Vivekananda Gupta Sunkari, Folke Lind, Ileana Ruxandra Botusan, Abad Kashif, Zhao‐Jun Liu, Seppo Ylä‐Herttuala, Kerstin Brismar, Omaida Velazquez, Sergiu‐Bogdan Catrina

Hyperbaric oxygen (HBO) therapy has been used as an adjunctive therapy for diabetic foot ulcers, although its mechanism of action is not completely understood. Recently, it has been shown that HBO mobilizes the endothelial progenitor cells (EPCs) from bone marrow that eventually will aggregate in the wound. However, the gathering of the EPCs in diabetic wounds is impaired due to the decreased levels of local stromal-derived factor-1α (SDF-1α). Therefore, we investigated the influence of HBO on HIF-1, which is a central regulator of SDF-1α and is down-regulated in diabetic wounds. The effects of HBO on HIF-1α function were studied in human dermal fibroblasts, SKRC7 cells and HIF-1α knock-out and wild-type mouse embryonic fibroblasts using appropriate techniques (Western blot, Quantitative-PCR and Luciferase hypoxia-responsive element (HRE) reporter assay). Cellular proliferation was assessed using H(3) -thymidine incorporation assay. The effect of HIF in combination with HBOT was tested by inoculating stable HIF-1α-expressing adenovirus (Adv-HIF) into experimental wounds in db/db mice exposed to HBO. HBO activates HIF-1α at several levels by increasing both HIF-1α stability (by a non-canonical mechanism) and activity (as show both by induction of relevant target-genes and by a specific reporter assay). HIF-1α induction has important biological relevance because the induction of fibroblast proliferation in HBO disappears when HIF-1α is knocked down. Moreover, the local transfer of stable HIF-1α-expressing adenovirus (Adv-HIF) into experimental wounds in diabetic (db/db mice) has an additive effect on HBO-mediated improvements in wound healing. In conclusion HBO stabilizes and activates HIF-1, which contributes to increased cellular proliferation. In diabetic animals, the local transfer of active HIF further improves the effects of HBO on wound healing.