang, Wu Shuai, Zhang Xiaowei, Liu Wenjie, Zhang Lingjuan State Key Laboratory of Cell Stress Biology, School of Pharmacy, Xiamen University, Xiamen 361102, China Corresponding author: Zhang Lingjuan , Email: 该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。

【Abstract】

Objective To explore the heterogeneity and growth factor regulatory network of dermal fibroblasts (dFbs) in mouse full-thickness skin defect wounds based on single -cell RNA

Methods The experimental research methods were adopted . The normal skin tissue from 5 healthy 8-week-old male C57BL/6 mice (the same mouse age, sex, and strain below) was harvested, and the wound tissue of another 5 mice with full-thickness skin defect on the back was harvested on post injury day (PID) 7. The cell suspension was obtained by digesting the tissue with collagenase D and DNase Ⅰ , sequencing library was constructed using 10x Genomics platform, and single -cell RNA sequencing was performed by Illumina Novaseq6000 sequencer. The gene expression matrices of cells in the two kinds of tissue were obtained by analysis of Seurat 3.0 program of software R4.1.1, and two-dimensional tSNE plots classified by cell group, cell source, and gene labeling of major cells in skin were used for visual display. According to the existing literature and the CellMarker database searching, the expression of marker genes in the gene expression matrices of cells in the two kinds of tissue was analyzed, and each cell group was numbered and defined. The gene expression matrices and cell clustering information were introduced into CellChat 1.1.3 program of software R4.1.1 to analyze the intercellular communication in the two kinds of tissue and the intercellular communication involving vascular endothelial growth factor (VEGF), platelet -derived growth factor (PDGF), epidermal growth factor (EGF), and fibroblast growth factor (FGF) signal pathways in the wound tissue, the relative contribution of each pair of FGF subtypes and FGF receptor (FGFR) subtypes (hereinafter referred to as FGF ligand receptor pairs) to FGF signal network in the two kinds of tissue, and the intercellular communication in the signal pathway of FGF ligand receptor pairs with the top 2 relative contributions in the two kinds of tissue.The normal skin tissue from one healthy mouse was harvested, and the wound tissue of one mouse with full-thickness skin defect on the back was harvested on PID 7. The multiple immunofluorescence staining was performed to detect the expression and distribution of FGF7 protein and its co -localized expression with dipeptidyl peptidase 4 (DPP4), stem cell antigen 1 (SCA1), smooth muscle actin (SMA), and PDGF receptor α (PDGFRα) protein.

Results Both the normal skin tissue of healthy mice and the wound tissue of full -thickness skin defected mice on PID 7 contained 25 cell groups , but the numbers of cells in each cell group between the two kinds of tissue were different . Genes PDGFRα, platelet endothelial cell adhesion molecule 1, lymphatic endothelial hyaluronic acid receptor 1, receptor protein tyrosine phosphatase C, keratin 10, and keratin 79 all had distinct distributions on two-dimensional tSNE plots, indicating specific cell groups respectively . The 25 cell groups were numbered by C0 − C24 and divided into 9 dFb subgroups and 16 non -dFb groups . dFb subgroups included C 0 as interstitial progenitor cells, C5 as adipose precursor cells, and C13 as contractile muscle cells related fibroblasts, etc. Non-dFb group included C3 as neutrophils, C8 as T cells, and C18 as erythrocytes, etc. Compared with that of the normal skin tissue of healthy mice, the intercellular communication in the wound tissue of full-thickness skin defected mice on PID 7 was more and denser, and the top 3 cell groups in intercellular communication intensity were dFb subgroups C0, C1, and C2, of which all communicated with other cell groups in the wound tissue. In the wound tissue of full-thickness skin defected mice on PID 7, VEGF signals were mainly sent by the dFb subgroup C0 and received by vascular related cell groups C19 and C21, PDGF signals were mainly sent by peripheral cells C14 and received by multiple dFb subgroups, EGF signals were mainly sent by keratinocyte subgroups C9 and C11 and received by the dFb subgroup C0, and the main sender and receiver of FGF signals were the dFb subgroup C6. In the relative contribution rank of FGF ligand receptor pairs to FGF signal network in the normal skin tissue of healthy mice and the wound tissue of full -thickness skin defected mice on PID 7, FGF7-FGFR1 was the top 1, and FGF7-FGFR 2 or FGF10 -FGFR 1 was in the second place, respectively ; compared with those in the normal skin tissue , there was more intercellular communication in FGF 7 - FGFR1 signal pathway , while the intercellular communication in FGF7 -FGFR2 and FGF10-FGFR 1 signal pathways decreased slightly or did not change significantly in the wound tissue; the intercellular communication in FGF7 -FGFR 1 signal pathway in the wound tissue was stronger than that in FGF7-FGFR2 or FGF10-FGFR1 signal pathway; in the two kinds of tissue, FGF7 signal was mainly sent by dFb subgroups C0, C1, and C2, and received by dFb subgroups C6 and C7. Compared with that in the normal skin tissue of healthy mouse, the expression of FGF7 protein was higher in the wound tissue of full-thickness skin defected mouse on PID 7; in the normal skin tissue, FGF7 protein was mainly expressed in the skin interstitium and also expressed in the white adipose tissue near the dermis layer; in the two kinds of tissue , FGF 7 protein was co -localized with DPP4 and SCA1 proteins and expressed in the skin interstitium , co -localized with PDGFR α protein and expressed in dFbs , but was not co -localized with SMA protein, with more co - localized expression of FGF 7 in the wound tissue than that in the normal skin tissue.

      Conclusions In the process of wound healing of mouse full-thickness skin defect wound, dFbs are highly heterogeneous, act as potential major secretory or receiving cell populations of a variety of growth factors , and have a close and complex relationship with the growth factor signal pathways. FGF7-FGFR1 signal pathway is the main FGF signal pathway in the process of wound healing, which targets and regulates multiple dFb subgroups.

【Key words】 Wound healing ; Skin; Dermis; Fibroblasts; Fibroblast growth factors; Single -cell RNA sequencing ; Growth factor; Intercellular communication Fund program : National Key Research and Development Program of China (2020YFA0112901); General Program of National Natural Science Foundation of China (81971551); Youth Science Fund Project of National Natural Science Foundation of China (82103702); China Postdoctoral Science Foundation (2020M682095)