Turmeric extract gel and honey in post-cesarean section wound healing: A preliminary study

Background Delivery by cesarean section (SC) increases the risk of a surgical site infection (SSI). Therapy from health services and complementary therapy reduce the risk of infection and accelerate the wound-healing process. This study compared wound healing after SC with a turmeric extract gel and original Trigona honey. Methods Female white rats ( Rattus novergicus) with pre- and post-testing and a control group were included in this experiment, which was conducted in June-July 2022. The test animals were 56 female white rats, 2-4 months old, weighing 150–350 g. The treatment group was divided into three subgroups with application of 50% and 75% turmeric extract gel and Trigona honey. The turmeric was given twice daily, and the honey was divided into two applications of twice a day and once a day. Wounds were assessed using the Reeda Scale. Results The fastest wound healing occurred in the group given Trigona honey twice daily. Redness, ecchymosis, and edema disappeared in this group on day 9 (score 0), and granulation tissue formed on day 9. The group that was administered 50% and 75% turmeric gel extract and Trigona honey once a day healed by days 12 and 15, respectively; all three of these interventions were better than the control group. Conclusions Administering Trigona honey twice daily was more effective for accelerating wound healing than the 50% or 75% turmeric extract gel. Original Trigona honey has the potential to be a post-SC wound healing agent.


Introduction
Delivery by Cesarean section (SC) increases the risk of surgical site infection (SSI), which can prolong the hospital stay and increase anxiety.Sepsis can follow if the infection is not resolved.The choice of surgical technique and antibiotic reduces this risk; however, particular risk factors, such as anemia, obesity, hypertension, and parity, continue to make SSI extremely prevalent. 1,2aphylococcus aureus is the most prevalent pathogenic bacteria in patients with SSI, and 9.8% of these bacteria are resistant to methicillin.Other bacteria include Klebsiella pneumoniae, Escherichia coli, and Enterococcus faecalis. 3,4ntibiotics, such as azithromycin, reduce the risk of SSI, although some studies suggest that the long-term effects of using antibiotics are unclear. 5mplementary therapy based on natural ingredients has received attention because consumers tend to prefer natural ingredients. 6,7There is a scarcity of published research on the use of herbal medicine for treating surgical site infections.The local wisdom of Indonesian people, especially those in South Sulawesi, a province in the eastern part of Indonesia, and various studies have shown that honey and turmeric have anti-inflammatory activities and reduce the expression of proinflammatory cytokines.Treating wounds with honey significantly increases angiogenesis, re-epithelialization, and the formation of granulation tissue.[9] Turmeric is a yellow rhizome that is often used as a cooking spice.Turmeric contains active compounds, such as curcuminoids and essential oils.Curcuminoids consist of curcumin, desmethoxycumin, and bisdesmethoxycurcumin. 10he mechanism of action of turmeric extract on wounds is to inhibit cyclooxygenase (COX-2) and lipoxygenase, which play roles in the inflammatory stage to accelerate tissue re-epithelialization, cell proliferation, and collagen synthesis. 11e antibacterial activity of honey is exhibited by components such as H 2 O 2 , glucose, and several polyphenols.The phenolic components inhibit bacterial growth through pro-oxidative activity by increasing H 2 O 2 activity.The acidic pH of honey (3.2-4.5) also functions as an antibacterial due to the presence of gluconate acid from the oxidation of glucose, which creates an acidic environment.The flavonoid and phenolic components are anti-inflammatory and suppress the activity of the proinflammatory cytokines, such as COX-2 and inducible nitric oxide synthase.Proline, arginine, methionine, and glycine contribute to the formation of collagen and fibroblasts during wound healing. 8Honey has been clinically applied successfully to treat elderly wounds that do not heal after homecare services.Scar tissue has also been treated successfully at the preclinical trial stage.Significant changes in angiogenic biomarkers occur, such as hypoxia-inducible factor-1α, vascular endothelial growth factor (VEGF), and VEGF receptor-II.[14] Turmeric gel and honey have been preclinically tested on post-SC wounds and produced satisfactory results.Researchers tested turmeric gel and applied pure honey to general wounds.We continued this research on more specific wounds, such as postoperative SC wounds in experimental animals.The turmeric was formulated in 50% and 75% gel products, whereas the honey used was 100% pure honey from Apis trigona bees used once or twice a day.Both were made with local ingredients from South Sulawesi Province, Indonesia.
This study used female Wistar strain Rattus norvegicus rats because they have a gene structure and physiology similar to humans.We compared wound healing, such as redness, swelling, ecchymosis, edema, pus, and tissue granulation, between the turmeric extract gel and pure Trigona honey.This study will hopefully become the basis for clinical trials to prevent SSI in post-SC wounds.

Research design and ethics approval
This research was an experimental pre-post-test laboratory study with female rats (R. novergicus) using a control group.The study utilized female Wistar strain Rattus norvegicus rats due of their genetic and physiological resemblance to humans.This research received approval from the ethical clearance commission of Hasanuddin University Makassar (number 4883/UN4.14.1/TP.01.02/2022).

REVISED Amendments from Version 1
We answered all relevant reviewers' comments, major changes were made to the table, we added statistical analysis as recommended by the reviewer.

Research setting
The first stage of the research was carried out at the Hasanuddin University Biopharmaceutical Laboratory to manufacture the turmeric gel extract and the honey.The husbandry and treatment of the experimental animals were carried out at the Animal Laboratory, Faculty of Veterinary Medicine, Hasanuddin University Makassar.This study was conducted during June-July 2022.

Research subjects
The testing was carried out on 56 female white rats.The inclusion criteria for the study were female Wistar white rats, 2-4 months of age, weighing 150-350 g in good health (actively moving, fur not dull, not shedding, eyes clear, and nimble).The exclusion criteria were illness and inactivity throughout the study.
Thirty-one rats did not meet the inclusion criteria (28 rats under 150 g, and three were not active and ill), so 25 rats (n=5/group) were used in the study.

Research procedure
All efforts were undertaken to minimize the suffering of the animals.Wounds were created after shaving the fur on the part to be cut.The rats were anesthetized intraperitoneally with ketamine (80 mg/kg) before wounding to relieve pain and prevent excessive movement.The area to be cut was marked, and a 2 cm-long incision was made to penetrate the peritoneum.Five groups were prepared: 1. Turmeric gel at 50% and 75% concentrations were applied to the wound using sterile cotton every morning and evening 2. Trigona honey gel was applied twice daily (0.13 mg) (morning and evening) or once daily (0.064 mg) in the morning to the respective subgroups

Control, without intervention
The wound healing was monitored by observing moisture, redness, edema, pus, and granulation tissue in the wound (Reeda Scale).The rats were euthanized after closing the intrathoracic transection of the great vessels and heart. 15ta analysis Data were grouped according to purpose and type, and descriptive statistical methods were used.The characteristics of the basic data are described to see improvements and no statistics were used.The score entered in the table is the average score (mean) which is calculated by adding up all the female Wistar white rat wound scores in each group, then dividing it by the number of group members.The score was calculated using Microsoft Excel.

Research results
Table 1 shows that the groups given the 50% and 75% turmeric extract gel had a redness score of 0 (redness disappeared) on day 12 post-intervention.The groups that were given Trigona honey twice daily and once daily had scores of 0 (redness disappeared) 3 days earlier than the group that was given turmeric, which was on day 9.
Statistical analysis showed that all intervention groups experienced significant changes in redness scores based on day.Analysis between groups showed that significant differences in scores occurred on day 9 and day 12.On days 15, 18 and 21, redness was no longer detected in the intervention and control groups (Table 1).
Table 2 shows that none of the groups administered the 50% or 75% turmeric extract gel scored 0 (ecchymosis disappeared) on day 15 post-intervention.The group given Trigona honey twice daily had a score of 0 (ecchymosis disappeared) on day 9, whereas the group given Trigona honey once daily had a score of 0 (ecchymosis disappeared) on day 15.
Statistical analysis showed that all intervention groups experienced significant changes in ecchymosis scores based on day.Analysis between groups showed that significant differences in scores occurred from day 3 to day 15.On days 18 and 21 there were no significant differences between all groups (score 0 for all groups) (Table 2).
Table 3 shows that the groups administered the 50% or 75% turmeric extract gel had scores of 0 (edema disappeared) on day 12 post intervention.The group given Trigona honey twice daily had a score of 0 (redness disappeared) 3 days earlier than the group given turmeric on day 9 (edema disappeared).
Table 1.Redness score of the wounds in the turmeric extract gel and honey groups.

Intervention Group
Redness Score of the wounds day 0      Statistical analysis showed that all intervention groups experienced significant changes in edema scores based on day.Analysis between groups showed that significant differences in scores occurred starting on day 9 and day 12.On days 15, 18 and 21 there were no significant differences between all groups (score 0 for all groups) (Table 3).
Table 4 shows that the control group displayed pus on day 12 and scored 0 (pus disappeared) on day 15 post-intervention, whereas none of the other groups experienced pus in a wound.
Table 5 shows that granulation occurred the quickest (score 2) in the group given Trigona honey twice daily, whereas the group given 50% or 70% turmeric gel extract experienced granulation (score 2.0) on day 15; the longest time to granulation was the control group on day 18.
Statistical analysis showed that all intervention groups experienced significant changes in granulation tissue scores based on day.Analysis between groups showed that significant differences in scores occurred from day 3 to day 18.On day 21 there were no significant differences between all groups (Table 5).

Discussion
Drugs have been used to speed up the wound-healing process.Wound healing is a natural repair process for tissue injury involving inflammatory mediators, blood cells, the extracellular matrix, and parenchymal cells. 16The drugs used in traditional medicines are derived from plants and animals. 17Some of the plants used to treat wounds in mice include turmeric and honey. 18e present study showed that administering Trigona honey twice daily accelerated wound healing based on redness, moisture, edema, granulation tissue, and scabs in the wound compared with the 50% and 75% turmeric gel extract groups (Tables 2-5).Trigona honey administered twice daily did not result in wound edema (Table 4).Honeys have different chemical compositions, biological properties, and effects depending on the environmental, geographical, and nutritional factors of the plant pollen collected. 17Trigona honey increases angiogenic activity, which is very important during wound healing and accelerates the formation of granulation tissue and re-epithelialization of the skin.Honey has antioxidant, antibacterial, and anti-inflammatory properties. 18The flavonoid content in honey increases angiogenesis; thus, fibrosis and collagen formation increase.Flavonoids also have antibacterial, antioxidant, and anti-inflammatory properties. 19e results of this study indicate that administering Trigona honey twice daily led to a faster healing process than once daily; this agreed with research conducted by Takzaree et al., who reported that applying honey to wounds twice daily increases healing, shortens the inflammatory process, and increases the granulation rate. 20rmeric extracts in 50% and 75% gels can be used as an alternative treatment because they accelerate wound healing, although not as quickly as Trigona honey (Tables 2-5).2][23] Turmeric rhizome extracts have antibacterial activity.Turmeric leaf oil at various concentrations inhibits the mycelial growth of Aspergillus flavus and Aspergillus parasiticus.4][25] The turmeric rhizome is prepared as a gel for topical application.A gel is a semisolid system that provides a cool and soothing feeling to the skin with a high water content so it increases hydration in the stratum corneum and dries easily to form a film layer. 11he results of this study indicate that the turmeric extract gel and Trigona honey can be used as alternative treatments for post-CS wounds.However, further research is needed on humans to determine the appropriate dose.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.

Arfa Nasrine
Department of Pharmaceutics, College of Pharmaceutical Sciences Dayananda Sagar University, Bengaluru, Karnataka, India Title: Review of Manuscript -"Turmeric extract gel and honey in post-cesarean section wound healing: A preliminary study" Overall Impression: The manuscript presents an interesting study on the use of turmeric extract gel and Trigona honey for wound healing in post-Cesarean section (SC) wounds in rats.The study design, methodology, and results are well-documented, providing valuable insights into the potential benefits of these natural products in wound healing.However, there are a few points that need clarification and improvement.

Title and Keywords:
The keywords adequately capture the main topics of the manuscript, but it might be helpful to include terms like "Cesarean section" and "Rattus norvegicus" for enhanced discoverability.

Introduction:
a.The introduction effectively establishes the background and rationale for the study.However, it would be beneficial to provide more recent statistics or studies related to surgical site infections (SSI) and the use of alternative therapies.b.The section on Staphylococcus aureus and antibiotic resistance is well-presented.However, it would be useful to include references to support the mentioned prevalence rates and resistance percentages.
3. Literature Review: a.The literature review provides a comprehensive overview of the anti-inflammatory properties of honey and turmeric.However, including recent references and studies, especially those related to wound healing, would strengthen this section.b.Clarify whether the studies mentioned are specific to the Trigona honey from Apis trigona bees, as this distinction is crucial.
4. Methods: a.The research design is clearly described, but it would be helpful to provide a brief rationale for choosing the Wistar strain Rattus norvegicus rats, considering the similarity of their gene structure and physiology to humans.b.Include information on the randomization process for assigning rats to different intervention groups.c.Specify the blinding procedures, if any, during the wound healing assessments.
5. Results: a.The presentation of results in tables is clear and organized.However, consider providing standard deviations or confidence intervals for the reported mean scores to assess the variability within each group.b.The discussion of the results should reference the relevant tables for better clarity.
6. Discussion: a.The discussion provides a good interpretation of the results.However, the comparison of the effectiveness between turmeric extract gel and Trigona honey could be more nuanced.Consider discussing potential synergistic effects of combining these treatments.b.The limitations of the study should be explicitly mentioned, such as the use of animal models and the need for further human trials.
7. Data Availability: a. Ensure that the data availability statement is accurate, and the provided DOI links lead to the correct datasets.
8. Language and Style: a.The manuscript is generally well-written, but some sentences could be clarified for better readability.Consider revising for conciseness and clarity.

Conclusion:
The manuscript presents a promising study on the potential benefits of turmeric extract gel and Trigona honey in wound healing.Addressing the mentioned points would enhance the manuscript's overall quality and impact.

Maulana Yusuf Alkandahri
Universitas Buana Perjuangan Karawang, Karawang Regency, West Java, Indonesia Please complete all your bio-assay with completed validation methods (Please read https://doi.org/10.1016/j.jpba.2022.114735, it maybe can help you to revise your manuscript (at least please calculate Z factor of your methods).Without validation data, the reported results maybe not be replicated by other researchers).

2.
The study groups, the pattern of using the extract, and administration intervals should be given in a separate section under the title of "treatment groups".Also, the protocol and study design should be added as a graphic schematic design to help the author's inference.

3.
This manuscript needs editing in English language and grammar by a native English speaker.Also, a major spacing problem were noticed all over the text.Please consider thorough editing on that aspect.

4.
Overall scientific term also needs to be edited.They are very informally written, which is not acceptable for publishing in a scientific journal in current format.
The revised and corrected manuscript should be subjected to plagiarism checker (<10%).Reviewer Expertise: Molecular Pharmacology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com Test.NA (data constant).Source: Descriptive.

1 Reviewer
Expertise: Pharmaceutical novel formulation development I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.Version Report 31 January 2024 https://doi.org/10.5256/f1000research.147035.r232732© 2024 Nasrine A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

©
2023 Alkandahri M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.The author(s) is/are employees of the US Government and therefore domestic copyright protection in USA does not apply to this work.The work may be protected under the copyright laws of other jurisdictions when used in those jurisdictions.

7 . References 1 .
Indrayanto G: The importance of method validation in herbal drug research.J Pharm Biomed Anal .2022; 214: 114735 PubMed Abstract | Publisher Full Text 2. Gandevia S, Cumming G, Amrhein V, Butler A: Replication: Do not trust your p-value, be it small or large.The Journal of Physiology.2021; 599(11): 2989-2990 Publisher Full TextIs the work clearly and accurately presented and does it cite the current literature?YesIs the study design appropriate and is the work technically sound?YesAre sufficient details of methods and analysis provided to allow replication by others?PartlyIf applicable, is the statistical analysis and its interpretation appropriate?I cannot comment.A qualified statistician is required.Are all the source data underlying the results available to ensure full reproducibility?PartlyAre the conclusions drawn adequately supported by the results?PartlyCompeting Interests: No competing interests were disclosed.

Table 2 .
Ecchymosis scores of the wounds in the turmeric extract gel and honey groups.
a Friedman Test.b Kruskal-wallis Test.Source: Descriptive.

Table 3 .
Edema score of the wounds in the turmeric extract gel and honey groups.
a Friedman Test.b Kruskal-wallis Test.Source: Descriptive.

Table 4 .
Pus score of the wounds in turmeric extract gel and honey groups.

Table 5 .
Granulation tissue score in the wound of the turmeric extract gel and honey groups.
a Friedman Test.b Kruskal-wallis Test.Source: Descriptive.

the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests:
No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
https://doi.org/10.5256/f1000research.147035.r224741