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Managment

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Qualification | BTEC Higher National Diploma in Biomedical Science | Level | 5 | Module Name | Biology of Disease | Module Number | BIOM517 | Name of Candidate | Amila Eliyapura | Candidate Number | BIO/502/290211 | Submission Date | 30.04.2013 | Word Count | |

Discuss The Factors Which Influence The Processes Involved In Wound Healing 1. Introduction
A wound is defined by its aetiology, anatomical location, acute or chronic stages, and the method of closure by its presenting symptoms and predominant tissue types in the wound bed. Injury to the skin or underlying tissues/ organs caused by surgery, a blow, a cut, chemicals, heat/ cold, friction/ shear force, pressure or as a result of disease, such as leg ulcers or carcinomas, Infectious (bacterial, Virus); Immunologic (Autoimmune disease; Genetic derangement e.g. Sickle cell anaemia); Nutritional (Vitamin deficiency; Oxygen imbalance) and Metabolic imbalance (ATP depletion) breakdowns the protective function of the skin by losing the continuity of epithelium, with or without the loss of underlying connective tissues (i.e. muscle, bone, nerves). Hence, the immune system initiates to recover wounds through complex pathways. Wound healing consists of four stages which are in the order hemostasis phase, inflammatory phase, cell proliferation phase and the remolding phase (Table 01) (Leaper DJ and Harding KG. (1998 and Hutchinson J 1992)

2. Phases in wound healing
(Table 1): Phases of normal wound healing process. The table interprets the order in phases that take place in wound healing (Guo and DiPietro, 2010).

The hemostasis phase is initially conducted through the release of protein factors thromboxane A2 and prostaglandin 2-alpha initiate vasoconstriction to control hemorrhage. The growth factors released from adhered platelets and protein factors like thrombin and fibrin promote the activation of the coagulation system for the colt formation. In inflammatory phase, platelets release histamine to promote vasodilation and release growth factors [α-granules liberate platelet-derived growth factor (PDGF), platelet factor IV, and transforming growth factor beta (TGF-b)] to attract inflammatory cells to the wound site to phagocyte debris and microorganisms and to attract fibroblast. In cell proliferation phase fibroblasts initiates angiogenesis (formation of new blood vessels from existing blood vessels), epithelization (formation of epithelial cells) and collagen formation (ECM synthesis). In remodeling phase, while the collagen formation occurs, fibroblasts differentiate to myofibroblasts to contract the tissue. The collagen recognizes these tension lines and crosslinks to give an added strength. In the end of these four phases in healing process, leaves a scar( Gabriel A. (2011), Mera Steven L. (1997). 3 Factors influenced in wound healing 3.1 Introduction The wound healing is influenced under local and systemic factors (Steven, 1997). Under local factors can consider many attributes like physical nature of the wound, presence or absence of infection and foreign bodies, continuous proper blood supply, oedema, low oxygen tension and proper coordination of growth factors/cell mediators etc. Under systemic factors can consider nutrition, immunological aspects, genetic defects, drug therapies, existing medical conditions like diabetes and behavioural habits (smoking). These factors limit the initiation of angiogenesis, epithelization and collagen formation. 3.2 Local factors 3.2.1 Blood Supply and physical nature of the wound
Healing needs an adequate blood supply to bring along adequate perfusions which are other local factors such as cell mediators (macrophages, platelets, neutrophils, T Cells). These cell mediators release growth factors (cytokines and integrins) to stimulate platelets, keratinocytes and fibroblasts for angiogenesis, epiethilizaton and collagen formation. These also release proteins like histamine for vasodilation; serotonin and ADP to attract (chemotax) more platelets for adherence in clot formation. Cell mediators also phagocyte infectious agents/ apoptotic cells. Besides cell mediators the blood also brings systemic factors like nutrition (glucose, protein etc.) and oxygen that contribute in ATP production to provide energy for cells. Negative systemic factors such as smoking releases nicotine to the blood stream which acts upon the sympathetic nervous system that result in release of epinephrine which contribute in vasoconstriction to decrease peripheral blood supply to the tissue. Besides nicotine, atherosclerosis restricts the supply of RBC/cell mediators and perfusions to the wound site by blocking blood vessels. Additionally,smoking and diabetes also increase the blood viscosity for RBC/cell mediators to flow freely to the wound site (Gabriel, 2011,Steven 1997 and Bishop ,2008) . Apart from these factors, If the wound damage is high or is a chronic wound or a granulomatous tissue the recovering period is longer than a small or an acute wound due to the extended inflammation stage. Table 2 shows the growth factors which release from cell mediators Growth Factor | Production | Known Effects | 1. Epidermal Growth Factor (EGF) | Platelets, macrophages | Stimulates fibroblasts to secrete collagenase to degrade the matrix during the remodeling phase. Stimulates keratinocyte and fibroblast proliferation. May reduce healing time when applied topically. | 2. Transforming Growth Factor | Platelets, macrophages, lymphocytes, hepatocytes | TGF-a: Mitogenic and chemotactic for keratinocytes and fibroblasts

TGF-b1 and TGF-b2: Promotes angiogenesis, up-regulates collagen production and inhibits degradation, promotes chemoattraction of inflammatory cells.

TGF-b3 (antagonist to TGF-b1 and b2): Has been found in high levels in fetal scarless wound healing and has promoted scarless healing in adults experimentally when TGF-b1 and TGF-b2 are suppressed. | 3. Vascular Endothelial Growth Factor (VEGF) | Endothelial cells | Promotes angiogenesis during tissue hypoxia. | 4. Fibroblast Growth Factor (FGF) | Macrophages, mast cells, T-lymphocytes | Promotes angiogenesis, granulation, and epithelialization via endothelial cell, fibroblast, and keratinocyte migration, respectively. | 5. Platelet-Derived Growth Factor (PDGF) | Platelets, macrophages, and endothelial cells | Attracts macrophages and fibroblasts to zone of injury. Promotes collagen and proteoglycan synthesis. | 6. Interleukins | Macrophages, keratinocytes, endothelial cells, lymphocytes, fibroblasts, osteoblasts, basophils, mast cells | IL-1: Proinflammatory, chemotactic for neutrophils, fibroblasts, and keratinocytes. Activates neutrophils

IL-4: Activates fibroblast differentiation. Induces collagen and proteoglycan synthesis.

IL-8: Chemotactic for neutrophils and fibroblasts. | 7. Colony-Stimulating Factors | Stromal cells, fibroblasts, endothelial cells, lymphocytes | Granulocyte colony stimulating factor (G-CSF): Stimulates granulocyte proliferation.

Granulocyte Macrophage Colony Stimulating Factor (GM-CSF): Stimulates granulocyte and macrophage proliferation. | 8. Keratinocyte growth factor | Fibroblasts | Stimulates keratinocyte migration, differentiation, and proliferation. | Table 02: Growth factors and cytokines in wound healing (Stojadinovic, 2008).

3.2.3 Infections Infection is another influential local factor which prolongs the wound healing process. To minimise the infection should have correct levels of oxygen as discussed, nutrition, growth factors/cell mediators and drugs like antibiotics. The infectious state severed due to the rapid colonization of pathogens due to limitations of above discussed local and systemic factors. This condition further releases pro-inflammatory growth factors such as interleukin-1 (IL-1) and TNF-α, to prolong the inflammatory phase which leads the wound to an unhealed chronic state (Stashak, no date). Prolong pro-inflammation leads to the production in proteases such as matrix metalloproteases which degrade the extra cellular matrix of the cell (Stashak, no date). Pathogens like Staphylococcus aureus, Pseudomonas aeruginosa, and β-hemolytic streptococci colonise and produce biofilms (complex colonization with self-secreted extracellular polysaccharide matrix) which provide protection for bacteria from antibiotics and phagocytes. Therefore, strong antibiotics would not contribute to eradicate these microorganisms. In virus and bacterial infections the T-cells (T helper and cytotoxin T cells) and B-cells aid to eradicate the microorganisms. However, if an individual have a genetic disorders like di-George syndrome or burton’s agammaglobulinaemia make immunosuppressed to these pathogens and eventually cause death to the patient. 3.2.4 Oxygenation Oxygenation is another key local factor which is useful in ATP production (oxidative phosphorylation), production of superoxides in polymorphonuclear leukocytes (neutrophils) for phagocytosis and for angiogenesis. In the initial process of wound healing, the metabolically activated cells deprive for oxygen. Therefore oxygen level declines. Other systemic conditions like ageing, medical conditions (diabetes, atherosclerosis); genetic conditions (sickelcellamina) also reduce the availability of oxygen for cells. This state is known as hypoxia and increase in oxygen levels during healing which is known as hyperoxia. Both these states cause in high levels of ROS production (superoxides and H2O2) that result in production of cytokinesis from macrophages, keratinocytes and fibroblasts that contribute in angiogenesis (Bishop , 2008). Growth factors that stimulate in hypoxia are PDGF, TGF-β, VEGF, tumor necrosis factor-α (TNF-α), and endothelin-1. Prolonged hypoxia does not result to stimulation in growth factors but delays the wound healing process and prolong hyperoxia causes high levels of ROS that result in free radical tissue damaged (Bishop, 2008). Hyperbaric oxygen therapy is a successful way to overcome hypoxia and also can be a treatment to kill anaerobic pathogens in wound healing (Gabriel, 2011). 3.3 Systemic factors
The main systemic factor to discuss is nutrition. In angiogenesis and deposition of new tissues the cells should undergo mitotic cycle to regenerate new identical cells. Therefore, the possible energy derives from ATP by hydrolysing carbohydrate (glucose) as the energy fuel. Apart from carbohydrate, proteins are essential as an energy source, precursors, and in collagen formation etc. for wound healing. Caloric needs of the severely injured patient can exceed 35 kcal/kg/d and 0.8-2 g/kg/d of protein. Therefore protein markers Albumin should be at minimum of 3.5 g/dL or Prealbumin should be at minimum of 17 g/dL (Stojadinovic, 2008).
In collagen formation for the connective tissue needs glycine, proline, and hydroxyproline amino acids along with Cofactors such as ferrous irons and vitamin C (Anon EIKS ,2008,Williams ,not stated and MacKay ,2004). Arginine is another amino acid which increase in stress injuries and work as a precursor for proline. Therefore, it is important in collagen deposition and angiogenesis. Glutamine amino acid involves in metabolism to provide energy in mitotic cycle (cell proliferation) for leukocytes, epithelial cells, fibroblasts and macrophages (Arnold and Barbul , 2006 and MacKay 2004). Fatty acids such as omega 3 and omega 6 benefit in wound healing by stimulating angiogenesis, affecting pro-inflammatory cytokine production, cell metabolism and gene expression (McDaniel et al , 2010) Vitamins such as vitamin C act as a cofactor in collagen formation. Deficiency in Vitamin C reduces collagen synthesis and fibroblast proliferation, reduces angiogenesis and increases capillary fragility. Also, vitamin C deficiency leads to an impaired immune response and increased susceptibility to wound infection.
Vitamin A has anti-oxidant activity which neutralises free radicals in inflammatory phase. Vitamin A increases fibroblast proliferation, modulates cellular differentiation and proliferation, increases collagen and hyaluronate synthesis, and decreases MMP-mediated extracellular matrix degradation. Vitamin A also contributes to reverse corticosteroid function on blunting the macrophages (Anon, 2011, Anon, 2011and MacKay 2004). Vitamin E, an anti-oxidant, prevents lipid peroxidation to maintain and stabilise cellular membrane integrity and decreases excess scar formation in chronic wounds. Negative effect on vitamin E is slowdown of collagen synthesis (Anon, 2011, Anon, 2011and MacKay 2004). Magnesium, copper and zinc act as co-factors for enzymes. Magnesium involves in protein and collagen synthesis. Copper involves in cytochrome oxidase, cytosolic anti-oxidant superoxide dismutase, and for optimal cross-linking of collagen. Zinc involves in both RNA and DNA polymerase and deficiency in Zn causes impaired wound healing. Iron is required for the hydroxylation of proline and lysine, and, as a result, in severe iron deficiency results impaired collagen production (MacKay, 2004). Medical conditions like diabetes, pressure ulcer affect negatively in wound healing. The main medical conditions are diabetes and atherosclerosis. Atherosclerosis causes inadequate perfusion to the wound site which prolongs the wound healing. Diabetes interrupts angiogenesis by making the rigid cell walls in blood vessels to decrease the flow of cells (RBC and inflammatory cells) and the high sugar concentration in the blood disrupt the red blood cell permeability towards O2 which result prolong hypoxia at the wound site that leads to increase production of ROS which increase the damage of the wound. Diabetes results in neuropathy by inhibiting neuropeptides (nerve growth factor, substance P, and calcitonin gene-related peptide) that promote cell chemotaxis, induce growth factor production, and stimulate the proliferation of cells (Galiano , 2004). High levels of metalloproteases are a feature of diabetics and result in destruction to ECM. A genetic disorder that causes imbalance in between throboxanes and prostacyclin is a negative factor where prostacyclin acts as an inhibitor to regulate platelet aggregation while throboxanes involves in vasoconstriction (Steven, 1997).
Aging impairs the mechanisms such as re-epithelialization, collagen synthesis, secretion of growth factors and angiogenesis (Swift, 1999). Medications like chemotherapeutic drugs suppress immunity, decrease cellular metabolism and inhibits DNA, RNA, protein synthesis which contribute for cell proliferation. Non-steroidal Anti-inflammatory Drugs (ibuprofen) delays epithelialisation and promote impaired angiogenesis. Glucocorticoid Steroids increase infection, suppress fibroblast proliferation and collagen synthesis in wound healing (Anon, 2011). Obesity is another negative systemic factor where adipocytes and macrophages in adipose tissue produce adipokines (leptin, adiponectin, resistin, cytokines: TNF-alpha, IL-1, IL-6, IL-8, IL-10, chemokines: IL-8, MCP-1, IP-10) that influence negatively on immune system and inflammatory responses. Besides, obesity also links to atherosclerosis which results inadequate perfusion (Stojadinovic, 2008). Smoking and alcohol consumption also relate in impaired wound healing. Alcohol strictly effect in angiogenesis and collagen production, and altering the protease balance at the wound site. Nicotine and hydrogen cyanide that release form cigarette smoking cause hypoxia that result on depletion of cellular metabolism and cause free radical damage to the wound (Galiano, 2004). 4. Treatment and Conclusion
These local and systemic factors give insight about how these factors influence in wound healing process. Modern treatments directed against these factors aid in wound healing. Insulin showed depletion in inflammation and increase collagen deposition (Madibally, 2003). He-Ne laser therapy increased the healing process by promoting collagen formation and re-epithalisation (Gonçalves,2007). Recombinant human PDGF-BB reduces the healing time and promotes complete healing of stage3 and stage4 ulcer (Gabriel, 2011). Negative outcome drugs such as anti-cancer drugs inhibit angiogenesis to prevent spread the tumor but the side effect cause complications in wound healing (National Cancer Institute, 2011). Hence, maintaining these factors from these treatments can overcome chronic wounds which may lead to necrosis or cancer.

References:

* Ahn C, Mulligan P, and Salcido RS. (2008) Smoking-the bane of wound healing: biomedical interventions and social influences. Advances in skin and wound care; 21(5):227-36. [Accessed: 10 March 2013].

* Anon, EIKS wound healing organization, 2008. ‘Factors Affecting Wound Healing’ [Online].Available at: http://www.woundandhyperbaric.org/physicians/wound/factors.php [Accessed: 11 March 2013].

* Leaper DJ and Harding KG. (1998) ‘Wounds: Biology and Management’. Oxford UniversityPress[Online].Availableat:http://www.clinimed.co.uk/Wound-Care/Education/Wound-Essentials/What-is-a-Wound-.aspx [Accessed: 12 March 8 2013].

* Hutchinson J (1992). ‘The Wound Programme’. Centre for Medical Education: Dundee, [Online].Available at: http://www.clinimed.co.uk/Wound-Care/Education/Wound-Essentials/What-is-a-Wound-.aspx[Accessed: 11 March 2013].

* Anon, 2011. ‘factors interfere with wound healing’ [Online].Available at: http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/160706.htm [Accessed: 20 April 2013].

* Anon, 2011. Antioxidants: What you need to know [Online].Available at: http://health.howstuffworks.com/wellness/food-nutrition/facts/antioxidant3.htm [Accessed: 25 April 2013].

* Arnold M, Barbul A. (2006) Nutrition and wound healing. Plastic and reconstructive surgery; 117(7 Suppl):42S-58S.

* Bishop, A. (2008). ‘Role of oxygen in wound healing’. Journal of Wound Care;17(9):399-402

* Douglas MacKay, ND, and Alan L. Miller, ND (2004) ‘Nutritional support for wound healing’Alternative Medicine Review; 8(4): 359-377.

* Driscoll P. 2010, ‘Factors Affecting Wound Healing’ [Online].Available at: http://mediligence.com/blog/2010/05/26/factors-affecting-wound-healing/ [Accessed: 25 April 2013].

* Gabriel A, 2011. ‘Wound healing and growth factors’, [Online].Available at: http://emedicine.medscape.com/article/1298196-overview#aw2aab6b4 [Accessed: 25 April 2013].

* Galiano RD, Tepper OM, Pelo CR, Bhatt KA, Callaghan M, Bastidas N, Bunting S, Steinmetz HG, and Gurtner GC. (2004) Topical vascular endothelial growth factor accelerates diabetic wound healing through increased angiogenesis and by mobilizing and recruiting bone marrow-derived cells. The American Journal of Pathology;164(6):1935-47.

* Gonçalves WL, Souza FM, Conti CL, Cirqueira JP, Rocha WA, Pires JG, Barros LA, Moysés MR. (2007) Influence of He-Ne laser therapy on the dynamics of wound healing in mice treated with anti-inflammatory drugs. Braz J Med Biol Res.;40(6):877-84.

* Guo, S., & DiPietro, L. A. (2010). Factors affecting wound healing. Journal of dental research, 89(3), 219-229.

* Madibally SV, Solomon V, Mitchell RN, Van De Water L, Yarmush ML, Toner M. (2003) Influence of insulin therapy on burn wound healing in rats. The Journal of Surgical Research;109(2):92-100.

* McDaniel,J.C., Belury, M., Ahijevych, K.and Blakely,W (2008) ω-3 fatty acids effect on wound healing. Wound Repair Regen; 16(3), pp. 337–345.

* National Cancer Institute, 2011. ‘Angeogenisis inhibitors’ http://www.cancer.gov/cancertopics/factsheet/Therapy/angiogenesis-inhibitors, [Accessed: 25 April 2013]

* Silverstein P., 1992. ‘Smoking and Wound healing’ [Online].Available at: http://www.ncbi.nlm.nih.gov/pubmed/1323208 [Accessed: 25 April 2013]

* Stashak T.S. (no date). ‘Management practices that influence wound infection and healing’[Online].Available at: http://www.abraveq.com.br/eventos_pdf/abr_ne09_pal_ted.pdf [Accessed: 24 April 2013]

* Steven L.M., 1997. Pathology and Understanding Disease Prevention. Stanley Thornes publishers

* Stojadinovic, O. 2008, ‘Growth factors and cytokines in wound healing’ [Online].Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1524-475X.2008.00410.x/full [Accessed: 23 April 2013]

* Swift M.E, 1999. ‘Impaired wound repair and delayed angiogenesis in aged mice’ [Online].Available at: http://www.ncbi.nlm.nih.gov/pubmed/10616199 [Accessed: 23April 2013]

* Williams R.J, (No date). ‘Vitamin C and Collagen’ [Online].Available at: http://www.vitamincfoundation.org/collagen.html [Accessed: 28 April 2013]…...

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