BACKGROUND:Our previous study showed that electroacupuncture (EA) increases the concentration and reorganisation of collagen in a rat model of tendon healing. However, the ultrastructure of collagen fibrils after acupuncture is unknown.

OBJECTIVES:To assess the effect of acupuncture protocols on the ultrastructure of collagen fibrils during tendon healing.

METHODS:Sixty-four rats were divided into the following groups: non-tenotomised (normal group), tenotomised (teno group), tenotomised and subjected to manual acupuncture at ST36 (ST36 group), BL57 (BL57 group) and ST36+BL57 (SB group) and EA at ST36+BL57 (EA group). The mass-average diameter (MAD) and the reorganisation of collagen fibril diameters were determined during the three phases of tendon healing (at 7, 14 and 21 days).

RESULTS:The MAD increased during the three phases of healing in the SB group. In the EA group, MAD increased initially but was reduced at day 21. The reorganisation of collagen fibrils was improved in the EA and SB groups at days 14 and 21, respectively. EA at day 21 appeared to reduce the reorganisation.

CONCLUSIONS:These results indicate that the use of EA up to day 14 and manual acupuncture at ST36+BL57 up to day 21 improve the ultrastructure of collagen fibrils, indicating strengthening of the tendon structure. These data suggest a potential role for acupuncture in rehabilitation protocols.

BACKGROUND:Our previous study showed that electroacupuncture (EA) increases the concentration and reorganisation of collagen in a rat model of tendon healing. However, the ultrastructure of collagen fibrils after acupuncture is unknown.

OBJECTIVES:To assess the effect of acupuncture protocols on the ultrastructure of collagen fibrils during tendon healing.

METHODS:Sixty-four rats were divided into the following groups: non-tenotomised (normal group), tenotomised (teno group), tenotomised and subjected to manual acupuncture at ST36 (ST36 group), BL57 (BL57 group) and ST36+BL57 (SB group) and EA at ST36+BL57 (EA group). The mass-average diameter (MAD) and the reorganisation of collagen fibril diameters were determined during the three phases of tendon healing (at 7, 14 and 21 days).

RESULTS:The MAD increased during the three phases of healing in the SB group. In the EA group, MAD increased initially but was reduced at day 21. The reorganisation of collagen fibrils was improved in the EA and SB groups at days 14 and 21, respectively. EA at day 21 appeared to reduce the reorganisation.

CONCLUSIONS:These results indicate that the use of EA up to day 14 and manual acupuncture at ST36+BL57 up to day 21 improve the ultrastructure of collagen fibrils, indicating strengthening of the tendon structure. These data suggest a potential role for acupuncture in rehabilitation protocols.

BACKGROUND:Aggressive, or even minimally aggressive, aesthetic interventions are almost inevitably followed by such events as discomfort, erythema, edema and hematoma formation which could lengthen patient downtime and represent a major problem to the surgeon. Recently, low level light therapy with light-emitting diodes (LED-LLLT) at 830 nm has attracted attention in wound healing indications for its anti-inflammatory effects and control of erythema, edema and bruising.

RATIONALE:The wavelength of 830 nm offers deep penetration into living biological tissue, including bone. A new-generation of 830 nm LEDs, based on those developed in the NASA Space Medicine Laboratory, has enabled the construction of planar array-based LED-LLLT systems with clinically useful irradiances. Irradiation with 830 nm energy has been shown in vitro and in vivo to increase the action potential of epidermal and dermal cells significantly. The response of the inflammatory stage cells is enhanced both in terms of function and trophic factor release, and fibroblasts demonstrate superior collagenesis and elastinogenesis.

CONCLUSIONS:A growing body of clinical evidence is showing that applying 830 nm LED-LLLT as soon as possible post-procedure, both invasive and noninvasive, successfully hastens the resolution of sequelae associated with patient downtime in addition to significantly speeding up frank wound healing. This article reviews that evidence, and attempts to show that 830 nm LED-LLLT delivers swift resolution of postoperative sequelae, minimizes downtime and enhances patient satisfaction.

OBJECTIVE: Hydroxyl radical and hypochlorite anion formed at the wound site from superoxide anion produced by activated polymorphonuclear neutrophils (PMNs) are considered important factors in impaired wound healing. Superoxide anion may also react with nitric oxide produced by macrophages to form peroxynitrite, a third strong oxidant that damages surrounding tissue. In order to select honey for use in wound-healing products, different samples were compared for their capacity to reduce levels of reactive oxygen species (ROS) in vitro. METHOD: Honey samples were tested in assays for inhibition of ROS production by activated human PMNs, antioxidant activity (scavenging of superoxide anion in a cell-free system) and inhibition of human complement (reducing levels of ROS by limiting formation of complement factors that attract and stimulate PMNs). For buckwheat honey (NewYork, US), moisture and free acid content were determined by refractive index measurement and potentiometric titration respectively. Honey constituents other than sugars were investigated by thin layer chromatography, using natural product reagent to detect phenolic compounds. Constituents with antioxidant properties were detected by spraying the chromatogram with DPPH. RESULTS: Although most honey samples were shown to be active, significant differences were observed, with the highly active honey exceeding the activities of samples with minor effects by factors of 4 to 30. Most pronounced activities were found for American buckwheat honey from the state of NewYork. Phenolic constituents of buckwheat honey were shown to have antioxidant activity. CONCLUSION: As buckwheat honey was most effective in reducing ROS levels, it was selected for use in wound-healing products. The major antioxidant properties in buckwheat honey derive from its phenolic constituents, which are present in relatively large amounts. Its phenolic compounds may also exert antibacterial activity, whereas its low pH and high free acid content may assist wound healing.

High concentration of ascorbic acid (vitamin C) has been found in corneal epithelium of various species. However, the specific functions and mechanisms of ascorbic acid in the repair of corneal epithelium are not clear. In this study, it was found that ascorbic acid accelerates corneal epithelial wound healing in vivo in mouse. In addition, ascorbic acid enhanced the stemness of cultured mouse corneal epithelial stem/progenitor cells (TKE2) in vitro, as shown by elevated clone formation ability and increased expression of stemness markers (especially p63 and SOX2). The contribution of ascorbic acid on the stemness enhancement was not dependent on the promotion of Akt phosphorylation, as concluded by using Akt inhibitor, nor was the stemness found to be dependent on the regulation of oxidative stress, as seen by the use of two other antioxidants (GMEE and NAC). However, ascorbic acid was found to promote extracellular matrix (ECM) production, and by using two collagen synthesis inhibitors (AzC and CIS), the increased expression of p63 and SOX2 by ascorbic acid was decreased by around 50%, showing that the increased stemness by ascorbic acid can be attributed to its regulation of ECM components. Moreover, the expression of p63 and SOX2 was elevated when TKE2 cells were cultured on collagen I coated plates, a situation that mimics the in vivo situation as collagen I is the main component in the corneal stroma. This study shows direct therapeutic benefits of ascorbic acid on corneal epithelial wound healing and provides new insights into the mechanisms involved.© Stem Cells Translational Medicine 2017.

OBJECTIVE:The aim of this preliminary study was to investigate whether ultrasound-guided high-intensity focused ultrasound (HIFU) can play a role in treating cesarean scar pregnancy (CSP).

STUDY DESIGN:Between November 2011 and December 2012, 16 patients with CSP were treated with ultrasound-guided HIFU ablation. Successful treatment was defined as disappearance of CSP mass, undetectable serum beta human chorionic gonadotropin, and no serious complications such as severe bleeding, uterine rupture, or hysterectomy.

RESULTS:All patients were successfully treated in the outpatient department and none required readmission. After 2-5 treatment sessions, the mean time for achieving undetectable serum beta human chorionic gonadotropin was 4.94± 2.32 weeks, and the mean time for CSP mass disappearance was 6.69 ± 3.36 weeks. Three patients experienced moderate abdominal pain that subsided in 1-2 days, and nine patients experienced mild vaginal bleeding (<30 mL) that resolved within 2-3 days. All 16 patients had recovered their normal menstruation function at follow-up.

CONCLUSION:These preliminary results suggest that ultrasound-guided HIFU ablation is a noninvasive, feasible, and effective method for the treatment of CSP.

In this single case study, the possible effect of low-level laser therapy (LLLT) was explored in the form of light emitting diodes on a chronic non-healing wound of 6 months duration in an 18-year-old male patient suffering from thalassemia intermedia. After irradiation, with LLLT dosage of 17.3 J/cm(2) for 8 min for 2 weeks duration followed by proliferative dosage of 8.65-4.33 J/cm(2) for 4 min from 3(rd) week to 6(th) week for 2 min along with antibiotics vancomycin (15 mg/kg) and a combination of amoxicillin and clavulanic acid (1 g). Proliferation of healthy granulation tissue was observed with decrease in score of pressure ulcer scale with complete re-epithelialization eventually LLLT irradiation could be a novel method of treatment for chronic non-healing wound in a thalassemia intermedia patient and an useful adjunct to standard care of treatment of pressure ulcers. It is postulated that LED irradiation augments wound healing with an early closure and no recurrence at the irradiated site even after follow up of 6 months.

Cutaneous wounds can present significant clinical problems because of abnormal healing after deep dermal damage. Despite technical advances in wound care, there are still unmet needs that result from inefficient treatment. In this study, we aimed to improve skin wound healing using a contractibility band with static magnetic field (SMF), termed a Magnetic band (Mb). To examine the effect of the Mb on wound healing, full-thickness 15 mm× 35 mm excision wounds were surgically created on the dorsum of rats. An elastic and contractile band (non-treatment), or one neodymium magnet (Nd-1) or two magnets with an elastic and contractile band (Nd-2) were topically applied to the wound daily and the wound size was measured from day 1 to 7after surgery. Nd-2 showed a significant (95%) reduction in the wound size at day 3. Histological analysis showed that pro-inflammatory cytokine levels were diminished by Nd-2, and granulation tissue and microvessels were increased compared with those in the sham group. During Mb-induced wound healing, apoptosis was significantly reduced and matrix remodeling-related factors were initially regulated. The results suggest that combination therapy comprising an SMF and an elastic and contractile band could be a promising tool to heal cutaneous wounds rapidly.

BACKGROUND:Venous leg ulcers (VLUs) are a health problem in clinical care. Several options can be employed as adjuvant to standard treatment.

OBJECTIVES:We have aimed to analyze the effect of standard ulcer care alone with high-frequency ultrasound (HFU) and MIST ultrasound therapy on VLUs.

MATERIAL AND METHODS:Ninety patients with VLUs were assigned into the standard treatment, HFU and MIST ultrasound groups. All groups received the standard wound care. In the ultrasound groups, HFU and MIST ultrasound therapy was administered to wounds 3 times per week until the wound healed. Time of complete wound healing was recorded. Wound size, pain, and edema were assessed at baseline and after 2 and 4 months. Also, patients were instructed to contact our clinic monthly, and recurrence of VLUs was recorded for 6 months after complete wound healing. The data was analyzed using a Student's t-test, ANOVA, c2, or Fisher's exact test. P<0.05 was considered significant.

RESULTS:Mean time duration of complete wound healing in the first, second and third groups was 8.13 (SD 1.40), 6.10 (SD 1.47) and 5.70 (SD 1.57) months, respectively (p<0.0001). Size of ulcer, mean degree of pain and edema in ultrasound therapy was decreased after the 4-month visit in comparison to the standard-treatment group (p=0.01, p<0.0001 and p<0.0001, respectively). Also, our results don't show any significant differences between groups in the recurrence of VLUs during a 6-month follow up after complete wound healing (p=0.37).

CONCLUSIONS:Our results in the present study show the significant effectiveness of ultrasound therapy in wound healing. Differences between the two ultrasound therapy groups were not statistically significant.

Oral mucositis (OM) induces severe pain and limits fundamental life behaviors such as eating, drinking, and talking for patients receiving chemotherapy or radiotherapy. In addition, through opportunistic microorganisms, OM frequently leads to systemic infection which then leads to prolonged hospitalization. Severe lesions often adversely affect curative effects in cancer cases. Therefore, the control of OM is important for oral health quality of life and prognosis. Low-level laser therapy (LLLT) and ozone may be useful to accelerate wound healing. In this study, 24 Sprague-Dawley rats were divided into three groups as control, ozone, and laser groups. All groups received 5-fluorouracil intraperitoneally and trauma to the mouth pouch with a needle. After the formation of OM in the mouth, the control group had no treatment; the ozone group was administered ozone, and the laser group, LLLT. Then, all groups were sacrificed and basic fibroblast growth factor (bFGF), transforming growth factor (TGF-β), and platelet-derived growth factor (PDGF) were evaluated in all groups. LLLT was determined to be statistically significantly more effective than ozone on FGF and PDGF. However, in respect of TGF-β, no statistically significant difference was observed between the groups. In conclusion, withinthe limitations of this study, LLLT is more effective than ozone. However, further studies on this subject are required.

Oral mucositis (OM) induces severe pain and limits fundamental life behaviors such as eating, drinking, and talking for patients receiving chemotherapy or radiotherapy. In addition, through opportunistic microorganisms, OM frequently leads to systemic infection which then leads to prolonged hospitalization. Severe lesions often adversely affect curative effects in cancer cases. Therefore, the control of OM is important for oral health quality of life and prognosis. Low-level laser therapy (LLLT) and ozone may be useful to accelerate wound healing. In this study, 24 Sprague-Dawley rats were divided into three groups as control, ozone, and laser groups. All groups received 5-fluorouracil intraperitoneally and trauma to the mouth pouch with a needle. After the formation of OM in the mouth, the control group had no treatment; the ozone group was administered ozone, and the laser group, LLLT. Then, all groups were sacrificed and basic fibroblast growth factor (bFGF), transforming growth factor (TGF-β), and platelet-derived growth factor (PDGF) were evaluated in all groups. LLLT was determined to be statistically significantly more effective than ozone on FGF and PDGF. However, in respect of TGF-β, no statistically significant difference was observed between the groups. In conclusion, withinthe limitations of this study, LLLT is more effective than ozone. However, further studies on this subject are required.

BACKGROUND: The management of diabetic foot ulcers remains a problem. A treatment modality that uses compressed air massage has been developed as a supplement to standard surgical and medical treatment. Compressed air massage is thought to improve local tissue oxygenation around ulcers. The aim of this study was to determine whether the addition of compressed air massage influences the rate of healing of diabetic ulcers. METHODS: Sixty consecutive patients with diabetes, admitted to one hospital for urgent surgical management of diabetic foot ulcers, were randomized into two groups. Both groups received standard medical and surgical management of their diabetes and ulcer. In addition, one group received 15-20 min of compressed air massage, at 1 bar pressure, daily, for 5 days a week, to the foot and the tissue around the ulcer. Healing time was calculated as the time from admission to the time of re-epithelialization. RESULTS: Fifty-seven patients completed the trial; 28 received compressed air massage. There was no difference in the mean age, Wagner score, ulcer size, pulse status, or peripheral sensation in the two groups. The time to healing in the compressed air massage group was significantly reduced: 58.1 +/- 22.3 days (95% confidence interval: 49.5-66.6) versus 82.7 +/- 30.7 days (95% confidence interval: 70.0-94.3) (P = 0.001). No adverse effects in response to compressed air massage were noted. CONCLUSIONS: The addition of compressed air massage to standard medical and surgical management of diabetic ulcers appears to enhance ulcer healing. Further studies with this new treatment modality are warranted.

PURPOSE:We evaluated the potential protective effects of Coenzyme Q10 (CoQ10) on human corneal cells and rabbit eyes after ultraviolet B (UVB) exposure and a model of wound healing in rabbit eyes after corneal epithelium removal.

METHODS:Human corneal epithelium cells (HCE) were exposed to a source of UVB radiation (312 nM) in the presence of different CoQ10 concentrations or vehicle. The mitochondrial function and cell survival were evaluated by means of 3-(4,5-dimethylthiazole-2-yl)2,5-diphenyl-tetrazolium (MTT) reduction and lactic dehydrogenase (LDH) release. Furthermore, quantitation of oxygen consumption and mitochondrial membrane potential were conducted. In vivo rabbit models were adopted to evaluate the effect of CoQ10 on UVB-induced conjunctival vessel hyperemia and corneal recovery after ethanol induced corneal lesion.

RESULTS:In UVB-exposed HCE cells, CoQ10 addition led to an increased survival rate and mitochondrial function. Furthermore, oxygen consumption was maintained at control levels and adenosine triphosphate (ATP) decline was completely prevented in the CoQ10-treated cells. Interestingly, in an in vivo model, CoQ10 was able dose-dependently to reduce UVB-induced vessel hyperemia. Finally, in a model of corneal epithelium removal, 12 hours from surgery, animals treated with CoQ10 showed a reduction of damaged area in respect to vehicle controls, which lasted until 48 hours.

CONCLUSIONS:We demonstrated that CoQ10 reduces corneal damages after UVB exposure in vivo and in vitro by preserving mitochondrial function. Also, for the first time to our knowledge we showed that the administration of CoQ10 after corneal epithelium removal promotes corneal wound healing.

Skin graft is a standard therapeutic technique in patients with deep ulcers, but managing donor site after grafting is very important. Although several modern dressings are available to enhance the comfort of donor site, using techniques that accelerate wound healing may enhance patient satisfaction. Low-level laser therapy (LLLT) has been used in several medical fields, including healing of diabetic, surgical, and pressure ulcers, but there is not any report of using this method for healing of donor site in burn patients. The protocols and informed consent were reviewed according to Medical Ethics Board of Shahid Beheshti University of Medical Sciences (IR.SBMU.REC.1394.363) and Iranian Registry of Clinical Trials (IRCT2016020226069N2). Eighteen donor sites in 11 patients with grade 3 burn ulcer were selected. Donor areas were divided into 2 parts, for laser irradiation and control randomly. Laser area was irradiated by a red, 655-nm laser light, 150 mW, 2 J/cm, on days 0 (immediately after surgery), 3, 5, and 7. Dressing and other therapeutic care for both sites were the same. The patients and the person who analyzed the results were blinded. The size of donor site reduced in both groups during the 7-day study period (P < 0.01) and this reduction was significantly greater in the laser group (P = 0.01). In the present study, for the first time, we evaluate the effects of LLLT on the healing process of donor site in burn patients. The results showed that local irradiation of red laser accelerates wound healing process significantly.

Low-level laser (light) therapy (LLLT) promotes wound healing, reduces pain and inflammation, and prevents tissue death. Studies have explored the effects of various radiant exposures on the effect of LLLT; however, studies of wavelength dependency in in vivo models are less common. In the present study, the healing effects of LLLT mediated by different wavelengths of light in the red and near-infrared (NIR) wavelength regions (635, 730, 810, and 980 nm) delivered at constant fluence (4 J/cm(2)) and fluence rate (10 mW/cm(2)) were evaluated in a mouse model of partial-thickness dermal abrasion. Wavelengths of 635 and 810 nm were found to be effective in promoting the healing of dermal abrasions. However, treatment using 730- and 980-nm wavelengths showed no sign of stimulated healing. Healing was maximally augmented in mice treated with an 810-nm wavelength, as evidenced by significant wound area reduction (p<0.05), enhanced collagen accumulation, and complete re-epithelialization as compared to other wavelengths and non-illuminated controls. Significant acceleration of re-epithelialization and cellular proliferation revealed by immunofluorescence staining for cytokeratin-14 and proliferating cell nuclear antigen (p<0.05) was evident in the 810-nm wavelength compared with other groups. Photobiomodulation mediated by red (635 nm) and NIR (810 nm) light suggests that the biological response of the wound tissue depends on the wavelength employed. The effectiveness of 810-nm wavelength agrees with previous publications and, together with the partial effectiveness of 635 nm and the ineffectiveness of 730 and 980 nm wavelengths, can be explained by the absorption spectrum of cytochrome c oxidase, the candidate mitochondrial chromophore in LLLT.

The aim of this study was to evaluate the effects of red laser, infrared, photodynamic therapy, and green light-emitting diode (LED) on the healing process of skin burns through clinical and histopathologic analysis in rats. For this, 100 animals were randomly divided into five groups: G1-untreated control (CTR), G2-red laser (LVER), G3-infrared (LINF), G4-photodynamic therapy (PDT), and G5-green LED. Burn was induced on the dorsum of the rat and the treatment of the experimental groups was red light (10 J/cm(2), 10 s, 40 mW, andλ660 nm), infrared (10 J/cm(2), 10 s, 40 mW, and λ780 nm), green LED irradiation (60 J/cm(2), 10 s, λ520, and 550 nm), and photodynamic therapy (10 J/cm(2), 40 mW, and λ660 nm), the latter combined with methylene blue photosensitizer at concentration 0.5 μg/mL. Applications were performed dailyuntil day prior to sacrifice of the animal at 3, 7, 14, and 21 days with intraperitoneal anesthetic overdose. The specimens collected were clinically examined and soon after processed and stained with hematoxylin-eosin and Picrosirius for analysis under light and polarized light microscopy, respectively. Animals treated with LVER, LINF, PDT (p < 0.001), and LED (p < 0.05) stimulated production and maturation of collagen, and increased the consumption of food and water compared to the CTR (p < 0.001). Laser λ660 nm and λ780 nm showed the largest wound reductions in all groups (p = 0.001). In conclusion, red laser, infrared, photodynamic therapy, and green LED favored the healing process of third-degree burns in rats.

The aim of this study was to evaluate the effects of red laser, infrared, photodynamic therapy, and green light-emitting diode (LED) on the healing process of skin burns through clinical and histopathologic analysis in rats. For this, 100 animals were randomly divided into five groups: G1-untreated control (CTR), G2-red laser (LVER), G3-infrared (LINF), G4-photodynamic therapy (PDT), and G5-green LED. Burn was induced on the dorsum of the rat and the treatment of the experimental groups was red light (10 J/cm(2), 10 s, 40 mW, andλ660 nm), infrared (10 J/cm(2), 10 s, 40 mW, and λ780 nm), green LED irradiation (60 J/cm(2), 10 s, λ520, and 550 nm), and photodynamic therapy (10 J/cm(2), 40 mW, and λ660 nm), the latter combined with methylene blue photosensitizer at concentration 0.5 μg/mL. Applications were performed dailyuntil day prior to sacrifice of the animal at 3, 7, 14, and 21 days with intraperitoneal anesthetic overdose. The specimens collected were clinically examined and soon after processed and stained with hematoxylin-eosin and Picrosirius for analysis under light and polarized light microscopy, respectively. Animals treated with LVER, LINF, PDT (p < 0.001), and LED (p < 0.05) stimulated production and maturation of collagen, and increased the consumption of food and water compared to the CTR (p < 0.001). Laser λ660 nm and λ780 nm showed the largest wound reductions in all groups (p = 0.001). In conclusion, red laser, infrared, photodynamic therapy, and green LED favored the healing process of third-degree burns in rats.

OBJECTIVE:Chronic wounds typically require several concurrent therapies, such as debridement, pressure offloading, and systemic and/or topical antibiotics. The aim of this study was to examine the efficacy of hyperbaric oxygen therapy (HBOT) towards reducing or eliminating bacterial biofilms in vitro and in vivo.

METHOD:Efficacy was determined using in vitro grown biofilms subjected directly to HBOT for 30, 60 and 90 minutes, followed by cell viability determination using propidium monoazide-polymerase chain reaction (PMA-PCR). The efficacy of HBOT in vivo was studied by searching our chronic patient wound database and comparing time-to-healing between patients who did and did not receive HBOT as part of their treatment.

RESULTS:In vitro data showed small but significant decreases in cell viability at the 30- and 90-minute time points in the HBOT group. The in vivo data showed reductions in bacterial load for patients who underwent HBOT, and ~1 week shorter treatment durations. Additionally, in patients' chronic wounds there was a considerable emergence of anaerobic bacteria and fungi between intermittent HBOT treatments.

CONCLUSION:The data demonstrate that HBOT does possess a certain degree of biofilm killing capability. Moreover, as an adjuvant to standard treatment, more favourable patient outcomes are achieved through a quicker time-to-healing which reduces the chance of complications. Furthermore, the data provided insights into biofilm adaptations to challenges presented by this treatment strategy which should be kept in mind when treating chronic wounds. Further studies will be necessary to evaluate the benefits and mechanisms of HBOT, not only for patients with chronic wounds but other chronic infections caused by bacterial biofilms.

PURPOSE OF REVIEW: This review evaluates the efficacy of vitamin supplementations for prevention and treatment of pressure ulcer and surgical wounds on the basis of recent clinical intervention studies. RECENT FINDINGS: Intervention studies show that an energy and protein-rich oral nutritional supplement providing high doses of vitamin C and zinc in combination with arginine may prevent the development of pressure ulcers. This measure seems to improve the healing of pressure ulcer, which is questionable for vitamin C alone. For surgical wounds, data from randomized controlled studies are scarce, but results on the use of vitamin C in combination with pantothenic acid are promising. SUMMARY: Considerable evidence suggests that supplementation of vitamin C together with zinc by an oral nutritional supplement rich in energy, protein and arginine may be an efficient tool for pressure ulcer healing in contrast to single vitamin C. The evidence for prevention of pressure ulcer by such an oral nutritional supplement is comparably low. This fits also for single vitamin C supplementation in the healing of surgical wounds. Further, well designed and well powered studies on the benefit of antioxidant vitamins for wound healing within a diet providing adequate energy and protein are necessary.

The calf muscles have been called the body's"second heart,"improving blood circulation when exercised, usually by walking. Structured exercise training (SET) increases calf muscle pump function, lower limb circulation, and walking capacity for those with limited ambulation due to peripheral arterial disease (PAD)1 or venous insufficiency.2 This resulted in the Centers for Medicare and Medicaid Services (CMS) decision to reimburse up to thirty-six 30- to 60-minute, properly supervised hospital outpatient or office-based SET sessions over 12 weeks to treat intermittent claudication for patients with PAD. Exercise improves acute wound healing in diabetic mice3 and healthy elderly humans,4 but insufficient evidence supports its healing efficacy on ischemic ulcers,1 venous leg ulcers (VLUs),5 and diabetic foot ulcers (DFUs).6 This month's Evidence Corner examines 2 recent randomized controlled trials (RCTs) testing the effects of foot exercises that activate calf muscles on chronic VLUs7 and DFUs.8.