Wound Healing & Limb Salvage - New Jersey Center for · PDF file · 2007-07-09Wound...

Wound Healing & LimbWound Healing & LimbSalvageSalvage

Dr. Harold BremThe Wound Healing Program

Columbia University Medical CenterNovember 8, 2006

NJ Center for Biomaterials Institute:Wound and Limb Salvage Program

Identifying the Problem of Limb Loss Healing Traumatic Wounds Utilizing Tissue Engineering to Prevent Limb Loss WEMR: Telemedicine to Accelerate Closure Data Bank for Traumatic Wounds Future

New Modalities: Sustained Release Angiogenesis Human Cell Bank Molecular Basis of Healing Limb Regeneration

February 12, 2006

The Wounded; Healing, With New Limbs and Fragile Dreams

By JULIET MACUR; Correction AppendedIt was a victory for Lance Cpl. Matthew Schilling to walk into the upper gallery of the House of Representatives onJan. 31 for the State of the Union address. He wore his dress blues and a prosthetic leg. Five months earlier, he

had been carried on a stretcher, wounded and bleeding, into a hospital in Iraq after a roadside bomb exploded 10feet from him…. The blast tore through his right foot and calf……Corporal Schilling's Marine Corps unit and a victimof the same blast, Lance Cpl. Mark Beyers, wheeled up to him at the Walter Reed physical therapy clinic. Corporal

Beyers's right arm and leg were amputated in Iraq . Since Aug. 26, when they were wounded, the two marines eachhave endured some 20 operations in three countries. Charting their care over the ensuing months, beginning justhours after the blast, has revealed a journey of medical setbacks and emotional turmoil. Among the more than ….About an hour later, Corporals Schilling and Beyers were in surgery at the nearby Al Asad Military Base. It was the

first of 13 operations they would endure in eight days, during stays at five hospitals in three countries. A doctoramputated Corporal Schilling's right leg below the knee. Corporal Beyers, with severe lung injuries, was in worse

shape. Doctors amputated his right lower leg and his entire right arm, including the shoulder; shrapnel haddestroyed his shoulder joint and just missed slicing his carotid artery, doctors said. For the next week he would bein an induced coma …After 19 operations and 63 days in hospitals, Corporal Beyers went home in October for a

visit..

…16,653 Americans wounded in Iraq are 387 amputees,including 62 who, like Corporal Beyers, have lost more than onelimb, said Lt. Col. Paul Pasquina, chief of physical medicine andrehabilitation at Walter Reed. The amputations, traumaticthough they are, are often accompanied by painfulcomplications. "It's not as easy as putting on even the mosthigh-tech prosthetic and just walking off," Colonel Pasquinasaid….

What is the amputation rate in battleinjuries?

163812.3Iraq2052833.4Vietnam

814771.4KoreanWar

714,9121.2WW II2726101.7WW IUnknown~50,00012Civil War

% multi-limbamputation

# amputeesRawpercentage

War

Potter BK, Scoville CR. Amputation Is Not Isolated: An Overview of the US Army Amputee Patient Care Program and Associated Amputee Injuries.

J Am Acad Orthop Surg. 2006 Oct;14(10):S188-90

441 limbs lost (337 lower extremity) in waron terrorism alone!

WHAT CAN BE DONE?WHAT CAN BE DONE?

Potter BK, Scoville CR. Amputation Is Not Isolated: An Overview of the US Army Amputee Patient Care Program and Associated Amputee Injuries.

J Am Acad Orthop Surg. 2006 Oct;14(10):S188-90

Wound Healing ProgramWound Healing Programat Columbia Universityat Columbia University

Dedicated Inpatient Unit: New YorkDedicated Inpatient Unit: New YorkPresbyterian HospitalPresbyterian Hospital

Outpatient Wound Center: Case ManagementOutpatient Wound Center: Case Management

Clinical Research, Mailman School of PublicClinical Research, Mailman School of PublicHealth: OutcomesHealth: Outcomes

Research Laboratory: College of PhysiciansResearch Laboratory: College of Physicians& Surgeons& Surgeons

Healing traumatic wounds : Could thishave been avoided?

Can a leg ulcer heal with humanCan a leg ulcer heal with humancell therapy ?cell therapy ?

Brem H, Gill K, Tarnovskaya A, Ehrlich HP, Carasa M, Weinberger S, Baskin-BeyE, Tomic-Canic M, Vladeck B.. Surgery Technology International. 2003; XI: 161-167

YES!

Ulcer healed at 7 weeks.

Brem H, Gill K, Tarnovskaya A, Ehrlich HP, Carasa M, Weinberger S, Baskin-Bey E, Tomic-Canic M, Vladeck B. Healing ofElderly Patients with Diabetic Foot Ulcers, Venous Stasis Ulcers, and Pressure Ulcers. Surgery TechnologyInternational. 2003; XI: 161-167

WoundWoundCareCare

ProviderProvider

PrimaryPrimaryCareCareMDMD

Leg Ulcer ProtocolLeg Ulcer ProtocolVenous ulcers are commonly on the ankle, but include any area below the knee that has + reflux (e.g. the foot)Venous ulcers are commonly on the ankle, but include any area below the knee that has + reflux (e.g. the foot)

Communication Medical RecordCommunication Medical Record

Laboratory TestsLaboratory TestsWeekly DigitalWeekly DigitalPhotography,Photography,

Objective Measurement Objective MeasurementTopical TherapyTopical Therapy Physical ExamPhysical Exam Venous RefluxVenous Reflux Arterial Brachial IndexArterial Brachial Index

Initial VisitInitial Visit

CBC with Manual DiffCBC with Manual DiffPlateletsPlatelets

Hemoglobin A1CHemoglobin A1CESRESR

PT/PTTPT/PTTLFTLFT’’ss

AlbuminAlbuminPrealbuminPrealbumin

NaNa++

KK++ClCl--

COCO22

BUNBUNCreatenineCreatenine

GlucoseGlucose 0.02.0

4.0

6.0

8.0

10.0

12.0

4/2

4/8

4/14

4/20

4/26 5/2

5/8

CellulitusCellulitus Or Or

Drainage* Drainage* Or Or

>2 months duration>2 months duration

(1) Evaluate(1) Evaluate(2) Treat(2) Treat

FungalFungalNailsNails

DebridementDebridement

PathologyPathology

Evaluate for:Evaluate for:(1) Tumor(1) Tumor(2) Infection(2) Infection(3) Necrosis(3) Necrosis(4) Scar(4) Scar

Deep CultureDeep Culture

++ ––AntibioticsAntibiotics

4-Layer Compression4-Layer Compression

No cellulitusNo cellulitusMinimal/decreased drainage*Minimal/decreased drainage*

<10% <10% ↓↓ area/2 weeks area/2 weeks

Bilayered Cellular Therapy Cell TherapyBilayered Cellular Therapy Cell Therapy

<10% <10% ↓↓ area/2 weeks area/2 weeks

Plastic TherapyPlastic Therapy

Skin graftSkin graftFlapFlap

Fibroblasts

Keratinocytes

(1) can pick up clot(1) can pick up clotin deep veinin deep vein(2) demonstrates(2) demonstratesblood flowing fromblood flowing fromdeep to superficialdeep to superficialveinvein(3) shows perforating veins(3) shows perforating veins

138 BRACHIAL 140IndexesL. THIGH

CALFANKLE-PTANKLE-DP

0.971.060.990.94

1.010.660.730.81

+-If ABI >1.2If ABI >1.2

Pulse Volume RecordingPulse Volume Recording

Vascular SurgeryVascular Surgery

If If ↓↓ or ABI <0.9 or ABI <0.9

(1) Vascular Consult(1) Vascular Consult(2) MRA Angiogram(2) MRA Angiogram(3) Angioplasty(3) Angioplasty(4) Stent Bypass(4) Stent Bypass

*Drainage is often a sign*Drainage is often a signof infection, in which caseof infection, in which casecompression is not advisable.compression is not advisable.

Brem H, Kirsner RS, Falanga V. Am J Surg 2004; 188:1-8

What is Cell Therapy?

cell therapy inPetri Dish

Liftedwith

Forceps

Saline Irrigation

KeratinocyteLayer

Fibroblast

What Quality Control is There toAssure the Cells Are Living?

Hematoxylin and eosin (H&E) stained is done as part ofquality assurance before shipping for use in a patient.

Note thekeratinocytes

Note thefibroblasts

Brem H, Young J, Tomic-Canic M, Isaacs C, Ehrlich, H.P. Clinical Efficacy and Mechanism of Bilayered Living Human SkinEquivalent in the Treatment of Diabetic Foot Ulcers. Surgery Technology International. 2003; XI: 23-31.

Use of Tissue Engineered Skin Already ShowsUse of Tissue Engineered Skin Already ShowsClinical Success in Promoting Wound HealingClinical Success in Promoting Wound Healing

Brem H, Balledux J, Sukkarieh T, Falanga V. Healing of Venous Ulcers of long Duration with a BilayeredLiving Skin Substitute: Results from a General Surgery and Dermatology Department. Dermatologic Surgery. 2001 Nov;27(11):915-9.

What is Clinical Presentation of the non-healingWhat is Clinical Presentation of the non-healingWound?Wound?

Initial presentation ofInitial presentation ofdiabetic foot ulcerdiabetic foot ulcer

Callous is indication forCallous is indication fordebridementdebridement

Appears healthy,Appears healthy,significant underminingsignificant undermining

Rapid healing with earlyRapid healing with earlytreatment after Celltreatment after Cell

therapytherapyBrem H, Sheehan P, Boulton AJM: Protocol for the treatment of diabetic foot ulcers. American Journal of Surgery.2004;187:1-10.

Can toe ulcers be a source ofCan toe ulcers be a source ofamputation?amputation?Figure 1A

Clinical Efficacy and Mechanism of Human Skin Equivalent in the Treatment of Diabetic Foot Ulcers

Harold Brem , MD; Jan Young, PhD ; Cary Isaacs , MS; Marjana Tomic -Canic , PhD ; and H. Paul Ehrlich , PhD

Non-neuropathic“DFU”

Immediate treatmentwith cell therapy

Early treatmentprevents amputation


What is the mechanism of celltherapy? Clue comes from wounds

with large deficits

Four Days After celltherapy

Healed at 49 Days

celltherapy

5 – 0 AbsorbableSuture

Brem H, Balledux J, Bloom T, Kerstein M, Hollier L: Healing of diabetic ulcers and pressure ulcers w+ith human skinequivalent: a new paradigm in wound healing. Archives of Surgery 2000;135:627-634.

Mechanism of Cell Therapy:Mechanism of Cell Therapy:Keratinocytes and Fibroblasts release atKeratinocytes and Fibroblasts release at

least 17 growth factorsleast 17 growth factors


: Looks “good”but

Physiologicallyimpaired

Sewing celltherapy to NewWound Edge

Application ofRedundant cell

therapy

Healed at 20Weeks

New EpithelialEdge

Sutured 1-mm innerWound Edge so

Keratinocytes arestimulated

Importance of protocol for FootUlcer x 17 years?

Is Amputation Necessary?

Tendon Tendon

Brem H, Tomic-Canic M, Tarnovskaya A, Gill K, Ehrlich HP, Carasa M, Weinberger S, Baskin-Bey E,Entero. Healing of Elderly Patients with Diabetic Foot Ulcers, Venous Stasis Ulcers, and Pressure

Ulcers. Surg Technol Int 2003;XI:161-167.

Do Co-morbidities Stop aDo Co-morbidities Stop aWound From Healing?Wound From Healing?

Brem H, Tomic-Canic M, Tarnovskaya A, Vladeck B. SurgTechnol Int 2003; 11:161-7

Healing rate of cell therapy incomplicated leg ulcers?

Age (years) Center A (n=32) Center B (n=18)

Wound Size (cm2)

Mean 39 ± 68

Median 1265

± 21

9

Wound Duration (years)Median (years)

Mean 8.2 ± 9.4

Median 57.6

± 7.1

4.2

Number of Applicatoins2 ± 1

Median 2 1.7

± 0.5

2

Time to Healing (days)Median 61

± 12

Median 5555

± 14

31

Dermatologic Surgery 2001, p. 915-921H. Brem, MD, Balledux J, Falanga V, et al

Can Telemedicine Accelerate WoundClosure: WEMR

What is the importance of the WoundWhat is the importance of the WoundElectronic Medical Record (WEMR) forElectronic Medical Record (WEMR) for

accurate data?accurate data?

How do you interpret data? Percentage of HealingHow do you interpret data? Percentage of HealingPatientsPatients

Protocol Only. Not Compliance Driven.Protocol Only. Not Compliance Driven.703 Wounds, 431 Patient Visits703 Wounds, 431 Patient Visits

Q/A Non Healing WoundsQ/A Non Healing Wounds

93.90%433016100382577914223118703JULYTOTALS

94.60%864217612213402814707_29_05

91.40%11742080592101212807_22_05

92.50%10113166912171412313407_15_05

94.20%84318837191312413907_08_05

96.10%6222574211371013115507_01_05

Percentage ofPercentage ofHEALINGHEALING

Non-Non-HealingHealingWoundWound

OtherOtherSurgSurgArtArtVSUVSUDFDFPU IVPU IVPU IIIPU IIIPU IIPU IIPU IPU IPUPUtotaltotal

NumberNumberofof

WoundsWoundsVisit DateVisit Date

What are the clinical signs of aWhat are the clinical signs of awound infection?wound infection?

8/6/068/6/06 8/9/068/9/06

0

50,000

100,000

150,000

200,000

250,000

Hospital Acquired

Pressure Ulcers

Community Acquired

Pressure Ulcers

Co

st

($)

PublishedAverage Costs

Actual chargesdirectly relatedto HospitalStage IVpressure ulcers

How much does a non healing woundHow much does a non healing woundcost? The James Peters VA experiencecost? The James Peters VA experience

Brem H, Vladeck B, Nierman D, et al. Wound Repair and Regeneration 2001

Can large ulcers heal?Can large ulcers heal?

0

1

2

3

4

5

6

7

8

9

10

10/12/0110/28/0111/13/0111/29/0112/15/01

Length

Width

Depth

Area

1. Zimny S, Schatz H, Pfohl M. Exp Clin Endocrinol Diabetes 2004; 112:191-42. Kantor J, Margolis DJ. Arch Dermatol 1998; 134:1571-4

Demographics:Demographics:145 Consecutive Hospitalized Patients145 Consecutive Hospitalized Patients

Institutional Review BoardInstitutional Review Boardconsent to measure rate ofconsent to measure rate ofhealing and take photographshealing and take photographs

Age: 62.52 yearAge: 62.52 year Albumin 2.46 Albumin 2.46 ±± 0.58 g/dl0.58 g/dl Prealbumin 14.56 Prealbumin 14.56 ±± 6.92 mg/dl 6.92 mg/dl

Wallenstein S, Brem H. Am J Surg 2004; 188:73-8

ALL PATIENTS (n = 130)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8

Time in Weeks

Op

en

Wo

un

d A

rea

Healing of Pressure UlcersHealing of Pressure Ulcers

145 consecutive pressure ulcers treated

All Patients (n=145)

Wallenstein S, Brem H. Am J Surg 2004; 188:73-8

What are theWhat are theexpected healing rates?expected healing rates?

Diabetic foot ulcers Diabetic foot ulcers - - 100%100% of diabetic foot of diabetic footulcers will heal in absence of ischemia andulcers will heal in absence of ischemia andosteomyelitisosteomyelitis

Venous ulcers Venous ulcers - - 100%100% healing of venous ulcers healing of venous ulcersless than a year duration; less than a year duration; 78%78% healing of venous healing of venousulcers greater than a year durationulcers greater than a year duration

Pressure Ulcer Pressure Ulcer - - PreventPrevent stage IV; stage IV; 100%100% healing healingstages 2 and 3stages 2 and 3

Future: Can we make blood vesselsgrow in wounds? VEGF

Figure 2

Adenovirus Delivery System

Mechanical properties of healing wounds areMechanical properties of healing wounds aremeasured by tensile strengthmeasured by tensile strength

Human cell bank

Through partnership with Coriell Cell Bank. All cellThrough partnership with Coriell Cell Bank. All cellcultures are grown and frozen in antibiotic-free mediacultures are grown and frozen in antibiotic-free mediato aid in the detection and prevention of contamination.to aid in the detection and prevention of contamination.

Cultures are tested and found free of mycoplasma,Cultures are tested and found free of mycoplasma,bacteria, and fungi during expansion, at the time ofbacteria, and fungi during expansion, at the time offrozen storage, and after recovery of stock forfrozen storage, and after recovery of stock fordistribution from liquid nitrogen.distribution from liquid nitrogen.

1. Molecular tools allow for purification and isolation of1. Molecular tools allow for purification and isolation ofEpidermal Stem Cells from which one can recreate fullyEpidermal Stem Cells from which one can recreate fullydifferentiated epidermisdifferentiated epidermis

Morasso MI and Tomic-Canic, M. Biol Cell. 2005Morasso MI and Tomic-Canic, M. Biol Cell. 200597(3):173-83.97(3):173-83.

How can we grow skin ?How can we grow skin ?

Stem Cell Stem Cell

+ Niche + Niche Transit Transit Amplifying Amplifying

CellsCells

Differentiating Differentiating CellsCells EpidermisEpidermis

Stem Cell Stem Cell

+ Niche + Niche Transit Transit Amplifying Amplifying

CellsCells

Differentiating Differentiating CellsCells EpidermisEpidermisEpidermisEpidermis

BulgeBulge

ORSORS

IRSIRS

Dermal Dermal papillapapilla

BulgeBulge

ORSORS

IRSIRS


BulgeBulge

ORSORS

IRSIRS


3. Epidermal stem cells (ESC) can be genetically3. Epidermal stem cells (ESC) can be geneticallyengineered to sustain persistent expression of a transgeneengineered to sustain persistent expression of a transgenein tissue engineered skinin tissue engineered skin

OpportunitiesOpportunities

Cultured ESC transduced with b-galgene sustain its expression inxenograft for more than a year

Ghazizadeh S and Taichman LB : EMBO J (2001) 20, 1215Ghazizadeh S and Taichman LB : EMBO J (2001) 20, 1215––1222; 1222; J Invest Dermatol. (2005) 124(2):367-72 J Invest Dermatol. (2005) 124(2):367-72

Cell RepositoryCell RepositoryProtocolProtocol

Human Skin Equivalent (HSE) Reconstructed inHuman Skin Equivalent (HSE) Reconstructed invitro from Normal Human Primary Keratinocytesvitro from Normal Human Primary Keratinocytes

and Fibroblasts Heals in a Similar Manner toand Fibroblasts Heals in a Similar Manner toHuman SkinHuman Skin

Day2

Day4

Day6

2424hrshrs

4848hrshrs

7272hrshrs

HSEHSE Normal HumanNormal HumanSkinSkin

What is the Molecular Basis of Healing?

UntreatedUntreated Wound HealingWound HealingInhibitor GCInhibitor GC

CHRONIC ULCERCHRONIC ULCER

c-myc IS INDUCED IN NON HEALING WOUNDSc-myc IS INDUCED IN NON HEALING WOUNDS

Stojadinovic O, Brem H, Vouthounis C, Lee B, Fallon J, Stallcup M, Merchant A, Galiano RD, Tomic-Canic M. Molecularpathogenesis of chronic wounds: the role of beta-catenin and c-myc in the inhibition of epithelialization and wound

healing.Am J Pathol. 2005 Jul;167(1):59-69.

Patient3

Gene ExpressionProfiles

Location

Patient1

Patient2

Identification of the Chronic Wound TranscriptomeIdentification of the Chronic Wound Transcriptome

201645_at 1.62 2.01 1.59 2.29 2.25 1.39 1.72 1.36 1.95 1.93 Adhesion

201561_s_at -2.34 -2.26 -2.06 -1.61 -2.12 -1.72 -1.66 -1.51 -1.18 -1.56 Adhesion

201681_s_at -1.90 -1.53 -1.36 -1.39 -1.54 -1.96 -1.59 -1.41 -1.44 -1.60 Adhesion

213369_at -9.14 -2.99 -4.15 -4.67 -5.35 -5.59 -1.83 -2.54 -2.85 -3.27 Adhesion, cadherin

208153_s_at -2.46 -2.11 -2.50 -2.00 -2.51 -2.00 -1.72 -2.03 -1.62 -2.04 Adhesion, cadherin



204750_s_at 12.77 3.99 8.96 5.41 13.93 5.38 1.68 3.78 2.28 5.87 Adhesion, desmosomal

207324_s_at -61.89 -2.80 -6.70 -1.33 -3.31 -52.50 -2.37 -5.69 -1.13 -2.81 Adhesion, desmosomal

211075_s_at 1.73 1.21 1.96 1.58 2.09 1.57 1.10 1.77 1.44 1.90 Adhesion, integrin

204455_at -1.78 -1.87 -2.29 -1.37 -1.14 -2.13 -2.22 -2.73 -1.63 -1.36 Adhesion, integrin

210869_s_at 3.45 1.84 2.22 2.89 2.41 2.87 1.53 1.84 2.40 2.00 Adhesion, junctional


201615_x_at 2.84 1.31 1.99 2.42 1.67 2.67 1.23 1.86 2.27 1.57 Adhesion, junctional

205490_x_at -2.03 -2.09 -1.83 -2.30 -1.46 -1.79 -1.85 -1.61 -2.03 -1.28 Adhesion, junctional

201470_at 1.91 2.24 3.12 1.55 2.06 1.67 1.96 2.73 1.36 1.80 Antioxidant

202967_at -3.13 -1.93 -2.48 -1.92 -2.27 -3.21 -1.98 -2.55 -1.97 -2.33 Antioxidant

201427_s_at -1.66 -1.61 -3.85 -1.62 -3.20 -1.55 -1.50 -3.59 -1.51 -2.98 Antioxidant

204168_at -2.57 -1.94 -2.14 -1.81 -2.22 -1.85 -1.39 -1.53 -1.30 -1.59 Antioxidant

209276_s_at -2.60 -1.53 -3.26 -1.09 -3.43 -4.62 -2.72 -5.80 -1.94 -6.10 Antioxidant

201432_at -2.41 -1.99 -2.83 -1.32 -1.71 -2.05 -1.69 -2.41 -1.12 -1.45 Antioxidant

202831_at 1.21 -1.25 -2.31 -2.31 -2.94 -1.11 -1.69 -3.11 -3.11 -3.97 Antioxidant

206662_at -2.32 -1.11 -2.24 -1.34 -2.85 -3.08 -1.48 -2.98 -1.78 -3.79 Antioxidant

211922_s_at -1.93 -2.25 -3.20 1.06 -1.54 -2.54 -2.95 -4.20 -1.24 -2.02 Antioxidant

218856_at 2.94 2.23 2.30 1.96 2.23 3.14 2.38 2.45 2.09 2.38 Apoptosis

209230_s_at -4.09 -1.94 -2.97 -1.52 -2.56 -3.19 -1.51 -2.32 -1.19 -1.99 Apoptosis

212593_s_at -3.34 -2.03 -3.46 -2.03 -3.53 -2.16 -1.32 -2.24 -1.31 -2.28 Apoptosis

204004_at -1.61 -3.21 -3.61 -1.06 -1.48 -1.86 -3.71 -4.17 -1.22 -1.70 Apoptosis

201631_s_at 3.48 2.54 3.61 1.71 4.01 4.32 3.16 4.49 2.13 4.99 Apoptosis inhibitor

202037_s_at -5.35 -2.69 -4.12 -1.78 -3.51 -4.95 -2.49 -3.81 -1.65 -3.25 Apoptosis inhibitor

203528_at -3.36 -1.72 -4.34 -2.21 -3.04 -3.01 -1.54 -3.89 -1.99 -2.73 Apoptosis inhibitor

219454_at 7.37 7.23 1.81 2.15 1.09 6.79 6.67 1.66 1.98 1.00 Ca binding

61734_at 2.45 1.92 1.12 3.32 1.19 2.38 1.87 1.09 3.22 1.15 Ca binding

200755_s_at 3.04 1.43 1.34 3.20 1.93 2.65 1.25 1.17 2.79 1.68 Ca binding

219197_s_at -4.75 -4.34 -8.64 -2.90 -9.01 -3.74 -3.42 -6.81 -2.29 -7.10 Ca binding

202870_s_at 4.25 5.28 8.28 4.01 7.78 3.80 4.72 7.41 3.58 6.96 Cell cycle

204170_s_at 2.40 1.86 2.69 1.94 2.57 3.24 2.51 3.62 2.62 3.47 Cell cycle

204026_s_at 2.43 2.11 3.28 2.00 2.94 2.39 2.07 3.23 1.96 2.90 Cell cycle

202388_at 1.76 5.18 2.07 1.49 3.22 1.43 4.19 1.68 1.21 2.61 Cell cycle

201853_s_at 1.14 1.60 1.49 1.82 1.67 1.27 1.78 1.66 2.03 1.87 Cell cycle

201371_s_at -1.95 -2.04 -2.20 -2.06 -2.27 -1.77 -1.85 -2.00 -1.87 -2.07 Cell cycle

211382_s_at -4.35 -2.17 -3.35 -2.08 -2.63 -3.31 -1.65 -2.55 -1.58 -2.00 Cell cycle

201482_at 1.37 1.77 1.75 1.45 2.34 1.33 1.72 1.71 1.41 2.28 Cell cycle inhibitor

218346_s_at -3.58 -2.16 -4.65 -2.36 -3.88 -2.59 -1.57 -3.37 -1.71 -2.81 Cell cycle inhibitor


201236_s_at -1.77 -1.13 -2.54 -1.59 -1.79 -1.57 1.00 -2.25 -1.41 -1.58 Cell cycle inhibitor


201289_at 6.77 3.52 4.17 10.89 5.94 3.71 1.93 2.28 5.97 3.26 Cell growth, proliferation

201540_at -2.43 -1.90 -2.81 -1.60 -3.99 -1.55 -1.22 -1.80 -1.02 -2.56 Cell growth, proliferation

217733_s_at 2.48 1.95 2.58 1.75 2.30 2.24 1.76 2.33 1.58 2.07 Cytoskeletal


202565_s_at -1.22 -1.92 -1.84 -1.71 -1.84 -1.26 -1.98 -1.90 -1.76 -1.90 Cytoskeletal

204083_s_at 5.03 3.68 2.79 5.78 2.70 5.16 3.77 2.86 5.93 2.77 Cytoskeletal, actin

201954_at 2.19 2.78 3.10 1.84 2.38 1.60 2.03 2.26 1.34 1.74 Cytoskeletal, actin

211160_x_at 2.27 1.99 1.98 1.74 2.89 1.86 1.64 1.63 1.43 2.38 Cytoskeletal, actin

60528_at -3.46 -1.46 -1.80 -1.55 -1.75 -3.66 -1.54 -1.90 -1.64 -1.85 Cytoskeletal, actin

209046_s_at -1.47 -1.57 -1.81 -1.22 -1.51 -1.65 -1.76 -2.02 -1.37 -1.70 Cytoskeletal, actin


211776_s_at 5.89 2.13 4.06 1.74 3.04 4.11 1.49 2.84 1.21 2.12 Cytoskeletal, actin, membrane

200974_at 3.12 1.59 1.30 2.86 1.93 3.49 1.78 1.45 3.19 2.15 Cytoskeletal, actin, motility

200801_x_at 1.87 1.52 1.47 1.39 1.77 1.85 1.50 1.46 1.37 1.75 Cytoskeletal, actin, motility

205157_s_at 29.86 21.16 23.71 16.07 27.76 12.39 8.78 9.84 6.67 11.52 Cytoskeletal, keratin

209800_at 4.97 4.18 4.96 5.17 5.16 2.32 1.95 2.31 2.42 2.41 Cytoskeletal, keratin


214580_x_at 2.01 1.62 1.94 1.73 1.90 1.86 1.50 1.79 1.60 1.76 Cytoskeletal, keratin

204734_at -7.82 -8.99 -33.05 -7.68 -16.21 -4.84 -5.57 -20.47 -4.76 -10.04 Cytoskeletal, keratin


218963_s_at -11.65 -2.10 -4.35 -1.51 -3.03 -13.08 -2.36 -4.88 -1.70 -3.40 Cytoskeletal, keratin




214624_at -35.58 -2.87 -9.26 -42.03 -23.21 -25.44 -2.05 -6.62 -30.06 -16.60 Cytoskeletal, membrane

217918_at -1.32 -2.06 -1.52 -1.24 -1.50 -1.36 -2.12 -1.57 -1.27 -1.55 Cytoskeletal, motility

212372_at 2.58 1.26 1.34 1.88 1.20 3.07 1.51 1.61 2.25 1.43 Cytoskeletal, myosin

201976_s_at -1.63 -1.54 -2.85 -2.03 -1.76 -1.44 -1.36 -2.52 -1.79 -1.56 Cytoskeletal, myosin

203910_at -2.14 -1.95 -3.79 -1.57 -4.43 -2.52 -2.30 -4.46 -1.85 -5.21 Cytoskeletal, Rho,Cdc42 pathway

218062_x_at -2.68 -1.60 -1.85 -1.86 -2.22 -2.25 -1.34 -1.55 -1.56 -1.86 Cytoskeletal, Rho,Cdc42 pathway



213476_x_at 3.14 1.58 3.33 1.60 3.36 3.04 1.53 3.22 1.55 3.25 Cytoskeletal, tubulin

201645_at 1.62 2.01 1.59 2.29 2.25 1.39 1.72 1.36 1.95 1.93 Adhesion

201561_s_at -2.34 -2.26 -2.06 -1.61 -2.12 -1.72 -1.66 -1.51 -1.18 -1.56 Adhesion

201681_s_at -1.90 -1.53 -1.36 -1.39 -1.54 -1.96 -1.59 -1.41 -1.44 -1.60 Adhesion





204750_s_at 12.77 3.99 8.96 5.41 13.93 5.38 1.68 3.78 2.28 5.87 Adhesion, desmosomal

207324_s_at -61.89 -2.80 -6.70 -1.33 -3.31 -52.50 -2.37 -5.69 -1.13 -2.81 Adhesion, desmosomal

211075_s_at 1.73 1.21 1.96 1.58 2.09 1.57 1.10 1.77 1.44 1.90 Adhesion, integrin

204455_at -1.78 -1.87 -2.29 -1.37 -1.14 -2.13 -2.22 -2.73 -1.63 -1.36 Adhesion, integrin



201615_x_at 2.84 1.31 1.99 2.42 1.67 2.67 1.23 1.86 2.27 1.57 Adhesion, junctional

205490_x_at -2.03 -2.09 -1.83 -2.30 -1.46 -1.79 -1.85 -1.61 -2.03 -1.28 Adhesion, junctional

201470_at 1.91 2.24 3.12 1.55 2.06 1.67 1.96 2.73 1.36 1.80 Antioxidant

202967_at -3.13 -1.93 -2.48 -1.92 -2.27 -3.21 -1.98 -2.55 -1.97 -2.33 Antioxidant

201427_s_at -1.66 -1.61 -3.85 -1.62 -3.20 -1.55 -1.50 -3.59 -1.51 -2.98 Antioxidant

204168_at -2.57 -1.94 -2.14 -1.81 -2.22 -1.85 -1.39 -1.53 -1.30 -1.59 Antioxidant

209276_s_at -2.60 -1.53 -3.26 -1.09 -3.43 -4.62 -2.72 -5.80 -1.94 -6.10 Antioxidant

201432_at -2.41 -1.99 -2.83 -1.32 -1.71 -2.05 -1.69 -2.41 -1.12 -1.45 Antioxidant

202831_at 1.21 -1.25 -2.31 -2.31 -2.94 -1.11 -1.69 -3.11 -3.11 -3.97 Antioxidant

206662_at -2.32 -1.11 -2.24 -1.34 -2.85 -3.08 -1.48 -2.98 -1.78 -3.79 Antioxidant

211922_s_at -1.93 -2.25 -3.20 1.06 -1.54 -2.54 -2.95 -4.20 -1.24 -2.02 Antioxidant

218856_at 2.94 2.23 2.30 1.96 2.23 3.14 2.38 2.45 2.09 2.38 Apoptosis

209230_s_at -4.09 -1.94 -2.97 -1.52 -2.56 -3.19 -1.51 -2.32 -1.19 -1.99 Apoptosis

212593_s_at -3.34 -2.03 -3.46 -2.03 -3.53 -2.16 -1.32 -2.24 -1.31 -2.28 Apoptosis

204004_at -1.61 -3.21 -3.61 -1.06 -1.48 -1.86 -3.71 -4.17 -1.22 -1.70 Apoptosis

201631_s_at 3.48 2.54 3.61 1.71 4.01 4.32 3.16 4.49 2.13 4.99 Apoptosis inhibitor

202037_s_at -5.35 -2.69 -4.12 -1.78 -3.51 -4.95 -2.49 -3.81 -1.65 -3.25 Apoptosis inhibitor

203528_at -3.36 -1.72 -4.34 -2.21 -3.04 -3.01 -1.54 -3.89 -1.99 -2.73 Apoptosis inhibitor

219454_at 7.37 7.23 1.81 2.15 1.09 6.79 6.67 1.66 1.98 1.00 Ca binding

61734_at 2.45 1.92 1.12 3.32 1.19 2.38 1.87 1.09 3.22 1.15 Ca binding

200755_s_at 3.04 1.43 1.34 3.20 1.93 2.65 1.25 1.17 2.79 1.68 Ca binding

219197_s_at -4.75 -4.34 -8.64 -2.90 -9.01 -3.74 -3.42 -6.81 -2.29 -7.10 Ca binding

202870_s_at 4.25 5.28 8.28 4.01 7.78 3.80 4.72 7.41 3.58 6.96 Cell cycle

204170_s_at 2.40 1.86 2.69 1.94 2.57 3.24 2.51 3.62 2.62 3.47 Cell cycle

204026_s_at 2.43 2.11 3.28 2.00 2.94 2.39 2.07 3.23 1.96 2.90 Cell cycle

202388_at 1.76 5.18 2.07 1.49 3.22 1.43 4.19 1.68 1.21 2.61 Cell cycle

201853_s_at 1.14 1.60 1.49 1.82 1.67 1.27 1.78 1.66 2.03 1.87 Cell cycle

201371_s_at -1.95 -2.04 -2.20 -2.06 -2.27 -1.77 -1.85 -2.00 -1.87 -2.07 Cell cycle

211382_s_at -4.35 -2.17 -3.35 -2.08 -2.63 -3.31 -1.65 -2.55 -1.58 -2.00 Cell cycle

201482_at 1.37 1.77 1.75 1.45 2.34 1.33 1.72 1.71 1.41 2.28 Cell cycle inhibitor



201236_s_at -1.77 -1.13 -2.54 -1.59 -1.79 -1.57 1.00 -2.25 -1.41 -1.58 Cell cycle inhibitor


201289_at 6.77 3.52 4.17 10.89 5.94 3.71 1.93 2.28 5.97 3.26 Cell growth, proliferation

201540_at -2.43 -1.90 -2.81 -1.60 -3.99 -1.55 -1.22 -1.80 -1.02 -2.56 Cell growth, proliferation



202565_s_at -1.22 -1.92 -1.84 -1.71 -1.84 -1.26 -1.98 -1.90 -1.76 -1.90 Cytoskeletal

204083_s_at 5.03 3.68 2.79 5.78 2.70 5.16 3.77 2.86 5.93 2.77 Cytoskeletal, actin

201954_at 2.19 2.78 3.10 1.84 2.38 1.60 2.03 2.26 1.34 1.74 Cytoskeletal, actin

211160_x_at 2.27 1.99 1.98 1.74 2.89 1.86 1.64 1.63 1.43 2.38 Cytoskeletal, actin


209046_s_at -1.47 -1.57 -1.81 -1.22 -1.51 -1.65 -1.76 -2.02 -1.37 -1.70 Cytoskeletal, actin


211776_s_at 5.89 2.13 4.06 1.74 3.04 4.11 1.49 2.84 1.21 2.12 Cytoskeletal, actin, membrane

200974_at 3.12 1.59 1.30 2.86 1.93 3.49 1.78 1.45 3.19 2.15 Cytoskeletal, actin, motility

200801_x_at 1.87 1.52 1.47 1.39 1.77 1.85 1.50 1.46 1.37 1.75 Cytoskeletal, actin, motility

205157_s_at 29.86 21.16 23.71 16.07 27.76 12.39 8.78 9.84 6.67 11.52 Cytoskeletal, keratin



214580_x_at 2.01 1.62 1.94 1.73 1.90 1.86 1.50 1.79 1.60 1.76 Cytoskeletal, keratin







214624_at -35.58 -2.87 -9.26 -42.03 -23.21 -25.44 -2.05 -6.62 -30.06 -16.60 Cytoskeletal, membrane

217918_at -1.32 -2.06 -1.52 -1.24 -1.50 -1.36 -2.12 -1.57 -1.27 -1.55 Cytoskeletal, motility

212372_at 2.58 1.26 1.34 1.88 1.20 3.07 1.51 1.61 2.25 1.43 Cytoskeletal, myosin

201976_s_at -1.63 -1.54 -2.85 -2.03 -1.76 -1.44 -1.36 -2.52 -1.79 -1.56 Cytoskeletal, myosin


218062_x_at -2.68 -1.60 -1.85 -1.86 -2.22 -2.25 -1.34 -1.55 -1.56 -1.86 Cytoskeletal, Rho,Cdc42 pathway



213476_x_at 3.14 1.58 3.33 1.60 3.36 3.04 1.53 3.22 1.55 3.25 Cytoskeletal, tubulin

Location ALocation AControlControl Location BLocation B

Bench to Bedside: From Microarray Analyses toBench to Bedside: From Microarray Analyses toPatient BiopsiesPatient Biopsies

Location ALocation A Location BLocation B

Gene Expression ProfilesGene Expression Profiles

Location BLocation B

Location ALocation A

ControControll

Location ALocation A Location BLocation B

00hrs.hrs.

44hrs.hrs.

88hrs.hrs.

2424hrs.hrs.

0

20

40

60

80

100

120

Control Location A Location B% W

ou

nd

(s

cra

tch

) a

rea

0hrs 4hrs 8hrs 24hrs

VEGF

Cells from Location A do not Respond to WH StimuliCells from Location A do not Respond to WH Stimuliwith VEGFwith VEGF

Location BLocation B

Location ALocation A

Wound Healing (Days 1-2)Wound Healing (Days 1-2)

De-differentiation (Days 3-12)De-differentiation (Days 3-12)

Blastema formation (Days 13-21)Blastema formation (Days 13-21)

Re-differentiationRe-differentiation& Pattern& PatternFormation (DaysFormation (Days22-40)22-40)

Amphibian LimbAmphibian LimbRegenerationRegeneration

Amphibians

Limb Regeneration

Humans

??

Human LimbRegeneration

1. Healing Veterans’ wounds with current therapy2. Education3. Telemedicine4. New Delivery systems :cells, antibiotics5. Focus on developing tissue engineered5. Focus on developing tissue engineered

components comparable to human tissue: Skin,components comparable to human tissue: Skin,blood vessels, neurons, cartilage, bone,blood vessels, neurons, cartilage, bone,muscles.muscles.

Wound Healing & Limb Salvage - New Jersey Center for · PDF file · 2007-07-09Wound...

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