Military Medicine: The War on Wounds

To visit Wake Forest University's institute for Regenerative Medicine is to enter a surreal world where scientists create living organs—hearts, bladders and even kidneys—that function like the real thing. Skin, bone, cartilage, blood vessels, nerves: nothing seems too ambitious for director Anthony Atala and his staff of 150 to craft. And while none of their creations are available from your doctor yet—most are still being tested in animals—there have been enough small-scale successes in humans that the U.S. military is suddenly very interested.

War may be hell, but it has a way of accelerating medical research. World War I brought methods for collecting and preserving blood for transfusions. World War II saw the introduction of penicillin into medical practice. One day, medical historians may remember Iraq and Afghanistan for spurring regenerative medicine, a grab bag of techniques that share the same end—to repair human bodies by helping them regenerate living tissue, rather than relying on artificial parts. Last month Lt. Gen. Eric Schoomaker, the Army surgeon general, announced $85 million in government funding to create a new Armed Forces Institute of Regenerative Medicine (AFIRM). The effort, which involves researchers at two dozen institutions, is codirected by Atala at Wake Forest, together with colleagues at the University of Pittsburgh, Rutgers and the Cleveland Clinic. As the general put it, "We're embarking on a new generation of research that's going to redefine Army and military medicine as we know it today." And likely transform civilian medicine, too.

The military's need is enormous. Thanks to improved medical care, 90 percent of soldiers who are injured in Iraq and Afghanistan are surviving. But many of them come home with multiple traumatic injuries to the face, head and limbs that will take years to treat and will result in lifelong impairment. Even state-of-the-art treatments can leave burn victims with disfiguring scars, say doctors. Such injuries can be emotionally devastating. "Soldiers who've lost their faces have the highest suicide rate of severely wounded war victims," says Joachim Kohn of Rutgers, codirector of AFIRM. Currently, soldiers with burns covering 40 percent or more of their bodies have to undergo dozens of operations as surgeons harvest healthy skin from, say, their thighs, and transplant it onto damaged areas. The doctors must then wait several weeks for new, healthy skin to grow back on the thighs so they can repeat the process. But Dr. Jörg Gerlach at the University of Pittsburgh's McGowan Institute for Regenerative Medicine is isolating patients' own skin stem cells from a small patch of healthy skin. Then, using a specially developed skin-cell gun, he sprays them onto the wounded area in a fine mist. Over a period of two to six weeks, the cells grow into functional skin, including dermis, epidermis and blood vessels. There is little scarring, and because Gerlach includes the patient's own pigment cells in the mix, the new skin looks natural. In one pilot study, he treated eight patients in Germany with good results.

Researchers are also looking for ways to restore body parts. Doctors cannot make these parts regrow all by themselves—at least not yet. (The Defense Advanced Research Projects Agency is funding very-early-stage research on regenerating fingers, the way a salamander regrows lost limbs.) But regenerative medicine will do the next best thing. Robert Langer at MIT and Joseph Vacanti at Harvard, for example, want to help soldiers who have lost noses and ears. To build a nose, they will create a nose-shaped scaffold, made of biocompatible, biodegradable materials, then seed it with the patient's own cells and nurture it in a chamber called a bioreactor that mimics conditions in the body. Weeks later, when cells have multiplied to form tissues, the nose will be surgically implanted; over the ensuing months, the scaffold will dissolve and be resorbed into the body. Using these same basic techniques, Atala has created organs, including small kidneys that filter liquid and produce urine in the lab. When implanted in animals, the kidneys grow to full size and continue to work. "We start, and the body takes over," he says.

The full array of potential regenerative therapies being developed by AFIRM is astonishing. Newell Washburn at Carnegie Mellon University is working on special gels to help tamp down inflammation at the site of a deep wound, allowing skin to regenerate without scarring. Dr. Charles Sfeir at the McGowan Institute is developing a powder containing bone proteins, growth factors and biodegradable cement that can be mixed with water in the operating room and molded to the shape of missing bone. Atala has created nerves that conduct impulses—at least in mice. "There isn't a tissue you could name that someone isn't working on," says Alan Russell of the McGowan Institute, codirector of AFIRM. And one day, that will benefit us all.

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