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Wound Care

Extracorporeal Shockwave Therapy for Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis - (Louise Helen Hitchman, Joshua P. Totty, Ali Raza, Paris Cai, George E. Smith, Daniel Carradice, Tom Wallace, Amy E. Harwood, and Ian C. Chetter, Hull, United Kingdom) - Diabetes mellitus is one of the most common chronic diseases worldwide. Diabetic
foot ulcers (DFUs) occur in over 10% of diabetic patients and are associated with high morbidity. Clinical trials have shown benefit from extracorporeal shockwave therapy (ESWT) in a DFU healing. This systematic review aims to assess the currently available evidence examining the efficacy of ESWT on healing of DFU.

Extracorporeal shock wave therapy (ESWT) for wound healing: Technology, mechanisms, and clinical efficacy - (Rainer Mittermayr, MD; Vlado Antonic, MS; Joachim Hartinger ; Hanna Kaufmann, MD ; Heinz Redl, PhD ; Luc Téot, MD, PhD; Alexander Stojadinovic, MD ; Wolfgang Schaden, MD) - For almost 30 years, extracorporeal shock wave therapy has been clinically implemented as an effective treatment to disintegrate urinary stones. This technology has also emerged as an effective noninvasive treatment modality for several orthopedic and traumatic indications including problematic soft tissue wounds. Delayed/ nonhealing or chronic wounds constitute a burden for each patient affected, significantly impairing quality of life.

Efficacy and safety of extracorporeal shock wave therapy for acute and chronic soft tissue wounds: A systematic review and meta-analysis - (Department of Rehabilitation Medicine, Nan Lou of Chinese PLA General Hospital, Beijing, China) - This study aimed to evaluate and compare the effects of extracorporeal shock wave therapy (ESWT) and conventional wound therapy (CWT) for acute and chronic soft tissue wounds. All English-language articles on ESWT for acute and chronic soft tissue wounds indexed in PubMed, Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Library, Physiotherapy Evidence Database, and HealthSTAR published prior to June 2017 were included, as well as corresponding articles cited in reference lists of related review articles.

Extracorporeal Shock Wave Therapy as an Adjunct Wound Treatment: A Systematic Review of the Literature - (​Robert Dymarek, PhD, PT; Tomasz Halski, PhD, PT; Kuba Ptaszkowski, PhD, PT; Lucyna Slupska, PhD, PT; Prof. Joanna Rosinczuk, PhD, MSc; and Prof. Jakub Taradaj, PhD, PT) - Standard care procedures for complex wounds are sometimes supported and reinforced by physical treatment modalities such as extracorporeal shock wave therapy (ESWT). To evaluate available evidence of ESWT effectiveness in humans, a systematic review of the literature was conducted using MEDLINE, PubMed, Scopus, EBSCOhost, and PEDro databases. Of the 393 articles found, 13 met the publication date (year 2000–2013), study type (clinical study), language (English only), and abstract availability (yes) criteria.

Preoperative Shockwave Therapy Improves Wound Healing - (Med Esthetics Mag​) - A prospective, randomized, double‐blinded, controlled pilot trial of 24 abdominoplasty patients revealed that preoperative application of extracorporeal shockwave therapy (ESWT) reduces post-surgical scar thickness and improves the appearance of scars. The study, led by Elisabeth Russe, MD, is titled “Effects of Preoperative Extracorporeal Shockwave Therapy on Scar Formation—A Pilot Study on 24 Subjects Undergoing Abdominoplasty Surgery” and was published in Lasers in Surgery and Medicine (online April 29, 2019).

MTS Spark WaveTM  Technology and its mechanism of action in wound management - (MTS-Science​)  - Diabetic foot ulcers are one of the most serious complications of diabetes mellitus and are associated with high morbidity as well as mortality. They often predate amputation of the feet and / or the lower limbs and therefore have a major impact on the quality of life of the patients and their families as well as on national health care and social systems.

MSC-exosome: A novel cell-free therapy for cutaneous regeneration - (Peipei Wu, Bin Zhang, HuiShi, Hui Qian, Wenrong Xu) - Cutaneous regeneration is a dynamic and complex process that requires a series of coordinated interactions involving epidermal cells, dermal cells, growth factors, the extracellular matrix (ECM), nerves and blood vessels at a damaged site. Mesenchymal stromal cells (MSCs) have been reported to participate in all afore-mentioned stages. Exosomes are one of the key secretory products of MSCs, resembling the effect of parental MSCs. They can shuttle various proteins, messenger RNA (mRNA) and microRNAs (miRNAs) to modulate the activity of recipient cells, and play important roles in cutaneous wound healing. Compared with MSCs, exosomes are more convenient to store and transport.

The Exosome - A Naturally Secreted Nanoparticle and its Application to Wound Healing. - (Rani S, Ritter T) - Wound healing is a complex process and often delayed in patients with underlying chronic conditions. The cost of wound care is a significant burden to the society, warranting new techniques to prompt wound healing. Several studies have reported on the beneficial effects of mesenchymal stem cells (MSCs) function in recruiting host cells, releasing secretory factors and matrix proteins thereby increasing wound heal. These secrete bioactive trophic factors from MSCs also includes extracellular vesicles (EVs) or exosomes. Recent studies have shown that EVs are one of the key secretory products of MSCs mediating cell-to-cell communication to enhance wound healing. Current knowledge related to the potential use of EVs in wound healing is reviewed and the promising future for EVs - a naturally secreted nanoparticle - as an alternative to cell-based therapy is discussed.

Technology Assessment "Wound Care" dermagold100 - (MTS-Science) - ​Acute wounds are caused exogenously by traumatic (e.g. mechanical, chemical, thermical) or iatrogenic (e.g. surgical) injury. In general, they are sharply limited and heal within short time without major complications. If there is no progress in healing after more than 4 weeks, they are referred to as chronic wounds, which arise from disturbed wound healing processes due to other underlying diseases, like diabetes mellitus, venous diseases, circulation problems or disorders of the immune system. Chronic wound margins are imprecise and in the majority of cases they are infected. Chronic wounds have not completed the process of healing (restoring tissue loss and skin function), have not responded to initial treatment or persist despite appropriate care

ESWT minimizes ischemic tissue necrosis... - (Rainer Mittermayr, MD, Joachim Hartinger, Vlado Antonic, MS, Alexandra Meinl, PhD, Sabine Pfeifer, Alexander Stojadinovic, MD, Wolfgang Schaden, MD and Heinz Redl, PhD) - To assess the time-dependent treatment effects of extracorporeal shock wave therapy (ESWT) in a standard rodent ischemic epigastric flap model.  

The influence of comorbidities - ESWT for chronic soft tissue wounds -(Department of Surgery, Austrian Armed Forces Hospital-Vienna, Vienna, Austria;  AUVA Trauma Center Meidling, Vienna, Austria;  Department of Radiology, Medical University of Vienna, Vienna; Department of Surgery, Medical University of Vienna, Vienna, Austria; Center of Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria; Department of Vascular Surgery, Medical University of Vienna, Vienna, Austria and  Department of Surgery, Medical University of Ternopil, Ternopil, Ukraina) - Possible effects of comorbidities and of different wound etiologies on the success of extracorporeal shock wave therapy (ESWT) of chronic soft tissue wounds were investigated. From September 2003 until February 2007, 282 patients, being previously treated unsuccessfully were enrolled. Treatment consisted of ESWT occurring at defined intervals. At each treatment session a wound bed score was recorded, also at initial presentation a detailed patient history and wound etiology. Observed comorbidities were pooled according to the chapters of the ICD-10 system. Two hundred fifty-eight patients were analyzed (91.49%) and underwent follow-up for a median of 31.8 months. Wound closure occurred in 191 patients (74.03%) by a median of two treatment sessions. No wound reappeared at the same location. A multivariate logistic regression model showed that pooled comorbidities and wound etiologies did not have a significant influence on success. Comorbidities and wound etiologies have surprisingly no significant influence on the success of ESWT.

Molecular changes in diabetics foot ulcers -(​The Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan) - This study investigated the molecular changes of extracorporeal shockwave therapy (ESWT) and hyperbaric oxygen therapy (HBOT) in chronic diabetic foot ulcers. Methods: A cohort study consisted of 39 patients (44 ulcers) in the ESWT group and 38 patients (40 ulcers) in the HBOT group with similar demographic characteristics. The ESWT group received shockwave therapy twice per week for total six treatments. The HBOT group received hyperbaric oxygen therapy daily for total 20 treatments. Biopsy was performed from the periphery of the ulcer before and after treatment. The specimens were immunostained, and the positive immuno-activities of vWF, VEGF, eNOS, PCNA, EGF and TUNEL expressions were examined and quantified microscopically.

ESWT for Acute and Chronic Soft Tissue Wounds - (Wolfgang Schaden, M.D., Richard Thiele, M.D., Christine Kölpl, M.D., Michael Pusch, M.D., Aviram Nissan, M.D., Christopher E. Attinger, M.D., F.A.C.S., Mary E. Maniscalco-Theberge, M.D., F.A.C.S., George E. Peoples, M.D., F.A.C.S., Eric A. Elster, M.D., F.A.C.S., and Alexander Stojadinovic, M.D., F.A.C.S.) - Nonhealing wounds are a major, functionally-limiting medical problem impairing quality of life for millions of people each year. Various studies report complete wound epithelialization of 48 to 56% over 30 to 65 d with different treatment modalities including ultrasound, topical rPDGF-BB, and composite acellular matrix. This is in contrast to comparison control patients treated with standard wound care, demonstrating complete epithelialization rates of 25 to 39%. Extracorporeal shock wave therapy (ESWT) may accelerate and improve wound repair. This study assesses the feasibility and safety of ESWT for acute and chronic soft-tissue wounds.

ESWT for retracting scars of the hand - (Department of Medical Sciences, Oral and Biotechnology, ‘‘G. D’Annunzio’’ University, Chieti, Italy;  Department of Dermatology, University of Rome Tor Vergata, Rome, Italy; Department of Plastic and Reconstructive Surgery, ‘‘Sapienza’’ University, Policlinico Umberto I, Rome, Italy;  School of Specialties in Physical Medicine and Rehabilitation ‘‘G. D’Annunzio’’ University, Chieti, Italy and Department of Medicine and Science of Aging, ‘‘G. D’Annunzio’’ University, Chieti, Italy) - Prolonged and abnormal scarring after trauma, burns and surgical procedures often results in a pathologic scar. We evaluated the efficacy of unfocused shock wave treatment, alone or in combination with manual therapy, on retracting scars on the hands. Scar appearance was assessed by means of the modified Vancouver Scar Scale; functional hand mobility was evaluated using a range-of-motion scale, whereas a visual analogue score was implemented for detecting any improvements in referred pain. Additionally, biopsy specimens were collected for clinico-pathologic correlation. 

Prospective randomized phase II trial of accelerated reepithelialization.... - (Christian Ottomann, MD, Alexander Stojadinovic, MD, FACS,  Philip T. Lavin, PhD,§ Francis H. Gannon, MD, Michael H. Heggeness, MD, Richard Thiele, MD, Wolfgang Schaden, MD, and Bernd Hartmann, MD) As extracorporeal shock wave therapy (ESWT) can enhance healing of skin graft donor sites, this study focused on shock wave effects in burn wounds

Evidence supporting extracorporeal shockwave therapy for acute and chronic soft tissue wounds -  (From Henry M. Jackson Foundation for Advancement in Military Medicine, Rockville, MD; Combat Wound Initiative Program, Walter Reed Army Medical Center, Washington, DC; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria; AUVA Trauma Center, Meidling, Vienna, Austria)  Soft tissue wound healing is a complex and well-orchestrated sequence of events on multiple biological levels involving systemic, cellular, and molecular signals. The physiological process of wound healing leads to full tissue repair and regeneration with nearly complete restoration of tissue integrity and functionality.

Prospective randomized trial of accelerated re-epithelization of skin graft donor sites using extracorporeal shock wave therapy - (Christian Ottomann, MD, Bernd Hartmann, MD, Josh Tyler, MD, Heike Maier, MD, Richard Thiele, MD, Wolfgang Schaden, MD, Alexander Stojadinovic, MD) - Extracorporeal shock wave therapy may enhance revascularization and repair of healing soft tissue.

Extracorporeal shockwave treatment for chronic diabetic foot ulcers -Seventy-two patients with 72 chronic diabetic foot ulcers were randomly divided into two groups of similar demographics with 34 patients with 36 ulcers in the ESWT group and 36 patients with 36 ulcers in the HBO group. Patients in the ESWT group received 300 + 100/cm2 impulses of shockwave at 0.11 mJ/cm2 energy flux density every 2 wk for 6 wk, whereas patients in the HBO group received HBO daily for 20 treatments. The evaluations included clinical assessment of the ulcers with photo-documentation, blood flow perfusion scan, bacteriological examination, histological study, and immunohistochemical analysis.

Extracorporeal shock waves, a new non-surgical method to treat severe burns - (Department of Plastic, Aesthetic and Reconstructive Surgery and Burn Center Vall d’Hebron University Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, 08025 Barcelona, Spain ) - Extracorporeal shock wave treatment (ESWT) increases perfusion in ischaemic tissues, stimulates growth factors, decreases inflammation and accelerates wound healing. It is a safe technique classically used in urology and orthopaedic surgery with success, but there is still limited literature regarding its use in the management of burns.

Randomized control of extracorporeal shock wave therapy versus placebo for chronic decubitus ulceration - (Anna M Larking, Sophie Duport Institute of Neuropalliative Rehabilitation, Royal Hospital for Neuro-disability, Michael Clinton Department of Management, King’s College, Mary Hardy Practice Development, Royal Hospital for Neurodisability and Keith Andrews Institute of Neuropalliative Rehabilitation, Royal Hospital for Neuro-disability, London, UK) ​To assess whether extracorporeal shock wave therapy increases the rate of healing in chronic decubitus ulceration.

Extracorporeal shock wave therapy suppresses the early proinflammatory immune response to a severe cutaneous burn injury - (Thomas A Davis, Alexander Stojadinovic, Khairul Anam, Mihret Amare, Shruti Naik, George E Peoples, Douglas Tadaki, Eric A Elster) Following severe burn injury, persistent inflammation perpetuated by surface eschar, bacterial colonisation and neutrophil proteolytic activity can impede normal healing and result in further tissue damage. Extracorporeal shock wave treatment (ESWT) has been shown in the clinical setting to promote the healing of burn and difficult to-heal wounds; however, the mechanism is unclear. We investigated the role of ESWT on the early proinflammatory response using a severe, full-thickness and highly inflammatory cutaneous burn wound in a murine model. Various wound-healing parameters were measured and leukocyte infiltration quantitated. A panel of 188 candidate genes known to be involved in acute inflammation and wound healing was screened. We show that ESWT of burn wounds 1 hour post wounding significantly blunts polymorphonuclear neutrophil and macrophage infiltration into the wound.

Prophylactic low-energy shock wave therapy improves wound healing after vein harvesting for coronary artery bypass graft surgery: a prospective, randomized trial - (Department of Cardiothoracic Surgery, Medical University of Vienna, and AUVA Trauma Center, Vienna, Austria) Wound healing disorders after vein harvesting for coronary artery bypass graft surgery increase morbidity and lower patient satisfaction. Low-energy shock wave therapy (SWT) reportedly improves healing of diabetic and vascular ulcers by overexpression of vascular endothelial growth fractor and downregulation of necrosis factor B. In this study, we investigate whether prophylactic low-energy SWT improves wound healing after vein harvesting for coronary artery bypass graft surgery.

Low-energy shock wave for enhancing recruitment of endothelial progenitor cells: a new modality to increase efficacy of cell therapy in chronic hind limb ischemia - (Alexandra Aicher, MD*; Christopher Heeschen, MD*; Ken-ichiro Sasaki, MD; Carmen Urbich, PhD; Andreas M. Zeiher, MD; Stefanie Dimmeler, PhD) Stem and progenitor cell therapy is a novel approach to improve neovascularization and function of ischemic tissue. Enhanced tissue expression of chemoattractant factors such as stromal cell–derived factor 1 and vascular endothelial growth factor is crucial for the recruitment of circulating endothelial progenitor cells (EPCs) during acute ischemia. In chronic ischemia, however, expression of these chemoattractants is less pronounced, which results in insufficient EPC recruitment into the target tissue. Therefore, we investigated the effect of targeted extracorporeal shock wave (SW) application in order to facilitate EPC recruitment into nonischemic and chronic ischemic tissue

Antibacterial effects of extracorporeal shock waves -(Klinik und Poliklinik für Orthopädie und Sportorthopädie der Technischen Universität München, München, Germany; and  Institut für Medizinische Mikrobiologie, Universitätsklinikum Muenster, Muenster, Germany) - Despite considerable knowledge about effects of extracorporeal shock-wave therapy (ESWT) on eukaryotic tissues, only little data are available concerning their effect on prokaryotic microorganisms. The objective of the present study was to determine the bactericidal activity as a function of energy flux density and shock-wave impulse number. Standardised suspensions of Staphylococcus aureus ATCC 25923 were exposed to different impulse numbers of shock waves with an energy flux density (ED) up to 0.96 mJ mm2 (2 Hz). Subsequently, viable bacteria were quantified by culture and compared with an untreated control. After applying 4000 impulses, a significant bactericidal effect was observed with a threshold ED of 0.59 mJ mm2 (p < 0 · 05). A threshold impulse number of more than 1000 impulses was necessary to reduce bacterial growth (p < 0 · 05). Further elevation of energy and impulse number exponentially increased bacterial killing. ESWT proved to exert significant antibacterial effect in an energy-dependent manner.

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