Honey is a sticky solution which is made by worker honeybees. Nectar is a normal sweet material which is described as a plant exudation that is gathered by honeybees and combined with certain secretion for the purpose of ripening and maturation.1 The main source of honey is flower nectar which, after collection , is modified and stored in honeycombes in order to be used as nourishment for the young brood.2 Chronic wound treatment is expensive and complicated. It is estimated that 1% of the population of both the United Kingdom and United States have a chronic ulcer, in the company of wound treatment price in Britain only approximately about 1 billion pound per year. The chronic healing is always excruciating, malodorous gate for expansionist infection and a potential repository for antibiotic resistant bacteria.3
Its difficult for patients to endure chronic lesions for a long time and this could have effect on the patients quality of life, work prospects, relationships, and continual pain. Zumla and Lulat ( 1982 ) described that the ancient Egyptians remembered employment of honey in 500 of 900 remedies. Hippocrates recognized the worth of honey as a unit of the diet, mix it with vinegar for pain, water for thirst, and water with different other medical substances for acute fever.4
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There are many study conducted and shown successful result in several types of wounds. Chronic wounds are casing high incidence of hospital admission and the development of biofilms that inhabits the healing in this wounds. Pseudomonas argonosa one of the main bacteria that dalliances in the chronic wound healing. Manuka honey has approve to be the therapeutic treatment among the ether type of honey which inhabits the development of the biofilms in infected wounds.
In this study, I have compared between microtiter plate and Calgary plate and there effectiveness preventive and inhibition of manuka honey. I believe that they were many patients in Oman who have diabetic chronic wound and there are not getting good results for their cases which end them with imputative lamps. I have selected this topics because that the use of manuka honey will contribute enhancing the wound healing in chronic wounds.
Treatment of wounds using honey:
The medical letters on medicating wounds with honey has been consulted recently in expert wound-care journals, with a concentrate on the medical indication and the clinical face. In this stage, scientists are considered on the therapeutic effects notice when honey is taken as a wound dressing.5
There were many reports in the medical journals that show the different type of wounds has been treated successfully with honey: abrasions, fistula, amputations, foot ulcers in lepers, abscesses , infected wounds arising from arising from trauma, bed sores, large septic wounds, burns, burst abdominal wounds following caesarean delivery, leg ulcers, malignant ulcers, sickle cell ulcers, skin ulcers, cancrum, cervical ulcers, surgical wounds, chilblains, cracked nipples, cuts, tropical ulcers ,wounds to the abdominal wall and perineum, varicose ulcers, diabetic foot ulcers and other diabetic ulcers.5
Honey can generate a moist wound environment and can prevent or clear existing wound infections. Its can derided wounds and remove malodour, it reduces oedema and exudates, prevents and minimises hypertrophic scarring and hastens healing. Some honeys are available in the form of sterile product licensed for the use in wound care in Australia, Canada, the European Union, Hong Kong, New Zealand ant the USA.6
The type of honey which is normally used in the modern products is prepared specifically for wound management. It should be filtered, gamma irradiated and CE marked. The quantity of honey which can be used in the dressing is enough to cover the wound surface or fill the cavity or sinus, although It can overlap the wound margins. In the UK, wound treat honey is available in liquid form, in simple dressing form ( tulle or pad ) or in alginate dressings and the dressing may need to be changed daily initially until the level of exudates reduces with time the period between dressing changes can be extended.
PROPERTEES OF CHRONIC WOUNDS:
The process of acute wound healing has been divided into four steps: coagulation, inflammation, cell proliferation and repair of the matrix, and epithelialization and remodeling. The signs of an infected wound are : tumor, rubor, dolor, calor, and function laesa. Other standard have been suggested, like less transcutaneous oxygen tension ( TcPO2 ), presence of necrotic tissue, foul order, pan, wound break down, or simply lack of healing.
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The clinical endpoint for infection has been proposed: if Ë‚ 105 bacteria/g tissue are present, the wound is colonized whereas above 105 bacteria/g tissue it is infected.
The susceptibility of colonizing bacteria to generate themselves and proliferate in a biofilm due to the weak of successful antibiotic therapy. Chronic wounds divide into various groups such as venous leg ulcers, diabetic foot ulcers, and pressure ulcers. Each group has their specific principles for treatment based on current knowledge of pathogenesis. Venous leg ulcers are accelerate by malfunction of venous valves causing venous hypertension in the crural veins, raised pressure in capillaries, and edema. Venous pressure more than 45mmHg inevitably leads to development of a leg ulcer. The therapy of the venous leg ulcer is compression, which often heals the ulcer. Repetitive load of the neurophatic is the main cause of diabetic foot ulcer and usually ischemic foot and treatment is offloading and restoration of circulation. Pressure ulcers are produced by sustained or repetitive load on usually vulnerable areas such as the sciatic tuberculum, sacral region, heels, and shoulders in the immobilized patient. Medicament is pressure relief with discharge mattresses, cushion seats, and ambulation of the patient. Chronic wounds in the form of to be stuck in the inflammatory step characterized by a continuing influx of neutrophils (polymorphonuclear neutrophils [PMNs]) that lanch cytotoxic enzymes, free oxygen radicals, and inflammatory brokers that cause wide collateral harm to the host tissue.
The two responses cellular and humoral have a part in the inflammatory methed of chronic wounds. In the infection, (polymorphonuclear neutrophils [PMNs]) are detected in high amounts in chronic wounds. MMPs belong to a family of zincdependent endoproteinases that are involved in the degradation of extracellular matrix (ECM) components. They are maked by several different cells, for instance fibroblasts, macrophages, eosinophils, but in particular the PMNs. MMP production is stimulated by cytokines, growth factors, and cell-cell contact. The MMPs participate in the first stage of the wound-healing process, by throw devitalized tissue, and are therefore believed to play an important role in normal wound healing and remodeling. As for the repair stage, MMPs are important for angiogenesis, wound matrix contraction, migration of fibroblasts and keratinocytes, and epithelialization. However, many papers proposed that elevated levels of active MMPs impair wound healing. Consequently, wound care items have been developed that aim at relieving the supposedly disadvantage effects of elevated MMPs in order to promote healing. In especially, infections with P. aeruginosa show altered amount of MMPs and MMP-regulating cytokines. Additionally, there are rarely any reports on antibody evolution against P. aeruginosa, with specific reference to chronic wounds.16
Pseudomonas argonosa biofilm cells
Bacterial biofilms are polycellular communities in which cells are an integral component within an extracellular matrix at close vicinity to one another. Biofilms are after linked to solid surfaces but they converse to multicellular aggregates, flocks and grauls hanging in the aqueous phase in many habitats. It may produce foul, green-pigmented discharge and necrosis.7 Also they can be assimilation by single species or mixed species consortia.
They are some figure of definite features are required for the type of biofilm formation :
1 - Attachment to the involving particular agglutinant proteins.
2 - Cell to cell binding involving proteins,extra-cellular DNA and polysaccharide in order for the cells to resist the hydrodynamic forces.
3 - Cell motility to enable the cells to crawl on the surface.
The bulk of P.aeruginosa biofilm cells even at the early stage express a type that is recollecting of gene expression seen in the early stationary phase of planktonic cells by analysis based of transcriptomics. This would in part demonstrate the high tolerance to antibiotics since a lot of drugs are comparatively ineffective against slow or non-growing stationary cells. Furthermore quorum sensing ( QS ) regulated gene expression also contributes to biofilm tolerance. Davies et al. ( 1998) explained that a QS incomplete las I mutant of P.aeruginosa formalized biofilms that were much liable to biocides. Also, biofilms constituted by a las R, rhlR double mutant of P.aeruginosa is more exposed to killing by tobramycin and hydrogen peroxide than biofilms formed by a wild-type counterpart suggestive of biofilm specific QS controlled genes.8
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First, various species release to develop similar structural and functional endpoint over biofilm formation, including the various stage of microcolony formation, matrix embedded mature biofilms, and tolerance to antimicrobial agent. Moreover, these species may or may not employ cell surface structures such as pili, flagella and LPS.
Second, the use of various channel for biofilm formation and function occur also within a species like the development of tobramycin resistance in P. aeruginosa.8
The biofilm life cycle. 1: each cells populate the surface. 2: extracellular polymeric substance (EPS) is produced and attachment becomes irreversible. 3 & 4: biofilm architecture develops and matures. 5: single cells are released from the biofil.9
Honey has various antimicrobial factors. About 80% of honey content by weight is sugar and it is relatively acidic ( typical pH ranges from 3.2 to 4.5 ), making it unsuitable for microbial growth.6
Manuka honey has been promoted to therapeutic advantage over other honeys which are grown in New Zealand and Australia.10 It is reported to have a high concentration of a trimethoxybenzoic acid and methylglyoxal ; 2-methoxybenzoic acid and methlglyoxal were linearly related in fresh manuka honey.11 Recently it has been documented that the antibacterial activity of this honey is due to reactive methylglyoxal ( MG ) which is more concentrated ( up to 100 times ) in manuka honey compared others honeys.10 This led to the development of an industry standard phenol equivalent named unique manuka factor ( UMF ).11 Where MG is a strong protein-glycating agent and a serious harbinger of advanced glycation end products (AGEs), GM and AGEs play a role in the pathogenesis of weakening diabetic wound healing and can adjust the structure and the function of the target molecules. Along with MG, hydrogen peroxide, flavonoid and aromatic acids are present in natural honeys.10
Hydrogen peroxide is produced in low concentration by the enzyme glucose oxidase which is present in the honey from bee hypopharyageal glayls. It is produced when honey is diluted with the body fluids and the acidity of the honey is neutralised also the body fluids.
If the honey is used as topically like a wound dressing, hydrogen peroxide is formed by dilution of the honey with body fluids.
C6 H12 O6 + H2O + O2 C6 H12 O7 + H2O2
The New Zealand beekeeping industry recognized that storage of manuka honey increased the UMF rating and thus also its market value. The colour of honey is linked to the configuration of 1,2-dicarbonyl compounds output on non-enzymatic caramelisation or Maillard reactions see Figure 2.11
Figure 2. Main properties of manuka honey in the treatment of diabetic ulcers. The black arrow represents known action, the white arrows represent hypothetical mechanisms of action. MG: methylglyoxal; AGEs: advanced glycation end products; MRJP1: major royal jelly protein.3
In addition, ripeness of stored honeys has been showed to increase the 5-hydroxymethylfurfural ( HMF ) amount. Another thing is that some beekeeper in New Zealand are heating the honey to manipulate the UMF activity which may raise HMF beyond the current international standard of 40mg/kg for culinary honeys.11
The susceptibility of the honey to effect the action of the cells that are central to the wound healing method has been investigated by exposing monocytic cells to diluted honey and measuring the rate of release of cytokines that indicate cell activitation. Monocytes are precursors of macrophages, which are substantial cellular organizers of wound healing. Impaired healing is formed by numerous, complex factors which are not entirely understood at present, but it has been linked to reduced numbers of macroghages and inactive macrophages. The susceptibility of agents to stimulation such cells therefore has importance in estimate their wound healing potential.12
There were a study published for comparison of desloughing efficacy after 4 weeks and healing outcomes after 12 weeks in sloughy venous leg ulcers treated with Manuka honey ( Woundcare 18+ ) vs. Standard hydrogel therapy ( Intrasite Gel ). The study shows 108 patients with venous leg ulcers having â‰¥ 50 wound area covered in slough, not taking antibiotic or immunosuppressant therapy were recruited from ascular centres, acute and community care hospitals and leg ulcer clinics. The efficacy of wound care 18+ to deslough the wounds after 4 weeks and its impact on healing after 12 weeks when campared with IntraSite Gel control was determined. The treatment was applied weekly for 4 weeks and follow up was made at week 12.
From the results of the study it was demonstrated that at week 4, mean percentage of reduction in slough was 67% Wound Care 18+ vs. 52.9% Intra Site Gel (p = 0.054). Mean wound area covered in slough reduced to 29% and 43%, respectively (p = 0.065). Median reduction in wound size was 34% vs. 13% (p = 0.001). At 12 weeks, 44% vs. 33% healed (p = 0.037). Wounds having >50% reduction in slough had greater probability of healing at week 12 (95% confidence interval 1.12, 9.7; risk ratio 3.3; p = 0.029). Infection developed in 6 of the WoundCare18+ group vs. 12 in the IntraSite Gel group.
The WoundCare 18+ group had increased incidence of healing, effective desloughing and a lower incidence of infection than the control. Manuka honey has therapeutic value. This study confirmd that manuka honey may be considered by clinicians for use in sloughy venous ulcers.13
Calgary Biofilm Plates:
The Calgary Biofim Plates was developed at the University of Calgary by their microbiologists. This Device now has a commercial name as The MBEC assay. It working by the idea of the microorganisms to grow on 96 pegs protruding down from a plastic lid. The MBEC assay plate has two parts. The upper part of the plate is polystyrene lid with 96 identical pegs. The mean surface area of each peg is 108.9mm2. The lid is inserted into the lower part of the plate - a microtiter plate is set up to contain an inoculated growth medium. The plate is kept on a gyrorotary shaker in an incubator, which provides the shearing force that facilitates the formation of 96 biofilms on the peg lid. Biofilms take shape on the polystyrene pegs when planktonic bacteria adsorb to the surface. In the presence of shear, these bacteria become irreversibly attached and grow to form mature biofilms.14