Clinical Utility of Silk-Elastin Sponge in Patients with Chronic and Acute Skin Ulcers: Study Protocol of a Multicenter Clinical Trial.

INTRODUCTION: Not only chronic but also some acute wounds have a risk of infection and become unhealed wounds. Silk-elastin sponge has been developed to treat chronic wounds that are susceptible to infection. Preclinical and clinical studies suggested that silk-elastin sponge is safe for humans and can promote granulation tissue formation by reducing bacterial growth in chronic wounds. The central aim of this trial is to evaluate the clinical utility and safety of silk-elastin sponge for the treatment of chronic and acute skin ulcers. METHODS: This study is a prospective, multicenter, single-arm, uncontrolled clinical trial. In this study, 20 patients with chronic ulcers and five with an acute one will be included; patients with wound infection will be excluded. Silk-elastin sponges are applied and covered with a dressing for 14 days. PLANNED OUTCOMES: The primary endpoint is the frequency of patients with chronic wounds in whom the investigator confirms the formation of a healthy wound bed at 14 days after the initial application of the study device. In addition, safety for acute wounds and handiness of the study device will be assessed. TRIAL REGISTRATION NUMBER: jRCT2052210072.

Safety of Silk-elastin Sponges in Patients with Chronic Skin Ulcers: A Phase I/II, Single-center, Open-label, Single-arm Clinical Trial.

BACKGROUND: Although traditional wound dressings such as collagen scaffolds promote granulation tissue formation, the efficacy of these dressings in chronic wounds is limited because of high susceptibility to bacterial growth. Biomaterials that can be applied to chronic wounds should have an anti-bacterial function. We previously reported that administering a silk-elastin solution that forms moisturizing hydrogels to wound surfaces of diabetic mice reduced bacterial growth and promoted granulation tissue formation compared with control or carboxymethyl cellulose hydrogels. We hypothesized that silk-elastin promotes wound healing in human chronic wounds by suppressing bacterial growth. METHODS: An open-label, clinical case series was conducted with a prospective, single-arm design at Kyoto University Hospital in Kyoto, Japan. In this study, 6 patients with chronic skin ulcers of any origin (2 < ulcer area (cm2) < 25) on their lower extremities were included; patients with critical ischemia were excluded. Silk-elastin sponges were applied and covered with a polyurethane film without changing the dressing for 14 days. Inflammation triggered treatment discontinuation due to fear of infection. The primary study endpoint was adverse events, including inflammation and infection. RESULTS: Poor hydrogel formation, possibly due to continuous exudation, was observed. No serious adverse events were noted. Two patients discontinued treatment on day 6 and day 7, respectively, due to inflammation, but they were not infected. The other 4 patients completed the 14-day silk-elastin sponge treatment without infection. CONCLUSION: Silk-elastin sponge is safe for chronic skin ulcers, and its ability to promote wound healing should be determined by confirmatory clinical trials.

A matricellular protein fibulin-4 is essential for the activation of lysyl oxidase.

Fibulin-4 is a matricellular protein required for extracellular matrix (ECM) assembly. Mice deficient in fibulin-4 (Fbln4-/- ) have disrupted collagen and elastin fibers and die shortly after birth from aortic and diaphragmatic rupture. The function of fibulin-4 in ECM assembly, however, remains elusive. Here, we show that fibulin-4 is required for the activity of lysyl oxidase (LOX), a copper-containing enzyme that catalyzes the covalent cross-linking of elastin and collagen. LOX produced by Fbln4-/- cells had lower activity than LOX produced by wild-type cells due to the absence of lysine tyrosyl quinone (LTQ), a unique cofactor required for LOX activity. Our studies showed that fibulin-4 is required for copper ion transfer from the copper transporter ATP7A to LOX in the trans-Golgi network (TGN), which is a necessary step for LTQ formation. These results uncover a pivotal role for fibulin-4 in the activation of LOX and, hence, in ECM assembly.

Glucocorticoids suppress fibroblast apoptosis in an in vitro thermal injury model.

The wounds of full- and deep partial-thickness burns result in hypertrophic scars and lead to skin contracture more severely than those of superficial partial-thickness burns. Therefore, preventing burn progression may help improve the aesthetic and functional outcomes after healing. Although a number of studies have focused on elucidating the underlying mechanisms of and preventing burn wound progression, it is still difficult to rescue burned dermis unless early tangential excision is performed. To investigate the underlying mechanisms of and prevent cell death of heat-injured fibroblasts, we developed an in vitro experimental model of heat-injured fibroblasts. We confirmed that heating at 55°C for 30s caused fibroblast necrosis immediately after heating, whereas heating at 46°C for 30s induced apoptosis 24h after heating. We also found that the supplementation of 100ng/ml betamethasone to the culture medium after heating decreased the number of apoptotic cells and increased that of live cells. Our studies suggest that glucocorticoids suppress apoptosis of heat-injured fibroblasts and may be useful for preventing burn wound progression.

The Utility of Silk-elastin Hydrogel as a New Material for Wound Healing.

Cutaneous ulcers are treated with dressing materials and/or ointments to keep the wound in an appropriately moist environment. However, chronic cutaneous ulcers commonly have bacterial colonization that can cause local infection in such an environment. Therefore, the dressing materials and/or ointments should have antibacterial potency to treat chronic ulcers. Acute cutaneous wounds, by contrast, heal rapidly without local infection. The aim of treating acute cutaneous wounds is therefore not only wound closure but also preventing scar contracture after wound healing. However, no dressing materials or ointments available at present are simultaneously effective for preventing infection in chronic ulcers and reducing wound contracture in acute ulcers. Silk-elastin is a recombinant protein polymer with repeating units of silk-like and elastin-like blocks. Silk-elastin solution can self-assemble from a liquid to a hydrogel. We preliminarily reported that silk-elastin hydrogels have the potential to accelerate wound healing in decubitus ulcers of diabetic mice, which are animal models of severe, intractable cutaneous ulcers. In the present study, we examined the effects of silk-elastin hydrogels in chronic and acute ulcer models in comparison with conventional products (carboxymethyl cellulose gel). Silk-elastin hydrogels resulted in significantly higher epithelialization rates than conventional hydrogels in both the chronic and acute ulcer models and significantly larger areas of granulation tissue in acute ulcer models. These results show that silk-elastin hydrogel is a promising material for promoting the healing of cutaneous wounds, including decubitus ulcers, chronic ulcers, and acute ulcers.

The development of a novel wound healing material, silk-elastin sponge.

Silk-elastin is a recombinant protein polymer with repeating units of silk and elastin blocks. This novel wound healing promoting material has the ability to self-assemble from a liquid to a gel. We have already reported that an aqueous solution of silk-elastin has the potential to accelerate wound healing; however, there are several problems in applying silk-elastin in the clinical setting. To solve these problems, we developed a silk-elastin sponge that is easy to use in the clinical setting. In the present study, we examined whether the wound healing effect of the silk-elastin sponge is equal to the aqueous solution of silk-elastin in vivo. The granulation tissue formation promoting effect of the silk-elastin sponge was equal to that of the aqueous solution the silk-elastin, as after application to the wound surface, the sponge was absorbed and dissolved by the exudate. At body temperature the silk-elastin then formed temperature gel. The silk-elastin gel that was obtained contained abundant cytokines from the exudate. We believe that silk-elastin sponge can be applied to various wounds that are difficult to treat with the aqueous solution.

Latent TGF-ß binding protein 2 and 4 have essential overlapping functions in microfibril development.

Microfibrils are exracellular matrix components necessary for elastic fiber assembly and for suspending lenses. We previously reported that latent TGF-ß binding protein 2 (LTBP-2), a microfibril-associated protein, is required for forming stable microfibril bundles in ciliary zonules. However, it was not understood why Ltbp2 null mice only showed an eye-specific phenotype, whereas LTBP-2 is abundantly expressed in other tissues containing microfibrils in wild type mice. Here, we show that LTBP-4, another microfibril-associated protein, compensates for the loss of LTBP-2 in microfibril formation. Ltbp2/4S double knockout (DKO) mice showed increased lethality due to emphysema, which was much more severe than that found in Ltbp4S null mice. Elastic fibers in the lungs of Ltbp2/4S DKO mice were severely disorganized and fragmented. Cultured mouse embryonic fibroblasts (MEFs) from Ltbp2/4S DKO embryos developed reduced microfibril meshwork in serum-free conditions, whereas the microfibril formation was restored by the addition of either recombinant LTBP-2 or -4. Finally, ectopic expression of LTBP-4 in the whole body restored ciliary zonule microfibril bundles in the eyes of Ltbp2 null mice. These data suggest that LTBP-2 and -4 have critical overlapping functions in forming the robust structure of microfibrils in vitro and in vivo.

ß-Adrenergic Receptor Blockers Reduce the Occurrence of Keloids and Hypertrophic Scars after Cardiac Device Implantation: A Single-Institution Case-Control Study.

BACKGROUND: Keloids and hypertrophic scars are characterized by excessive proliferation of fibroblasts; abnormal accumulation of extracellular matrix; and clinical findings of raised, red, itchy, and painful lesions. There are few sufficient interventions for keloids, and the development of new therapeutic agents is urgently needed. Several studies suggest that a therapeutic possibility is ß-adrenergic receptor blocker treatment. METHODS: In this single-center case-control study, patients who had undergone cardiac device implantation 7 to 23 months earlier were identified. The implantation incision scars of the patients were deemed to be normal or abnormal depending on their redness. The cases (abnormal scars) and controls (normal scars) were compared in terms of their ß-blocker use rates. RESULTS: Of the 45 eligible patients, 12 and 33 patients were cases and controls, respectively. The cases tended to be less likely to have taken blockers than the controls (25 percent versus 45.5 percent). This difference became significant when the patients whose scars were diagnosed 7 or 8 months after implantation were excluded from the analysis: the age-adjusted odds ratios of the patients who were diagnosed 8 to 23 and 9 to 23 months after implantation were 0.10 (95 percent CI, 0.00 to 0.83; p = 0.0309) and 0.11 (95 percent CI, 0.00 to 0.98; p = 0.047), respectively. CONCLUSIONS: ß-Blockers may be an effective alternative modality for preventing and treating keloids and hypertrophic scars. Large-scale multicenter prospective studies that use histology to diagnose scars and diagnose the postoperative scars at the most suitable period are needed to confirm the effectiveness of blockers for abnormal scars. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Canonical and noncanonical intraflagellar transport regulates craniofacial skeletal development.

The primary cilium is a cellular organelle that coordinates signaling pathways critical for cell proliferation, differentiation, survival, and homeostasis. Intraflagellar transport (IFT) plays a pivotal role in assembling primary cilia. Disruption and/or dysfunction of IFT components can cause multiple diseases, including skeletal dysplasia. However, the mechanism by which IFT regulates skeletogenesis remains elusive. Here, we show that a neural crest-specific deletion of intraflagellar transport 20 (Ift20) in mice compromises ciliogenesis and intracellular transport of collagen, which leads to osteopenia in the facial region. Whereas platelet-derived growth factor receptor alpha (PDGFRα) was present on the surface of primary cilia in wild-type osteoblasts, disruption of Ift20 down-regulated PDGFRα production, which caused suppression of PDGF-Akt signaling, resulting in decreased osteogenic proliferation and increased cell death. Although osteogenic differentiation in cranial neural crest (CNC)-derived cells occurred normally in Ift20-mutant cells, the process of mineralization was severely attenuated due to delayed secretion of type I collagen. In control osteoblasts, procollagen was easily transported from the endoplasmic reticulum (ER) to the Golgi apparatus. By contrast, despite having similar levels of collagen type 1 alpha 1 (Col1a1) expression, Ift20 mutants did not secrete procollagen because of dysfunctional ER-to-Golgi trafficking. These data suggest that in the multipotent stem cells of CNCs, IFT20 is indispensable for regulating not only ciliogenesis but also collagen intracellular trafficking. Our study introduces a unique perspective on the canonical and noncanonical functions of IFT20 in craniofacial skeletal development.

Constitutively active mutation of ACVR1 in oral epithelium causes submucous cleft palate in mice.

Cleft palate is among the most common human birth defects. Submucous cleft palate (SMCP) is a subgroup of cleft palate, which may be as common as overt cleft palate. Despite the high frequency of SMCP in humans, only recently have several animal models of SMCP begun to provide insight into the mechanisms by which SMCP develops. In this study, we show that enhanced BMP signaling through constitutively active ACVR1 in palatal epithelium causes submucous cleft palate in mice. In these mutant mice, the fusion of both palatal mesenchyme in hard palate, and muscles in soft palate were hampered by epithelial tissue. During palatal fusion, enhanced SMAD-dependent BMP signaling impaired cell death and altered cell proliferation rate in medial edge epithelium (MEE), and resulted in MEE persistence. At the molecular level, downregulation of ΔNp63, which is crucial for normal palatal fusion, in MEE cells was impaired, leading to a reduction in caspase-3 activation. Our study provides a new insight into the etiology of SMCP caused by augmented BMP signaling.

Regeneration of elastic fibers by three-dimensional culture on a collagen scaffold and the addition of latent TGF-ß binding protein 4 to improve elastic matrix deposition.

The objective of this study was to investigate the effects of latent TGF-ß binding protein 4 (LTBP-4) on elastic fiber regeneration in three-dimensional cultures of human dermal fibroblasts (HDFs). Appropriate collagen scaffold for elastic fiber regeneration was also examined. Collagen sponges cross-linked at 120 °C and composed of small pores (25 µm on average) was favorable for elastic fiber regeneration by HDFs. Addition of LTBP-4, followed by culture for 21 days, accelerated elastic fiber accumulation within the scaffolds. Conditioned scaffolds containing either HDFs or LTBP-4-built mature elastic fibers were implanted between the dermis and the cutaneous muscle of mice. The combined use of HDFs and LTBP-4 resulted in thicker tissues containing elastic fibers. These results indicate that weakly cross-linked collagen sponges can be used as scaffolds for regenerating elastic fibers both in vitro and in vivo, and that the addition of LTBP-4 accelerates the deposition of both elastin and fibrillin-1, and increases cell proliferation. These techniques may be useful for generating cutaneous or cardiovascular tissue equivalents; furthermore, they may serve as a useful method for the three-dimensional analyses of drugs used to treat skin diseases or to examine the microstructure of elastin networks.

Fibulin-5 deficiency causes developmental defect of premaxillary bone in mice.

Craniofacial sutures govern the shape of the craniofacial skeleton during postnatal development. The differentiation of suture mesenchymal cells to osteoblasts is precisely regulated in part by signaling through cell surface receptors that interact with extracellular proteins. Here we report that fibulin-5, a key extracellular matrix protein, is important for craniofacial skeletal development in mice. Fibulin-5 is deposited as a fibrous matrix in cranial neural crest-derived mesenchymal tissues, including craniofacial sutures. Fibulin-5-null mice show decreased premaxillary bone outgrowth during postnatal stages. While premaxillo-maxillary suture mesenchymal cells in fibulin-5-null mice were capable of differentiating into osteoblasts, suture cells in mutant mice were less proliferative. Our study provides the first evidence that fibulin-5 is indispensable for the regulation of facial suture mesenchymal cell proliferation required for craniofacial skeletal morphogenesis.

SHP2-Deficiency in Chondrocytes Deforms Orofacial Cartilage and Ciliogenesis in Mice.

Congenital orofacial abnormalities are clinically seen in human syndromes with SHP2 germline mutations such as LEOPARD and Noonan syndrome. Recent studies demonstrate that SHP2-deficiency leads to skeletal abnormalities including scoliosis and cartilaginous benign tumor metachondromatosis, suggesting that growth plate cartilage is a key tissue regulated by SHP2. The role and cellular mechanism of SHP2 in the orofacial cartilage, however, remains unknown. Here, we investigated the postnatal craniofacial development by inducible disruption of Shp2 in chondrocytes. Shp2 conditional knockout (cKO) mice displayed severe deformity of the mandibular condyle accompanied by disorganized, expanded cartilage in the trabecular bone region, enhanced type X collagen, and reduced Erk production. Interestingly, the length of primary cilia, an antenna like organelle sensing environmental signaling, was significantly shortened, and the number of primary cilia was reduced in the cKO mice. The expression levels of intraflagellar transports (IFTs), essential molecules in the assembly and function of primary cilia, were significantly decreased. Taken together, lack of Shp2 in orofacial cartilage led to severe defects of ciliogenesis through IFT reduction, resulting in mandibular condyle malformation and cartilaginous expansion. Our study provides new insights into the molecular pathogenesis of SHP2-deficiency in cartilage and helps to understand orofacial and skeletal manifestations seen in patients with SHP2 mutations.

Latent TGF-ß binding protein-2 is essential for the development of ciliary zonule microfibrils.

Latent TGF-ß-binding protein-2 (LTBP-2) is an extracellular matrix protein associated with microfibrils. Homozygous mutations in LTBP2 have been found in humans with genetic eye diseases such as congenital glaucoma and microspherophakia, indicating a critical role of the protein in eye development, although the function of LTBP-2 in vivo has not been well understood. In this study, we explore the in vivo function of LTBP-2 by generating Ltbp2(-/-) mice. Ltbp2(-/-) mice survived to adulthood but developed lens luxation caused by compromised ciliary zonule formation without a typical phenotype related to glaucoma, suggesting that LTBP-2 deficiency primarily causes lens dislocation but not glaucoma. The suppression of LTBP2 expression in cultured human ciliary epithelial cells by siRNA disrupted the formation of the microfibril meshwork by the cells. Supplementation of recombinant LTBP-2 in culture medium not only rescued the microfibril meshwork formation in LTBP2-suppressed ciliary epithelial cells but also restored unfragmented and bundled ciliary zonules in Ltbp2(-/-) mouse eyes under organ culture. Although several reported human mutant LTBP-2 proteins retain normal domain structure and keep the fibrillin-1-binding site intact, none of these mutant proteins were secreted from their producing cells, suggesting secretion arrest occurred to the LTBP-2 mutants owing to conformational alteration. The findings of this study suggest that LTBP-2 is an essential component for the formation of microfibril bundles in ciliary zonules.

Latent TGF-ß binding protein 4 promotes elastic fiber assembly by interacting with fibulin-5.

Elastic fiber assembly requires deposition of elastin monomers onto microfibrils, the mechanism of which is incompletely understood. Here we show that latent TGF-ß binding protein 4 (LTBP-4) potentiates formation of elastic fibers through interacting with fibulin-5, a tropoelastin-binding protein necessary for elastogenesis. Decreased expression of LTBP-4 in human dermal fibroblast cells by siRNA treatment abolished the linear deposition of fibulin-5 and tropoelastin on microfibrils. It is notable that the addition of recombinant LTBP-4 to cell culture medium promoted elastin deposition on microfibrils without changing the expression of elastic fiber components. This elastogenic property of LTBP-4 is independent of bound TGF-ß because TGF-ß-free recombinant LTBP-4 was as potent an elastogenic inducer as TGF-ß-bound recombinant LTBP-4. Without LTBP-4, fibulin-5 and tropoelastin deposition was discontinuous and punctate in vitro and in vivo. These data suggest a unique function for LTBP-4 during elastic fibrogenesis, making it a potential therapeutic target for elastic fiber regeneration.

Fibulin-4 conducts proper elastogenesis via interaction with cross-linking enzyme lysyl oxidase.

Great arteries, as well as lungs and skin, contain elastic fibers as important components to maintain their physiological functions. Although recent studies have revealed that a glycoprotein fibulin-4 (FBLN4) is indispensable for the assembly of mature elastic fibers, it remains to be elucidated how FBLN4 takes part in elastogenesis. Here, we report a dose-dependent requirement for FBLN4 in the development of the elastic fibers in arteries, and a specific role of FBLN4 in recruiting the elastin-cross-linking enzyme, lysyl oxidase (LOX). Reduced expression of Fbln4, which was achieved with a smooth muscle-specific Cre-mediated gene deletion, caused arterial stiffness. Electron-microscopic examination revealed disorganized thick elastic laminae with aberrant deposition of elastin. Aneurysmal dilation of the ascending aorta was found when the Fbln4 expression level was reduced to an even lower level, whereas systemic Fbln4 null mice died perinatally from rupture of the diaphragm. We also found a specific interaction between FBLN4 and the propeptide of LOX, which efficiently promotes assembly of LOX onto tropoelastin. These data suggest a mechanism of elastogenesis, in which a sufficient amount of FBLN4 is essential for tethering LOX to tropoelastin to facilitate cross-linking.

Interosseous membrane of the forearm: length change of ligaments during forearm rotation.

PURPOSE: An earlier anatomic study described five ligamentous components in the interosseous membrane of the forearm (central band, accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord) and provided their precise location of attachment. In the present study, we investigated in vivo length changes of these five ligaments during forearm rotation to understand the function of each ligament. METHODS: We acquired computed tomographies of nine forearms from seven healthy volunteers for 3 rotation positions: maximum pronation, neutral position, and maximum supination. We created 3-dimensional models of the radius, ulna, and the 5 ligaments by combining osseous images and anatomic data of ligament attachment. We calculated 3-dimensional ligament lengths between attachments during forearm rotation using a markerless bone registration technique. We also examined relationships between the axis of forearm rotation and each ligament. RESULTS: The distal 3 ligaments (central band, accessory band, and distal oblique bundle) had little change in length during forearm rotation, with their ulnar attachments located almost on the axis of forearm rotation. The 2 proximal ligaments (proximal oblique cord and dorsal oblique accessory cord) changed substantially in length, with their attachments out of the course of the axis. CONCLUSIONS: The distal 3 ligaments of the interosseous membrane are essentially isometric stabilizers of the forearm. The distal oblique bundle in the distal membranous portion may stabilize the distal radioulnar joint in 40% of human subjects who have this ligament.

Interosseous membrane of the forearm: an anatomical study of ligament attachment locations.

PURPOSE: The interosseous membrane (IOM) of the forearm is a stout ligamentous complex that reportedly comprises several ligamentous components. The purpose of this cadaveric study was to define all IOM ligaments and to clarify the precise attachment locations. METHODS: Thirty forearms from 15 embalmed cadavers were used. After dissection, all IOM ligaments were identified, and attachments were measured from the tip of the radial styloid or the ulnar head. Attachment locations were represented as a percentage of total bone length from the distal end of the radius or ulna. RESULTS: The IOM included 5 kinds of ligaments: central band, accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord. The most distal and proximal ends of the radial origin of the central band were 53% and 64% of total radial length from the tip of the radial styloid, whereas those of the ulnar insertion were 29% and 44% of total ulnar length from the ulnar head. The center point of the radial origin and ulnar insertion of the accessory band were 37% and 23%, respectively. The center points of the ulnar origins and radial insertions were 15% and 10% for the distal oblique bundle; 80% and 79% for the proximal oblique cord; and 64% and 62% for the dorsal oblique accessory cord, respectively. CONCLUSIONS: The present study clarified precise attachment locations of all representative IOM ligaments. This information will be useful in planning proper graft placement in ligament reconstruction surgery and for future biomechanics research into the function of the IOM ligaments.

Apocrine adenocarcinoma of the eyelid with aggressive biological behavior: report of a case.

A case of apocrine adenocarcinoma of the eyelid that showed unusually aggressive biological behavior is reported. The patient was a 57-year-old man who complained of discomfort and excessive lacrimation of the left eye. A subcutaneous tumor measuring 2.5 cm was found at the medial canthus of the upper eyelid, and a plica-like subconjunctival spread was noted in the lacrimal caruncle. Invasion into the extraocular muscles and metastasis to the cervical lymph nodes and bone were already present at the time of initial presentation. Histopathologically, the tumor showed features of poorly differentiated adenocarcinoma, and polygonal tumor cells had large, hyperchromatic nuclei with prominent nucleoli and abundant eosinophilic cytoplasm. The formation of ductal structures was found occasionally. The differentiation of the tumor cells towards the apocrine gland was corroborated by immunohistochemistry using monoclonal antibodies GCDFP-15 and B72.3. The histogenesis and pathological differential diagnosis are discussed briefly, and the tumor was considered to have originated in the Moll's gland in the eyelid. This case emphasizes that apocrine adenocarcinomas of the ocular region have the potential for aggressive biological behavior, including distant metastasis.