The current burden of diabetic foot disease

Investigation and management of diabetic foot osteomyelitis: An update for the foot and ankle orthopaedic surgeon

Diabetic foot osteomyelitis (DFO) poses a significant challenge in the management of diabetic patients, often leading to severe complications and increased morbidity. Effective management of DFO requires a multidisciplinary approach, involving endocrinologists, infectious disease specialists, vascular surgeons, orthopaedic surgeons, and wound care experts. Early diagnosis is paramount, facilitated by advanced imaging techniques such as magnetic resonance imaging (MRI) and bone scintigraphy. Once diagnosed, the treatment strategy hinges on a combination of medical and surgical interventions. Antibiotic therapy, guided by culture results, plays a central role in managing DFO. Tailored regimens targeting the specific pathogens involved are administered, often for prolonged durations. Surgical intervention becomes necessary when conservative measures fall short. Surgical approaches range from minimally invasive procedures, like percutaneous drainage, to more extensive interventions like debridement and bone resection. Prevention of DFO recurrence is equally vital, emphasising glycemic control, meticulous foot care, patient education, monitoring of at-risk signs, revascularization and early intervention when indicated. The management of diabetic foot osteomyelitis mandates a comprehensive strategy that addresses both the infectious and surgical aspects of the condition. A collaborative, interdisciplinary approach ensures timely diagnosis, tailored treatment, and holistic care. Further research into novel therapeutic modalities and long-term outcomes remains essential in refining the management of this complex and debilitating complication of diabetes.

Impact of diabetic peripheral neuropathy on gait abnormalities in patients with type 2 diabetes mellitus

Background

Many patients with type 2 diabetes (T2DM) suffer from diabetic peripheral neuropathy (DPN) and impaired muscle coordination. These changes may lead to walking instability, and gait abnormalities resulting in increased fall risk and lower limb amputations. The aim of this study was to assess the impact of DPN and patient footwear on the gait in patients with diabetes, in addition to Comparing the peak plantar pressure (PPP) in patients with and without DPN and assessing its association with gait abnormalities.

Methodology

This is an observational case-control study. Forty Subjects with T2DM were divided into two age and sex-matched groups, 20 subjects each. Group A: subjects with DPN. Group B: subjects without DPN. All study participants were subjected to a thorough history taking, clinical examinations focusing on detailed foot examination, PPP assessment, and functional gait evaluation.

Results

The results obtained in this study showed a median gait assessment score of 21 (17.0-22.5) for group A and 26 (23.5-26.0) for group B which was statistically significant (p < 0.001). There was no statistically significant difference between both groups (p > 0.05) regarding the assessment of footwear appropriateness. Comparing the PPP measurement among both studied groups, the prevalence of an elevated PPP was 80% in group A compared to 65% in group B, which was statistically non-significant, p = 0.288.

Conclusions

Gait abnormalities are common among patients with T2DM even in the absence of DPN. However, the presence of DPN was the strongest independent risk factor for gait abnormalities among the studied factors.

Diabetes and Hospitalizations Among Mexican Americans Aged 75 Years and Older

OBJECTIVE

To examine factors associated with hospitalization among Mexican Americans aged 75 years and older with diabetes (with and without complications) and without diabetes over 12 years of follow up.

METHODS

Participants (N = 1454) were from the Hispanic Established Population for the Epidemiologic Study of the Elderly (2004/2005-2016) residing in Arizona, California, Colorado, New Mexico, and Texas. Measures included socio-demographics, medical conditions, falls, depressive symptoms, cognitive function, disability, physician visits, and hospitalizations. Participants were categorized as no diabetes (N = 1028), diabetes without complications (N = 180), and diabetes with complications (N = 246).

RESULTS

Participants with diabetes and complications had greater odds ratio (1.56, 95% Confidence Interval = 1.23-1.98) over time of being admitted to the hospital in the prior year versus those without diabetes. Participants with diabetes had greater odds of hospitalization if they had heart failure, falls, amputation, and insulin treatment.

CONCLUSIONS

In Mexican American older adults, diabetes and diabetes-related complications increased the risk of hospitalization.

Stem Cell-Based Tissue Engineering Approaches for Diabetic Foot Ulcer: a Review from Mechanism to Clinical Trial

Diabetic foot ulcer (DFU) is a complication from incomplete or prolonged wound healing, at times requires amputation, putting substantial health and socioeconomic burden. Wound healing is a dynamic overlapping process that can be regulated by arrays of molecular factors showing redundancy in function. However, dysregulation in the mechanism of angiogenesis, extra cellular matrix (ECM) formation and immune modulation are the major causes for impair wound healing in hyperglycaemic patients. Despite development of wound care research, there is a lack of well-accepted targeted therapy with multidisciplinary approach for DFU treatment. Stem cell therapy holds a promising outcome both in preclinical and clinical trials because of its ability to promote healing via regeneration and specialized tissue differentiation. Among different types of stem cells, regenerative potential of mesenchymal stem cell (MSC) is well demonstrated in both experimental and clinical trial. Still there is a huge knowledge gap among medical practitioners for deciding the best stem cell source, administration route, and safety. This review strengthens the fact that why stem cell therapy is a promising candidate to treat DFU and cited multiple tissue engineering and biomaterial-based approaches for delivering stem cells and their aftermath paracrine events. Based on the pre-clinical and clinical studies, the review tried to come up with optimum stem cell source and delivery route for the treatment of DFU. At last, the review glances on possible direction to enhance therapeutics strategy for the same, including different approaches like: phytocompounds, exosomes, scaffold geometry, cell preconditioning and licensing etc.

Improving Physical, Physiological, and Psychological Health Outcomes in Patients with Diabetic Foot Ulcers - State of the Art

Diabetic foot disease is a complex and challenging complication of diabetes mellitus, which imposes a significant burden of disease on patients, their carers, and the wider health systems. Recurrence rates are high, and current evidence indicates a high mortality associated with it. While management algorithms have primarily focused on the physical aspects of healing, there is increasing recognition of the critical role played by psychological and biomechanical factors in the development and resolution of diabetic foot disease. Therefore, in this paper, we aim to explore how diabetic foot outcomes can be improved by addressing not only the physical but also the psychological and biomechanical aspects that are integral to the development of this condition and its optimal resolution. We explore new technologies that allow for non-invasive objective assessment of the diabetic foot at risk, and we also explore the role of understanding biomechanics, which is essential to determining risk of foot disease, but also the potential for recurrence. In addition, we discuss the evidence linking depression and cognitive impairment to diabetic foot disease and offer our insight on the research direction required before implementing novel information into front-line clinics.

Preclinical study of diabetic foot ulcers: From pathogenesis to vivo/vitro models and clinical therapeutic transformation

Diabetic foot ulcer (DFU), a common intractable chronic complication of diabetes mellitus (DM), has a prevalence of up to 25%, with more than 17% of the affected patients at risk of amputation or even death. Vascular risk factors, including vascular stenosis or occlusion, dyslipidemia, impaired neurosensory and motor function, and skin infection caused by trauma, all increase the risk of DFU in patients with diabetes. Therefore, diabetic foot is not a single pathogenesis. Preclinical studies have contributed greatly to the pathogenesis determination and efficacy evaluation of DFU. Many therapeutic tools are currently being investigated using DFU animal models for effective clinical translation. However, preclinical animal models that completely mimic the pathogenesis of DFU remain unexplored. Therefore, in this review, the preparation methods and evaluation criteria of DFU animal models with three major pathological mechanisms: neuropathy, angiopathy and DFU infection were discussed in detail. And the advantages and disadvantages of various DFU animal models for clinical sign simulation. Furthermore, the current status of vitro models of DFU and some preclinical studies have been transformed into clinical treatment programs, such as medical dressings, growth factor therapy, 3D bioprinting and pre-vascularization, Traditional Chinese Medicine treatment. However, because of the complexity of the pathological mechanism of DFU, the clinical transformation of DFU model still faces many challenges. We need to further optimize the existing preclinical studies of DFU to provide an effective animal platform for the future study of pathophysiology and clinical treatment of DFU.

Recent advances in 3D printed cellulose-based wound dressings: A review on in vitro and in vivo achievements

Chronic wounds, especially diabetic ulcers, pose a significant challenge in regenerative medicine. Cellulose derivatives offer remarkable wound management properties, such as effective absorption and retention of wound exudates, maintaining an optimal moisture environment crucial for successful chronic wound regeneration. However, conventional dressings have limited efficacy in managing and healing these types of skin lesions, driving scientists to explore innovative approaches. The emergence of 3D printing has enabled personalized dressings that meet individual patient needs, improving the healing process and patient comfort. Cellulose derivatives meet the demanding requirements for biocompatibility, printability, and biofabrication necessary for 3D printing of biologically active scaffolds. However, the potential applications of nanocellulose and cellulose derivative-based inks for wound regeneration remain largely unexplored. Thus, this review provides a comprehensive overview of recent advancements in cellulose-based inks for 3D printing of personalized wound dressings. The composition and biofabrication approaches of cellulose-based wound dressings are thoroughly discussed, including the functionalization with bioactive molecules and antibiotics for improved wound regeneration. Similarly, the in vitro and in vivo performance of these dressings is extensively examined. In summary, this review aims to highlight the exceptional advantages and diverse applications of 3D printed cellulose-based dressings in personalized wound care.

Where does spinal cord stimulation fit into the international guidelines for refractory painful diabetic neuropathy? a consensus statement

BACKGROUND

Although pharmacotherapy with anticonvulsants and/or antidepressants can be effective for many people with painful diabetic neuropathy (PDN), albeit with frequent side-effects, a critical juncture occurs when neuropathic pain no longer responds to standard first- and second-step mono- and dual therapy and becomes refractory. Subsequent to these pharmacotherapeutic approaches, third-line treatment options for PDN may include opioids (short-term), capsaicin 8% patches, and spinal cord stimulation (SCS).

AIM

This document summarizes consensus recommendations regarding appropriate treatment for refractory peripheral diabetic neuropathy (PDN), based on outcomes from an expert panel convened on December 10, 2022, as part of the Worldwide Initiative for Diabetes Education Virtual Global Summit, "Advances in the Management of Painful Diabetic Neuropathy."

PARTICIPANTS

Nine attendees, eminent physicians and academics, comprising six diabetes specialists, two pain specialists, and one health services expert.

EVIDENCE

For individuals with refractory PDN, opioids are a high-risk option that do not provide a long-term solution and should not be used. For appropriately selected individuals, SCS is an effective, safe, and durable treatment option. In particular, high-frequency (HF) SCS (10 kHz) shows strong efficacy and improves quality of life. To ensure treatment success, strict screening criteria should be used to prioritize candidates for SCS.

CONSENSUS PROCESS

Each participant voiced their opinion after reviewing available data, and a verbal consensus was reached during the meeting.

CONCLUSION

Globally, the use of opioids should rarely be recommended for refractory, severe PDN. Based on increasing clinical evidence, SCS, especially HF-SCS, should be considered as a treatment for PDN that is not responsive to first- or second-line monotherapy/dual therapy.

Prevalence and associated factors of foot deformity among adult diabetic patients on follow-up at Debre Markos comprehensive specialized hospital, Northwest Ethiopia, 2022, cross-sectional study

INTRODUCTION

Diabetes foot deformity is among the major causes of diabetic foot ulceration, resulting in lower limb amputation. However, the study on the distribution of foot deformity and its risk factor among diabetic patients in Ethiopia is limited. This study determined the overall prevalence and associated factors of foot deformity among adult diabetic patients on follow-up at Debre Markos Comprehensive Specialized Hospital, Northwest Ethiopia.

METHODS

Hospital-based cross-sectional study was conducted among 392 diabetic patients using a systematic random sampling technique at Debre Markos Comprehensive Specialized Hospital. Data were collected by pre-tested, semi-structured questionnaires and diabetic foot assessment format. Multivariable binary logistic regression was used to determine the association between dependent and independent variables. Adjusted odds ratios (AOR) with their 95% confidence interval (CI) were used to determine the strength of the association, and a variable with a p-value < 0.05 was statistically significant factors of diabetes foot deformity.

RESULT

The overall prevalence of foot deformity was 33.4% [95% CI: 28.9-38.3]. In the final logistic regression analysis, rural residency [AOR = 2.64, 95% CI: 1.31, 5.31], poor glycemic control [AOR = 2.41; 95% CI: 1.34, 4.33], diabetes duration ≥ 10 years [AOR = 2.74; 95% CI: 1.50, 5.02], inadequate footwear [AOR = 2.11; 95% CI: 1.17, 3.82] and presence of peripheral neuropathy [AOR = 8.21; 95% CI: 4.54, 14.84] were statistically significant associated factors with diabetes foot deformity.

CONCLUSION

The prevalence of foot deformity among adult diabetic patients was high. It is recommended to incorporate foot deformity screening in routine diabetic patient follow-ups especially for those with poor glycaemic control, rural residency, long diabetes duration, inadequate footwear, and diabetic peripheral neuropathy.

Repurposing alagebrium for diabetic foot ulcer healing: Impact on AGEs/NFκB/NOX1 signaling

BACKGROUND

Diabetic foot ulcer (DFU) is a common diabetic complication associated with disability and reduced quality of life. Available therapeutics are not sufficient to combat the spread of DFU. Here we aim to investigate the impact of alagebrium, an advanced glycation end product (AGE)-crosslink breaker, on the healing of DFU.

METHODS

Diabetes was induced in Wistar rats by STZ, and after four weeks, wound was induced on the foot. Alagebrium (10 mg/kg) was administered orally for 14 days, and wound size was measured every 3 days. Behavioral tests i.e., hot plate and footprint tests, were performed to assess sensory function and gait. Blood was collected to assess HbA1c, serum AGEs, MDA and NOX1. Tissue was collected to assess histological changes and expression of NF-κB, iNOS, TNF-α, VEGF and EGF. In a subsequent set of experiments with similar design, alagebrium was applied topically as a film-forming gel.

RESULTS

Systemic alagebrium treatment accelerated the healing of diabetic wound, improved sensory functions and gait, and ameliorated histological changes. It also reduced serum levels of AGEs, MDA and NOX1, and the tissue expression of NF-κB, iNOS, TNF-α, and increased VEGF and EGF in diabetic rats. Topical alagebrium led to similar beneficial effects i.e., accelerated diabetic wound healing, improved wound histological changes, reduced expression of NF-κB and iNOS and increased VEGF.

CONCLUSIONS

Our findings suggest repurposing of alagebrium for the management of DFU to accelerate the healing process and improve the clinical outcomes in diabetic patients.

Racial and Ethnic Disparities in the Management of Diabetic Feet

PURPOSE OF REVIEW

Diabetes mellitus is a chronic medical condition affecting many individuals worldwide and leads to billions of dollars spent within the healthcare system for its treatment and complications. Complications from diabetes include diabetic foot conditions that can have a devasting impact on quality of life. Diabetic foot ulcers and amputations occur in minority individuals at an increased rate compared to Caucasian individuals. This review provides an update examining the racial and ethnic disparities in the management of diabetic foot conditions and the differences in rates of amputation.

RECENT FINDINGS

Current research continues to show a disparity as it relates to diabetic foot management. There are novel treatment options for diabetic foot ulcers that are currently being explored. However, there continues to be a lack in racial diversity in new treatment studies conducted in the USA. Individuals from racial and ethnic minority groups have diabetes at higher rates compared to Caucasian individuals, and are also more likely to develop diabetic foot ulcers and receive amputations. Over the last few years, more efforts have been made to improve health disparities. However, there needs to be an improvement in increasing racial diversity when investigating new therapies for diabetic foot ulcers.

Cost-per-Response Analysis of Pure Hypochlorous Acid Among Patients with Chronic Venous Leg Ulcers: A Health Economic Analysis

OBJECTIVE

To estimate the total cost-per-wound healing response (CPR) and the per-day CPR of patients with chronic leg ulcers treated with pure hypochlorous acid (pHA) as part of their overall would healing regimen.

METHODS

The authors developed a deterministic decision-tree model to estimate the incremental CPR for pHA. The analysis was performed using clinical data from a published single-arm prospective study. The outcome of interest was re-epithelialization at 90 days. Economic data for pHA were based on public prices of pHA per dressing change from the wound care center perspective. The following time points were assessed: 90, 60, and 30 days. Dressing changes occurred every 2.5 days. Sensitivity analysis was performed to gauge the robustness of the results.

RESULTS

A total of 31 patients (68% women) with 31 lesions (average age of wound, 29 months; range, 1-240 months) were included in the clinical study. Re-epithelialization occurred in 23 lesions (74%) at 90 days, 17 (55%) at 60 days, and 3 (10%) at 30 days. The total CPRs were $75.69, $68.27, and $193.44, and the per-day CPRs were $0.84, $1.13, and $6.45 at 90, 60, and 30 days, respectively. The sensitivity analysis revealed that CPRs ranged from $0.63 to $1.12 per day at 90 days.

CONCLUSIONS

Incorporating pHA into standard wound healing protocols is a minimal added expense and may yield a substantial economic savings of $2,695 at 90 days.

Diabetic Foot Ulcer Imaging: An Overview and Future Directions

Diabetic foot ulcers (DFUs) affect one in every three people with diabetes. Imaging plays a vital role in objectively complementing the gold-standard visual yet subjective clinical assessments of DFUs during the wound treatment process. Herein, an overview of the various imaging techniques used to image DFUs is summarized. Conventional imaging modalities (e.g., computed tomography, magnetic resonance imaging, positron emission tomography, single-photon emitted computed tomography, and ultrasound) are used to diagnose infections, impact on the bones, foot deformities, and blood flow in patients with DFUs. Transcutaneous oximetry is a gold standard to assess perfusion in DFU cases with vascular issues. For a wound to heal, an adequate oxygen supply is needed to facilitate reparative processes. Several optical imaging modalities can assess tissue oxygenation changes in and around the wounds apart from perfusion measurements. These include hyperspectral imaging, multispectral imaging, diffuse reflectance spectroscopy, near-infrared (NIR) spectroscopy, laser Doppler flowmetry or imaging, and spatial frequency domain imaging. While perfusion measurements are dynamically monitored at point locations, tissue oxygenation measurements are static two-dimensional spatial maps. Recently, we developed a spatio-temporal NIR-based tissue oxygenation imaging approach to map for the extent of asynchrony in the oxygenation flow patterns in and around DFUs. Researchers also measure other parameters such as thermal maps, bacterial infections (from fluorescence maps), pH, collagen, and trans-epidermal water loss to assess DFUs. A future direction for DFU imaging would ideally be a low-cost, portable, multi-modal imaging platform that can provide a visual and physiological assessment of wounds for comprehensive wound care intervention and management.

Comparison of customized vacuum sealing drainage and vacuum sealing drainage in the treatment of diabetic foot ulcers: a retrospective analysis

BACKGROUND

The prevalence of diabetic foot ulcers, a common, more serious chronic diabetes-related complication, is increasing. Vacuum sealing drainage (VSD) constitutes an effective adjunctive treatment for diabetic foot ulcers. Factors, such as poor glycemic control, ischemia, and infection prolong wound healing time, and VSD products are expensive and unaffordable for many patients.

OBJECTIVE

To compare the use of customized VSD and customized VSD in the treatment of diabetic foot ulcer.

METHOD

This retrospective study included 83 patients with diabetic foot ulcers in customized VSD (n = 44) and VSD (n = 39) groups. Baseline data, efficacy after 14 days, total treatment efficiency, final outcome (28 days after treatment, healing rate), average treatment cost, and hospitalization (days) of the two groups were compared. Factors affecting wound healing were analyzed.

RESULTS

No significant intergroup differences in the baseline data were detected (VSD vs. customized VAD, p > 0.05). Treatment efficacy was higher in the customized VSD group than in the VSD group after 14 days (p < 0.05), although total treatment efficiency in both groups reached 100%. The final outcome in the customized VSD group was better (vs. VSD group, p < 0.05), and the wound healing rate was higher than in the VSD group (66.7% vs. 33.3%). The mean treatment cost and hospital days were greater in the VSD group (vs. customized VSD group; p < 0.05). Factors affecting wound healing include age, Wagner classification, HDL-C, and fasting C-peptide. Younger age, low Wagner classification grade, low HDL-C level, and high fasting C-peptide contribute to higher healing rate, CONCLUSION: Efficacy and final outcome of customized VSD were better than that of VSD; the customized VSD device is simple and convenient to operate, and enables cost-effective treatment.

Impact of multidisciplinary care of diabetic foot infections for inpatients at Campbelltown Hospital

BACKGROUND

Diabetic foot infection (DFI), including diabetic foot ulcer, is a serious complication of diabetes, particularly in the South Western Sydney (SWS) region where it is a leading cause of diabetes-related hospitalisations. Multidisciplinary team (MDT) involvement is effective at improving the health outcomes of DFI patients. This study investigated the impact of MDT (High Risk Foot Service, HRFS) on the length of stay and surgical outcomes of inpatients with DFI in a Sydney tertiary hospital.

METHOD

A retrospective audit of electronic medical records of inpatient admissions for DFI at Campbelltown Hospital between January 2019 - December 2021, was performed. The main outcome of the study was MDT involvement, defined as having two or more specialities involved in the patient's treatment. The other measured variables included length of stay (defined as the total duration from admission to discharge), and surgical outcomes including debridement, minor amputation, and major amputation.

RESULTS

Over the three years, 78 participants presented to the hospital for 89 unique DFI admissions. There were 24 admissions in 2019, 28 admissions in 2020, and 37 admissions in 2021, with MDT attendance showing a steady increase at 62.5%, 75.0% and 83.8% respectively. Patients with serious comorbidities such as chronic kidney disease were more likely to have MDT involvement (84.8% vs. 15.2%, P = 0.048). Imaging was more likely to be performed with MDT involvement (78.8% vs. 21.3%, p < 0.05). Comparing patients who received and did not receive MDT care, the mean HbA1c (%) (8.4 ± 2.0 vs. 8.2 ± 2.7, P = 0.701), median length of stay (LOS: 7.8, IQR 15.0 days vs. 4.8 IQR 7.9 days, P = 0.243) and rate of surgical outcomes (74.6% vs. 72.7%, P = 0.262) were similar. Patients who required major amputation had significantly longer LOS (24 days, IQR 21.5 vs. 5.2 days, IQR 13.0, P = 0.004) but similar HbA1c (P = 0.552) compared to those who had conservative intervention.

CONCLUSION

Adopting an MDT approach was associated with more thorough investigation of DFI, with similar rates of surgical outcomes. Further research on the impacts of MDT on length of stay and surgical outcomes of DFI patients in other SWS hospitals is needed.

The Therapeutic Efficacy of Freeze-Dried Human Amniotic Membrane Allograft Gel for Diabetic Foot Ulcers: A Phase-1 Clinical Trial

Diabetic foot ulcers (DFUs) are classified as hard-to-heal wounds, which occur in approximately 15% of diabetic patients. Several interventions have shown efficacy in reducing the risk of amputation among patients with DFU, including timely diagnosis and management of infection and ischemia, debridement of necrotic tissues, reducing mechanical pressure on ulcers, and patient education. One major challenge in the management of DFUs is optimizing wound care to improve healing outcomes. Recently, interdisciplinary approaches proposed a new generation of wound dressing which increased efficacy and significantly decreased the healing time. The current study assessed the healing characteristics of chronic DFUs treated with lyophilized amniotic membrane gel (LAMG) in combination with standard care, versus a placebo hydrogel with standard care. In total, 18 patients (8 male, 10 female) were randomly assigned to the control group, which received standard care and a gelatin scaffold (placebo), or the intervention group, which received standard care along with LAMG. We evaluated the reduction in wound size and assessed the patient's health-related quality of life over 9 weeks. In the LAMG group (n = 9) and the Placebo group (n = 9), the wounds were reduced in size by a mean of 73.4% ± 15.3% and 13.1% ± 10.1%, respectively (P = .008). Patients treated with LAMG demonstrated significant improvements in the scores related to physical function, physical limitation, physical pain, general health, social function, emotional problems, and energy levels compared to the control group. The findings of this study indicate that using the LAMG with standard care significantly enhances wound healing.

Team-Based Approach to Reduce Malignancies in People with Diabetes and Obesity

PURPOSE OF REVIEW

Numerous observations have indicated an increased risk of developing various types of cancers, as well as cancer-related mortality, among patients with diabetes and obesity. The purpose of this review is to outline multiple-cancer screening among these patients through a team-based approach and to present the findings of a pioneering integrated care program designed for patients with obesity with a specific emphasis on cancer prevention.

RECENT FINDINGS

A community-based multi-cancer prevention program, which provides all services in one location and utilizes team-based approaches, is reported to be feasible and has the potential to enhance the uptake rate of multiple cancers screening among patients with diabetes and obesity. The team-based approach is a commonly utilized method for managing patients with diabetes, obesity, and cancer, and has been shown to be efficacious. Nevertheless, research on team-based cancer screening programs for patients with diabetes and obesity remains limited. Providing a comprehensive screening for colorectal, prostate, and breast cancer, as well as metabolic syndrome, during a single clinic visit has been proven effective and well-received by participants.

Engineering homologous platelet-rich plasma, platelet-rich plasma-derived exosomes, and mesenchymal stem cell-derived exosomes-based dual-crosslinked hydrogels as bioactive diabetic wound dressings

The management of diabetic wounds remains a critical therapeutic challenge. Platelet-rich plasma (PRP) gel, PRP-derived exosomes (PRP-Exos), and mesenchymal stem cell-derived exosomes (MSC-Exos) have demonstrated therapeutic potential in wound treatment. Unfortunately, their poor mechanical properties, the short half-lives of growth factors (GFs), and the burst release of GFs and exosomes have limited their clinical applications. Furthermore, proteases in diabetic wounds degrade GFs, which hampers wound repair. Silk fibroin is an enzyme-immobilization biomaterial that could protect GFs from proteases. Herein, we developed novel dual-crosslinked hydrogels based on silk protein (SP) (sericin and fibroin), including SP@PRP, SP@MSC-Exos, and SP@PRP-Exos, to promote diabetic wound healing synergistically. SP@PRP was prepared from PRP and SP using calcium gluconate/thrombin as agonist, while SP@PRP-Exos and SP@MSC-Exos were derived from exosomes and SP with genipin as crosslinker. SP provided improved mechanical properties and enabled the sustained release of GFs and exosomes, thereby overcoming the limitations of PRP and exosomes in wound healing. The dual-crosslinked hydrogels displayed shear-induced thinning, self-healing, and eradication of microbial biofilms in a bone-mimicking environment. In vivo, the dual-crosslinked hydrogels contributed to faster diabetic wound healing than PRP and SP by upregulating GFs expression, down-regulating matrix metalloproteinase-9 expression, and by promoting an anti-NETotic effect, angiogenesis, and re-epithelialization. Hence, these dual-crosslinked hydrogels have the potential to be translated into a new generation of diabetic wound dressings.

Particularities of Urinary Tract Infections in Diabetic Patients: A Concise Review

Diabetes mellitus is a chronic disease that, untreated or poorly controlled, can lead to serious complications, reducing life expectancy and quality. Diabetic patients are more likely to develop infections, including many common infections, but also pathognomonic ones such as emphysematous pyelonephritis, malignant otitis externa, mucormycosis and Fournier's gangrene. Considering the fact that diabetic patients experience more frequently urinary tract infections (UTIs) with a worse prognosis than non-diabetic people, we conducted a review study based on data in the literature, following the particularities of UTIs in this group of patients, the risk factors, the mechanisms involved and the challenges in their management. The findings highlight that UTI in diabetic patients have some particularities, including a more frequent evolution to bacteremia, increased hospitalizations, and elevated rates of recurrence and mortality than non-diabetic patients. The possible risk factors identified seem to be female gender, pregnancy, older age, UTI in the previous six months, poor glycemic control and duration of diabetes. The mechanisms involved are related to glucosuria and bladder dysfunction, factors related to bacterial strains and host response. The bacterial strains involved in UTIs in diabetic patients and their antibiotic susceptibility profile are, with some exceptions, similar to those in non-diabetic people; however, the antimicrobial agents should be carefully chosen and the duration of the treatment should be as those required for a complicated UTI. The data related to the risk of developing UTIs in patients treated with SGLT-2 inhibitors, a new class of oral hypoglycaemic agents with cardiovascular and renal benefits, are controversial; overall, it was evidenced that UTIs occurred at the initiation of the treatment, recurrent infection was uncommon and the majority of UTIs responded to treatment with standard antibiotics. Moreover, interruption or discontinuation of SGLT-2 inhibitor as a result of UTI was rare and SGLT-2 inhibitors did not increase the risk of severe infections such as urosepsis and pyelonephritis.

The Opportunity for Impactful Integration of Vascular and Podiatric Care

BACKGROUND

The importance of collaboration between vascular and podiatric surgeons has been well-established. High-level partnerships are integral to the development of multidisciplinary programs and wound care centers, ultimately resulting in improved patient outcomes. This vascular-podiatric integration is not universal, however, and podiatric surgery may not be aligned within a vascular surgery division at many institutions. As one such institution, we reviewed our single-center experience in order to identify opportunities for the impactful integration of vascular-podiatric patient care.

METHODS

Institutional electronic medical records were retrospectively reviewed for all procedures performed by vascular surgeons at a high volume, safety-net academic medical center. Data were collected on all primary and additional procedures, current procedural terminology (CPT) codes, case type (elective, urgent, emergent), surgeon specialty, and date/time of the procedures performed. CPT codes were linked to the Centers for Medicare & Medicaid Services' Physician Fee Schedule to estimate the work relative value unit (wRVU) per procedure.

RESULTS

From 2018 to 2022, vascular surgeons performed a total of 12,206 operations, of which 1102 (9.9%) involved podiatric procedures. The most common vascular-performed podiatry procedures performed were toe amputations (38.1%, n = 420), transmetatarsal foot amputations (20.1%, n = 222), and ankle/foot debridement (16.2%, n = 178). Foot/ankle-specific procedures were identified as the primary procedure in 726 (65.9%) cases and as the adjunct procedure in 376 (34.1%) cases. A substantial proportion of podiatric procedures occurred on an urgent (n = 278, 25.2%) or emergent (n = 28, 2.5%) basis. A total of 163 (14.8%) cases occurred after hours (either before 0600 or after 1800), and 133 (12.1%) cases were performed on a holiday or weekend. Procedure-specific revenue included 4243.39 wRVU for primary procedures and 2108.08 wRVU for additional procedures performed.

CONCLUSIONS

We report our single-center experience in which vascular surgeons provide a significant proportion of podiatric procedures. Our study underscores the potential for integrating podiatric surgeons within a vascular surgical division and presents opportunities for collaboration and enhanced patient care.

Enhancing Self-Management Skills of Patients With Existing Diabetic Foot Ulcerations: A Quality Improvement Project

PURPOSE

The purpose of this quality improvement initiative was to determine the impact of a nurse-administered foot care intervention bundle (NA-FCIB) upon self-management knowledge, skills, and outcomes in patients with diabetic foot ulcerations.

PARTICIPANTS AND SETTING

The sample comprised 39 patients being treated for diabetic foot ulceration at a wound care clinic in a tertiary care hospital in Arlington, Virginia. The project was conducted from August 2017 to February 2018.

APPROACH

This quality improvement project used the Johns Hopkins Plan-Do-Study-Act Method supplemented by self-regulation theory for diabetic patient education and evidence in clinical literature. The 12-week-long intervention included one-on-one teaching in the prevention of ulcerations and optimal care of the diabetic foot, blood glucose level tracking logs, patient "teach-back" and skills demonstration, and free foot care tools.

OUTCOMES

From baseline to post-NA-FCIB, the number of participants knowing the reasons for temperature foot protection increased by 92%, those knowing major factors leading to diabetic foot ulceration by 85%, those knowing what to look for in the foot self-exam by 85%, and those able to demonstrate correct foot self-exam by 84%. The number of participants understanding proper footwear increased by 74%, and those identifying ways to avoid/decrease the likelihood of diabetic foot ulcers by 72%. Mean serum hemoglobin A1c (HgbA1c) levels decreased from baseline to postintervention (8.27%; SD 2.05% vs 7.46%; SD 1.58%; P = .002).

IMPLICATIONS FOR PRACTICE

The NA-FCIB intervention was successfully incorporated into routine clinic care as the standard of care. Our experience suggests that the NA-FCIB may be feasible and effective for use at comparable wound care clinics and may have secondary benefits for HgbA1c regulation.

Hospital stays and costs of telemedical monitoring versus standard follow-up for diabetic foot ulcer: an open-label randomised controlled study

Background

Two randomised controlled trials (RCTs) have previously shown that telemedical monitoring of diabetic foot ulcer (DFU) reduces the number of visits to the outpatient clinic, without losing treatment efficacy or increasing costs. Here we present the results of an open-label, randomised controlled trial designed to investigate whether telemonitoring, provided by an expert nurse (with extensive experience in DFU and trained in remote monitoring), reduces the hospital stay and the associated costs for a patient with DFU (TELEPIED trial).

Methods

Eligible patients (n = 180) were randomly allocated to: (i) a control group, in which they received standard care, and (ii) an intervention group, in which they received asynchronous telemedicine follow-up by the expert nurse. The primary outcome was the cumulative hospital days over 12 months. The main secondary outcomes were (i) direct healthcare costs (estimated in a collective perspective), (ii) wound healing and (iii) amputation rates. ITT (intention-to-treat) population was analysed.

Findings

In the ITT population, cumulative hospital days were significantly higher in the control group (13.4 days [95% CI 9.0-17.8]) than in the intervention group (7.1 days [2.8-11.5]) (p = 0.0458, ANCOVA model). Cumulative direct costs over 12 months were 7185 € (95% CI 5144-9226) in the control group and 3471 € (95% CI 1430-5512) in the intervention group (p = 0.0120). The percentage of wounds healed and amputation rate were not significantly different between groups. Similar results were found with the PP population.

Interpretation

The implementation of a telemedical intervention with an expert nurse could lead to a length of hospitalization and direct costs that were two times lower compared to conventional follow-up. This lower medical and economic burden was obtained without losing effectiveness on the rate of healing, nor increasing the amputation rate. Additional studies are required to confirm these findings.

Funding

This study was designed, funded and conducted by CERITD (Study and Research Centre for Intensification of Diabetes Treatment, Evry, France), Genopole GIP, 20 rue Henri Desbruères, 91030 EVRY Cedex and Laboratoires URGO, 15 Avenue d'Iéna, 75116 Paris Cedex, France. The findings and conclusions in this study are those of the authors and do not necessarily represent the views of the sponsor. The corresponding author (DD) certify that authors were not precluded from accessing data in the study, and they accept responsibility to submit for publication.

Implication of Peripheral Neuropathy on Unplanned Readmissions in Patients Hospitalized for Complicated Diabetic Foot Disease

Introduction. Unplanned readmissions are common following discharge in patients after hospitalization for diabetic foot disease (DFD) complications. The aim of this study was to identify factors associated with readmissions in these high-risk patients, treated in a multidisciplinary setting and the implication of measures that could effectively reduce readmission rates. Methods. Patients presenting with DFDs admitted between 2015 and 2017 were studied retrospectively in a single-centre patient database. The demographics and clinical comorbidities were analyzed and comparison was made between 2 groups: patients readmitted within 30 days of discharge and those who did not require readmission. Multivariate analysis was performed to identify risk factors associated with readmissions. Results. In total, 340 patients were included. The unplanned readmission rate was 10.9%. More than half of readmissions (71%) were related to wound deterioration and infection. In the readmission group, the patients had lower body mass index, higher rate of osteomyelitis, lower rate of debridement, and evidence of peripheral vascular disease below the knee in the index admissions but these were not significant. In the multivariate analysis, peripheral neuropathy was the only significant risk associated with unplanned readmissions (odds ratio: 2.78, 95% confidence interval: 1.23-6.29, P = .014). Conclusion. This study demonstrates a significant association between peripheral neuropathy and unplanned readmissions. The implications of this nonmodifiable risk factor in reducing readmissions include all levels of patient care delivery such as adequate preparation for discharge and transition back into the community. Recognition and education in successful long-term offloading of insensate diabetic feet may help reduce rates of unplanned readmission.

Risk Factors for Ulcer Recurrence in Diabetic Patients Managed by an Integrated Foot Care Protocol

The aim of our study was to identify risk factors for the recurrence of diabetic foot ulcers (DFUs) in a selected population of patients in secondary prevention treated, according to International Guidelines, with an integrated foot care protocol by a referral diabetic foot clinic. A retrospective study was performed with the inclusion of selected outpatients with diabetes at higher risk for ulceration with a history of previous ulcer and/or amputation followed in our diabetic foot clinic between January 2015 and December 2021. According to the presence or absence of recurrence, patients were divided into 2 groups: ulcer recurrence and without ulcer recurrence. One hundred twenty-seven (127) patients were included, 47 patients (37%) developed an ulcer recurrence while 80 patients (63%) did not. The mean age was 71.7 years; 65% were male; 97% were affected by type 2 diabetes with a mean duration of 21.1 years, the mean HbA1c was 63 + 21 mmol/mol. Both groups of patients had foot deformities, such as claw and hammertoes; hallux valgus, and prominent metatarsal heads (MTHs). The presence of deformity was significantly associated with ulceration. The group with ulcer recurrence showed a higher rate of prominence MTHs in comparison to a group without ulcer recurrence. The MTHs resulted as the only independent predictor for recurrence. This study shows that the presence of the prominent MTH is a significant risk factor for ulcer recurrence in a selected population of diabetic foot patients treated in the best way with integrated foot care.

Corneal Confocal Microscopy Predicts Cardiovascular and Cerebrovascular Events and Demonstrates Greater Peripheral Neuropathy in Patients with Type 1 Diabetes and Foot Ulcers

OBJECTIVE

In this study, we evaluate small and large nerve fibre pathology in relation to diabetic foot ulceration (DFU) and incident cardiovascular and cerebrovascular events in type 1 diabetes (T1D).

METHODS

A prospective observational study was conducted on people with T1D without diabetic peripheral neuropathy (DPN) (n = 25), T1D with DPN (n = 28), T1D with DFU (n = 25) and 32 healthy volunteers. ROC analysis of parameters was conducted to diagnose DPN and DFU, and multivariate Cox regression analysis was performed to evaluate the predictive ability of corneal nerves for cardiac and cerebrovascular events over 3 years.

RESULTS

Corneal nerve fibre length (CNFL), fibre density (CNFD) and branch density (CNBD) were lower in T1D-DPN and T1D-DFU vs. T1D (all p < 0.001). In ROC analysis, CNFD (sensitivity 88%, specificity 87%; AUC 0.93; p < 0.001; optimal cut-off 7.35 no/mm2) and CNFL (sensitivity 76%, specificity 77%; AUC 0.90; p < 0.001; optimal cut-off 7.01 mm/mm2) had good ability to differentiate T1D with and without DFU. Incident cardiovascular events (p < 0.001) and cerebrovascular events (p < 0.001) were significantly higher in T1D-DPN and T1D-DFU. Corneal nerve loss, specifically CNFD predicted incident cardiovascular (HR 1.67, 95% CI 1.12 to 2.50, p = 0.01) and cerebrovascular (HR 1.55, 95% CI 1.06 to 2.26, p = 0.02) events.

CONCLUSIONS

Our study provides threshold values for corneal nerve fibre metrics for neuropathic foot at risk of DFU and further demonstrates that lower CNFD predicts incident cardiovascular and cerebrovascular events in T1D.

Machine learning profiles of cardiovascular risk in patients with diabetes mellitus: the Silesia Diabetes-Heart Project

AIMS

As cardiovascular disease (CVD) is a leading cause of death for patients with diabetes mellitus (DM), we aimed to find important factors that predict cardiovascular (CV) risk using a machine learning (ML) approach.

METHODS AND RESULTS

We performed a single center, observational study in a cohort of 238 DM patients (mean age ± SD 52.15 ± 17.27 years, 54% female) as a part of the Silesia Diabetes-Heart Project. Having gathered patients' medical history, demographic data, laboratory test results, results from the Michigan Neuropathy Screening Instrument (assessing diabetic peripheral neuropathy) and Ewing's battery examination (determining the presence of cardiovascular autonomic neuropathy), we managed use a ML approach to predict the occurrence of overt CVD on the basis of five most discriminative predictors with the area under the receiver operating characteristic curve of 0.86 (95% CI 0.80-0.91). Those features included the presence of past or current foot ulceration, age, the treatment with beta-blocker (BB) and angiotensin converting enzyme inhibitor (ACEi). On the basis of the aforementioned parameters, unsupervised clustering identified different CV risk groups. The highest CV risk was determined for the eldest patients treated in large extent with ACEi but not BB and having current foot ulceration, and for slightly younger individuals treated extensively with both above-mentioned drugs, with relatively small percentage of diabetic ulceration.

CONCLUSIONS

Using a ML approach in a prospective cohort of patients with DM, we identified important factors that predicted CV risk. If a patient was treated with ACEi or BB, is older and has/had a foot ulcer, this strongly predicts that he/she is at high risk of having overt CVD.

Vitamin D deficiency among outpatients and hospitalized patients with diabetic foot ulcers: A systematic review and meta-analysis

BACKGROUND

The definition of diabetic foot syndrome (DFS) varies depending on the location and resources. Few classifications are available according to the indication. DF ulcers and vitamin D deficiency are common diseases among patients with diabetes. Previous literature has shown an association between DF ulcer (DFU) and vitamin D deficiency. However, the available meta-0analysis was limited by substantial bias.

AIM

To investigate the association between DFUs and vitamin D levels.

METHODS

We searched PubMed, MEDLINE, and Cochrane Library, EBSCO, and Google Scholar for studies comparing vitamin D levels and DF. The keywords DFU, DFS, diabetic septic foot, vitamin D level, 25-hydroxy vitamin D, vitamin D status, and vitamin D deficiency were used. The search engine was set for articles published during the period from inception to October 2022. A predetermined table was used to collect the study information.

RESULTS

Vitamin D level was lower among patients with DFU compared to their counterparts [odds ratio (OR): -5.77; 95% confidence interval (CI): -7.87 to -3.66; χ² was 84.62, mean difference, 9; I² for heterogeneity, 89%; P < 0.001 and P for overall effect < 0.001]. The results remained robust for hospitalized patients (OR: -6.32 95%CI: -11.66 to -0.97; χ² was 19.39; mean difference, 2; I² for heterogeneity, 90%; P = 0.02).

CONCLUSION

Vitamin D was lower among outpatients and hospitalized patients with DFUs. Further larger randomized controlled trials are needed.

Innovative Functional Biomaterials as Therapeutic Wound Dressings for Chronic Diabetic Foot Ulcers

The imbalance of local and systemic factors in individuals with diabetes mellitus (DM) delays, or even interrupts, the highly complex and dynamic process of wound healing, leading to diabetic foot ulceration (DFU) in 15 to 25% of cases. DFU is the leading cause of non-traumatic amputations worldwide, posing a huge threat to the well-being of individuals with DM and the healthcare system. Moreover, despite all the latest efforts, the efficient management of DFUs still remains a clinical challenge, with limited success rates in treating severe infections. Biomaterial-based wound dressings have emerged as a therapeutic strategy with rising potential to handle the tricky macro and micro wound environments of individuals with DM. Indeed, biomaterials have long been related to unique versatility, biocompatibility, biodegradability, hydrophilicity, and wound healing properties, features that make them ideal candidates for therapeutic applications. Furthermore, biomaterials may be used as a local depot of biomolecules with anti-inflammatory, pro-angiogenic, and antimicrobial properties, further promoting adequate wound healing. Accordingly, this review aims to unravel the multiple functional properties of biomaterials as promising wound dressings for chronic wound healing, and to examine how these are currently being evaluated in research and clinical settings as cutting-edge wound dressings for DFU management.

A Nurse-Led Telehealth Program for Diabetes Foot Care: Feasibility and Usability Study

BACKGROUND

Diabetes mellitus can lead to severe and debilitating foot complications, such as infections, ulcerations, and amputations. Despite substantial progress in diabetes care, foot disease remains a major challenge in managing this chronic condition that causes serious health complications worldwide.

OBJECTIVE

The primary aim of this study was to examine the feasibility and usability of a telehealth program focused on preventive diabetes foot care. A secondary aim was to descriptively measure self-reported changes in diabetes knowledge, self-care, and foot care behaviors before and after participating in the program.

METHODS

The study used a single-arm, pre-post design in 2 large family medical practice clinics in Texas. Participants met individually with the nurse practitioner once a month for 3 months using synchronous telehealth videoconferencing. Each participant received diabetes foot education guided by the Integrated Theory of Health Behavior Change. Feasibility was measured with rates of enrollment and program and assessment completion. Usability was measured with the Telehealth Usability Questionnaire. Diabetes knowledge, self-care, and foot care behaviors were measured with validated survey instruments at baseline, 1.5 months, and 3 months.

RESULTS

Of 50 eligible individuals, 39 (78%) enrolled; 34 of 39 (87%) completed the first videoconference and 29 of 39 (74%) completed the second and third videoconferences. Of the 39 who consented, 37 (95%) completed the baseline assessment; 50% (17/34) of those who attended the first videoconference completed the assessment at 1.5 months, and 100% (29/29) of those who attended the subsequent videoconferences completed the final assessment. Overall, participants reported a positive attitude toward the use of telehealth, with a mean Telehealth Usability Questionnaire score of 6.24 (SD 0.98) on a 7-point scale. Diabetes knowledge increased by a mean of 15.82 (SD 16.69) points of 100 (P<.001) from baseline to 3 months. The values for the Summary of Diabetes Self-Care Activities measure demonstrated better self-care, with participants performing foot care on average 1.74 (SD 2.04) more days per week (P<.001), adhering to healthy eating habits on average 1.57 (SD 2.12) more days per week (P<.001), and being physically active on average 1.24 (SD 2.21) more days per week (P=.005). Participants also reported an improvement in the frequency of foot self-examinations and general foot care behaviors. The mean scores for foot care increased by a mean of 7.65 (SD 7.04) points (scale of 7 to 35) from baseline to 3 months postintervention (P<.001).

CONCLUSIONS

This study demonstrates that a nurse-led telehealth educational program centered on diabetes foot care is feasible, acceptable, and has the potential to improve diabetes knowledge and self-care, which are precursors to preventing debilitating foot complications.

Proteomics and transcriptomics explore the effect of mixture of herbal extract on diabetic wound healing process

BACKGROUND

The annual incidence of diabetic foot ulcers (DFUs) has been reported to vary from 0.2% to 11% in diabetes-specific clinical settings and less than 0.1% to 8% in community- and population-based cohorts. According to the International Diabetes Foundation, approximately 40 million to 60 million people worldwide are affected by DFUs, and a recent meta-analysis indicates a global prevalence of 6.3% among adults with diabetes, or about 33 million individuals. The cost of diabetes care is significant, amounting to $273 billion in direct and $90 billion in indirect expenses annually, in America. Foot complications in diabetes care excess annual expenditures ranging from 50% to 200% above the baseline cost of diabetes-related care. The cost of advanced-stage ulcers can be more than $50,000 per wound episode, and the direct expenses of major amputation are even higher. DFUs can be treated using various methods, including wound dressings, antibiotics, pressure-off loading, skin substitutes, stem cells, debridement, topical oxygen therapy, gene therapy and growth factors. For severe DFUs patients are at risk of amputation if treatment is not timely or appropriate. Amputating limbs not only causes physical pain to patients, but also brings economic burden due to lost productivity, and decreased employment linked to DFUs. Currently, long-term use of local antibiotics in clinical practice is prone to induce drug resistance, while growth factors do not effectively inhibit bacterial growth and control inflammation in wounds. Stem cell and gene therapies are still in the experimental stage. The method of local debridement combined with negative pressure therapy is expensive. Therefore, we urgently need an affordable, non-surgical method to treat diabetic ulcers. Extracts of bark of Bauhinia purpurea, Paeoniae rubrae, Angelica dahurica (Hoffm.) Benth. & Hook.f. ex Franch. & Sav. (Hoffm.) Benth. & Hook.f. ex Franch. & Sav., Acorus calamus L, and Radix Angelicae biseratae have been used as traditional remedies to treat inflammation-related diseases and cutaneous wounds due to their anti-inflammatory properties and their ability to promote vascular renewal. However, there have been few studies on the mixture of these five herbal extracts on diabetic wound healing.

PURPOSE

This study was designed to assess the healing effect of a mixture of five aforementioned herbal extracts on diabetic ulcer wounds in rats, and to reveal the potential mechanisms behind any potential wound healing using transcriptomics and proteomics.

STUDY DESIGN

We designed the experiment to explore the effects of five herbal extracts on diabetic wound healing process through in vivo experiments and to investigate the underlying mechanisms through proteomics and transcriptomics.

METHODS

We used a mixture of five aforementioned herbal extract to treat rat model of diabetic established by intraperitoneal injection of streptozotocin, and a 2 × 2 cm round full-thickness skin defect was created on the back of the rat. Staphylococcus aureus (1 ml of 1.5 × 10⁹ cfu/ml) was evenly applied to the wound. The wound was then observed for 72 h. The infected ulcer model of diabetic rats was considered to be successfully established if the wound was found to be infected with S. aureus. According to different medications, the rats were divided into three groups, namely mixture of herbal extract (MHE), Kangfuxin solution (KFS) and control (Ctrl). The effects of the medicine on wound healing were observed. HE staining and Masson staining were performed to evaluate the histopathological changes and collagen synthesis. IHC staining was used to assess the neovascularization, and M2 macrophage proliferation was determined by immunofluorescence staining. Proteomic and transcriptomic studies were performed to explore potential mechanism of five herbal extracts to promote wound healing. UHPLC-QE-MS was performed to identify the chemical composition of mixture of herbal extract.

RESULTS

The study show that the mixed herbal extract promotes angiogenesis, proliferation of M2 macrophages, and collagen synthesis. Transcriptomics showed that rno-miR-1298, rno-miR-144-5p, and rno-miR-92a-1-5p are vital miRNAs which also play a significant role in role in regulating wound healing. Proteomics results showed that the following proteins were important in wounds treated with MHE: Rack1, LOC100362366, Cops2, Cops6, Eif4e, Eif3c, Rpl12, Srp54, Rpl13 and Lsm7. Autophagy, PI3-Akt and mTOR signaling pathways were enriched after treatment with MHE compared to other groups.

CONCLUSION

Herein, we have shown that MHE containing extracts of bark of Bauhinia purpurea, P. rubrae, A. dahurica (Hoffm.) Benth. & Hook.f. ex Franch. & Sav., A. calamus L, and R. A. biseratae has significant wound healing effects in the diabetic ulcer wound rat model. These results suggest that local application of MHE in diabetic wounds can accelerate the wound healing process. Moreover, in vivo experiments revealed that the diabetic wound healing process was primarily mediated by angiogenesis and M2 macrophage transition. Therefore, this study may provide a promising and non-surgical therapeutic strategy to accelerate diabetic wound healing, thereby decreasing the number of limb amputations in diabetic patients.

Evaluation of Adjuvant Antibiotic Loaded Injectable Bio-Composite Material in Diabetic Foot Osteomyelitis and Charcot Foot Reconstruction

The management of diabetic foot osteomyelitis (DFO) is extremely challenging with high amputation rates reported alongside a five-year mortality risk of more than fifty percent. We describe our experience in using adjuvant antibiotic-loaded bio-composite material (Cerament) in the surgical management of DFO and infected Charcot foot reconstruction. We undertook a retrospective evaluation of 53 consecutive patients (54 feet) who underwent Gentamicin or Vancomycin-loaded Cerament application during surgery. The feet were categorised into two groups: Group 1, with infected ulcer and DFO, managed with radical debridement only (n = 17), and Group 2, requiring reconstruction surgery for infected and deformed Charcot foot. Group 2 was further subdivided into 2a, with feet previously cleared of infection and undergoing a single-stage reconstruction (n = 19), and 2b, with feet having an active infection managed with a two-stage reconstruction (n = 18). The mean age was 56 years (27-83) and 59% (31/53) were males. The mean BMI was 30.2 kg/m² (20.8-45.5). Foot ulcers were present in 69% (37/54) feet. At a mean follow-up of 30 months (12-98), there were two patients lost to follow up and the mortality rate was 11% (n = 5). The mean duration of post-operative systemic antibiotic administration was 20 days (4-42). Thirteen out of fifteen feet (87%) in group 1 achieved complete eradication of infection. There was a 100% primary ulcer resolution, 100% limb salvage and 76% bony union rate within Group 2. However, five patients, all in group 2, required reoperations due to problems with bone union. The use of antibiotic-loaded Cerament resulted in a high proportion of patients achieving infection clearance, functional limb salvage and decrease in the duration of postoperative antibiotic therapy. Larger, preferably randomised, studies are required to further validate these observations.

Where do you stand?: an exploration of perspectives toward feet, foot health, and footwear using innovative digital methods

BACKGROUND

The cost of losing foot health is significant to the person, healthcare systems, and economy, with diabetes related foot health issues alone costing over £1 billion annually in the UK. Yet many foot health problems are preventable through alternative health behaviour. It is therefore important to understand how feet, foot health and footwear are conceptualised to gain understanding about how these might influence foot health behaviour and inform health messages that seek to protect or improve foot health through altered health behaviour. This research seeks to explore attitudes and beliefs and identify phenomena that may act as barriers or motivators to the proactive self-management of foot health.

METHODS

Public conversations involving 2,699 expressions related to feet, footwear or foot health on Facebook, Twitter, and Instagram were extracted. Conversations on Facebook and Twitter were scraped with NVivo's NCapture plugin whereby data is extracted and downloaded to NVivo. Extracted files were uploaded to the Big Content Machine (software developed at the University of Salford) which facilitated the search for keywords 'foot', 'feet', 'footwear', 'shoe', and 'shoes'. Instagram was scraped by hand. Data was analysed using a Thematic Analysis approach.

RESULTS

Three themes were identified; 1) connections and disconnections derived from social and cultural constructs, 2) phenomena beyond attitudes and beliefs that relate to symbolic representations and the impact when foot health is lost, and 3) phenomena relating to Social Media as a conduit for the exploration of attitudes and beliefs.

CONCLUSIONS

This novel research exemplifies complex and sometimes incongruous perspectives about feet including their value for what they facilitate, contrasted with negative feelings about the negative impact that can have aesthetically when feet work hard. Sometimes feet were devalued, with expressions of disgust, disconnection, and ridicule. The importance of contextual, social, and cultural phenomena with implications for optimising foot health messages. Knowledge gaps including factors related to children's foot health and development, and how to treat foot health problems. The power of communities with shared experience to influence decisions, theories, and behaviour about foot health was also revealed. While people do talk about feet in some social contexts, it is not always in a way that promotes overt, positive foot health behaviour. Finally, this research demonstrates the benefit of exploring perspectives in uncontrived settings and illuminates the potential utility of social media (SoMe) platforms Facebook, Instagram, and Twitter as vehicles to promote foot health self-management behaviour that is responsive to the social and demographic variances of engagers who inhabit those spaces.

Timing of Revascularization and Parenteral Antibiotic Treatment Associated with Therapeutic Failures in Ischemic Diabetic Foot Infections

For ischemic diabetic foot infections (DFIs), revascularization ideally occurs before surgery, while a parenteral antibiotic treatment could be more efficacious than oral agents. In our tertiary center, we investigated the effects of the sequence between revascularization and surgery (emphasizing the perioperative period of 2 weeks before and after surgery), and the influence of administering parenteral antibiotic therapy on the outcomes of DFIs. Among 838 ischemic DFIs with moderate-to-severe symptomatic peripheral arterial disease, we revascularized 608 (72%; 562 angioplasties, 62 vascular surgeries) and surgically debrided all. The median length of postsurgical antibiotic therapy was 21 days (given parenterally for the initial 7 days). The median time delay between revascularization and debridement surgery was 7 days. During the long-term follow-up, treatment failed and required reoperation in 182 DFI episodes (30%). By multivariate Cox regression analyses, neither a delay between surgery and angioplasty (hazard ratio 1.0, 95% confidence interval 1.0–1.0), nor the postsurgical sequence of angioplasty (HR 0.9, 95% CI 0.5–1.8), nor long-duration parenteral antibiotic therapy (HR 1.0, 95% CI 0.9–1.1) prevented failures. Our results might indicate the feasibility of a more practical approach to ischemic DFIs in terms of timing of vascularization and more oral antibiotic use.

Screening for diabetic peripheral neuropathy in resource-limited settings

BACKGROUND

Diabetic neuropathy is the most common microvascular complication of diabetes mellitus and a major risk factor for diabetes-related lower-extremity complications. Diffuse neuropathy is the most frequently encountered pattern of neurological dysfunction and presents clinically as distal symmetrical sensorimotor polyneuropathy. Due to the increasing public health significance of diabetes mellitus and its complications, screening for diabetic peripheral neuropathy is essential. Consequently, a review of the principles that guide screening practices, especially in resource-limited clinical settings, is urgently needed.

MAIN BODY

Numerous evidence-based assessments are used to detect diabetic peripheral neuropathy. In accordance with current guideline recommendations from the American Diabetes Association, International Diabetes Federation, International Working Group on the Diabetic Foot, and National Institute for Health and Care Excellence, a screening algorithm for diabetic peripheral neuropathy based on multiphasic clinical assessment, stratification according to risk of developing diabetic foot syndrome, individualized treatment, and scheduled follow-up is suggested for use in resource-limited settings.

CONCLUSIONS

Screening for diabetic peripheral neuropathy in resource-limited settings requires a practical and comprehensive approach in order to promptly identify affected individuals. The principles of screening for diabetic peripheral neuropathy are: multiphasic approach, risk stratification, individualized treatment, and scheduled follow-up. Regular screening for diabetes-related foot disease using simple clinical assessments may improve patient outcomes.

Antibacterial, Anti-Biofilm and Pro-Migratory Effects of Double Layered Hydrogels Packaged with Lactoferrin-DsiRNA-Silver Nanoparticles for Chronic Wound Therapy

Antimicrobial resistance and biofilm formation in diabetic foot infections worsened during the COVID-19 pandemic, resulting in more severe infections and increased amputations. Therefore, this study aimed to develop a dressing that could effectively aid in the wound healing process and prevent bacterial infections by exerting both antibacterial and anti-biofilm effects. Silver nanoparticles (AgNPs) and lactoferrin (LTF) have been investigated as alternative antimicrobial and anti-biofilm agents, respectively, while dicer-substrate short interfering RNA (DsiRNA) has also been studied for its wound healing effect in diabetic wounds. In this study, AgNPs were complexed with LTF and DsiRNA via simple complexation before packaging in gelatin hydrogels. The formed hydrogels exhibited 1668% maximum swellability, with a 46.67 ± 10.33 µm average pore size. The hydrogels demonstrated positive antibacterial and anti-biofilm effects toward the selected Gram-positive and Gram-negative bacteria. The hydrogel containing AgLTF at 125 µg/mL was also non-cytotoxic on HaCaT cells for up to 72 h of incubation. The hydrogels containing DsiRNA and LTF demonstrated superior pro-migratory effects compared to the control group. In conclusion, the AgLTF-DsiRNA-loaded hydrogel possessed antibacterial, anti-biofilm, and pro-migratory activities. These findings provide a further understanding and knowledge on forming multipronged AgNPs consisting of DsiRNA and LTF for chronic wound therapy.

EGF, a veteran of wound healing: highlights on its mode of action, clinical applications with focus on wound treatment, and recent drug delivery strategies

Epidermal growth factor (EGF) has been used in wound management and regenerative medicine since the late 1980s. It has been widely utilized for a long time and still is because of its excellent tolerability and efficacy. EGF has many applications in tissue engineering, cancer therapy, lung diseases, gastric ulcers, and wound healing. Nevertheless, its in vivo and during storage stability is a primary concern. This review focuses on the topical use of EGF, especially in chronic wound healing, the emerging use of biomaterials to deliver it, and future research possibilities. To successfully deliver EGF to wounds, a delivery system that is proteolytically resistant and stable over the long term is required. Biomaterials are an area of interest for the development of such systems. These systems may be used in non-healing wounds such as diabetic foot ulcers, pressure ulcers, and burns. In these pathologies, EGF can reduce the risk of amputation of the lower extremities, as it accelerates the wound healing process. Furthermore, appropriate delivery system would also stabilize and control the EGF release profile in a wound. Several in vitro and in vivo studies have already proven the efficacy of such systems in the above-mentioned types of wounds. Moreover, several formulations such as ointments and intralesional injections are already available on the market. However, these products are still problematic in terms of inadequate diffusion of EGF, low bioavailability storage conditions, and shelf-life. This review discusses the nano formulations comprising biomaterials infused with EGF which could be a promising delivery system for chronic wound healing in the future.

Informal Family Caregiving of Patients with Diabetic Extremity Wounds: An Integrative Review

Annually, 26 million people worldwide develop diabetic extremity wounds, adversely impacting the lives of patients and their family caregivers, who provide vital health assistance to these patients. This integrative review synthesized scientific literature of informal caregiving experiences for patients with diabetic extremity wounds. Five databases were searched for relevant English-language quantitative or qualitative research; ten studies were included in the final analysis. The caregiving experience included disrupted routines, frustration, guilt, poor health care communication, helplessness, and anxiety. Increased caregiver burden and decreased quality of life were associated with higher patient amputation level, worsening wound appearance and patient pain, poor health care communication, lack of social support and/or caregiving help, and lack of caregiver employment outside the home. Future research opportunities include further exploration of caregiver tasks and priorities, caregiving experiences in settings lacking family support structures and equitable health system access, and relationships between the caregiver experience and patient health system utilization.

The challenging surgical vascular access creation

With the increasing life expectancy of patients with end-stage kidney disease, the creation and maintenance of hemodialysis vascular access are becoming more challenging. A comprehensive patient evaluation including a complete history, physical examination, and ultrasonographic vessel assessment is the foundation of the clinical evaluation. A patient-centered approach acknowledges the myriad of factors that impact the selection of optimal access for the distinct clinical and social circumstance of each patient. An interdisciplinary team approach involving various healthcare providers in all stages of hemodialysis access creation is important and associated with better outcomes. While patency is considered the most important parameter in most vascular reconstructive scenarios, the ultimate determinant of success in vascular access for hemodialysis is a circuit that allows consistent and uninterrupted delivery of the prescribed hemodialysis. The best conduit is one that is superficial, easily identified, straight, and of a large caliber. Individual patient factors and skill level of the cannulating technician also play a crucial role in the initial success and maintenance of vascular access. Special attention should be considered in dealing with more challenging groups such as the elderly population where the newest vascular access guidance from The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative will be transformative. The current guidelines recommend monitoring the vascular access by regular physical and clinical assessments, however, inadequate evidence is available to support routine ultrasonographic surveillance for improving access patency.

Green Antimicrobials as Therapeutic Agents for Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) are one of the most serious and devastating complications of diabetes and account for a significant decrease in quality of life and costly healthcare expenses worldwide. This condition affects around 15% of diabetic patients and is one of the leading causes of lower limb amputations. DFUs generally present poor clinical outcomes, mainly due to the impaired healing process and the elevated risk of microbial infections which leads to tissue damage. Nowadays, antimicrobial resistance poses a rising threat to global health, thus hampering DFU treatment and care. Faced with this reality, it is pivotal to find greener and less environmentally impactful alternatives for fighting these resistant microbes. Antimicrobial peptides are small molecules that play a crucial role in the innate immune system of the host and can be found in nature. Some of these molecules have shown broad-spectrum antimicrobial properties and wound-healing activity, making them good potential therapeutic compounds to treat DFUs. This review aims to describe antimicrobial peptides derived from green, eco-friendly processes that can be used as potential therapeutic compounds to treat DFUs, thereby granting a better quality of life to patients and their families while protecting our fundamental bio-resources.

Transcriptional heterogeneity in human diabetic foot wounds

Wound repair requires the coordination of multiple cell types including immune cells and tissue resident cells to coordinate healing and return of tissue function. Diabetic foot ulceration is a type of chronic wound that impacts over 4 million patients in the US and over 7 million worldwide (Edmonds et al., 2021). Yet, the cellular and molecular mechanisms that go awry in these wounds are not fully understood. Here, by profiling chronic foot ulcers from non-diabetic (NDFUs) and diabetic (DFUs) patients using single-cell RNA sequencing, we find that DFUs display transcription changes that implicate reduced keratinocyte differentiation, altered fibroblast function and lineages, and defects in macrophage metabolism, inflammation, and ECM production compared to NDFUs. Furthermore, analysis of cellular interactions reveals major alterations in several signaling pathways that are altered in DFUs. These data provide a view of the mechanisms by which diabetes alters healing of foot ulcers and may provide therapeutic avenues for DFU treatments.

Stress reduction interventions for patients with chronic diabetic foot ulcers: a qualitative study into patients and caregivers' perceptions

BACKGROUND

The present study aimed to assess the perceptions of patients with chronic diabetic foot ulcers (DFUs) and their family caregivers regarding the impact of two stress reduction interventions on DFU and psychological wellbeing. The intervention included progressive muscle relaxation and hypnosis sessions.

METHODS

This study used a qualitative exploratory design and included individual interviews with eight patients with chronic DFUs and six family caregivers, using a semi-structured interview guide. Transcript analysis employed thematic content analysis.

RESULTS

Four key themes common to patients and their caregivers were found: 1) perspectives regarding the intervention; 2) intervention effectiveness; 3) perceived importance of psychology in the DFU treatment; and 4) emotional consequences associated with DFUs. Although themes were common to both intervention groups, sub-themes from the last two themes differed for patients that received muscle relaxation versus those who received hypnosis.

CONCLUSION

Patients and caregivers reported perceived benefits from both interventions, regarding DFU healing and emotional wellbeing. Patients who received hypnosis and their caregivers also reported lasting effects. Participants suggested that psychological interventions such as stress reduction interventions could be included in the DFU standard treatment as an adjuvant to the clinical protocol for DFU treatment, preferably offered early on, when patients begin treatment at the diabetic foot consultation.

The perceptions of living with diabetic foot ulcers: A systematic review and meta-synthesis of qualitative studies

BACKGROUND

Diabetic foot ulcers are associated with decreased quality of life in patients with diabetes and impose a heavy burden on patients, their families, and the health care system. For health providers, a deeper understanding of the perceptions of patients is significant. They can provide better management and direction to patients with diabetic foot ulcers, thus improving their quality of life.

OBJECTIVES

To synthesize the findings of qualitative studies to explore the perceptions of individuals living with diabetic foot ulcers.

DESIGN

A systematic review and meta-synthesis of qualitative studies.

METHODS

Published qualitative research articles were identified in PubMed, CINAHL, Embase, ISI Web of Science, Ovid, and Scopus from inception to January 2022, and bibliographical reports were reviewed. In addition, combing with the search for unpublished studies in the Google Scholar ProQuest Dissertations and Theses Database, we conducted a meta-synthesis.

RESULTS

Fourteen articles were eligible for inclusion, and the total number of included individuals was 226, with ages ranging from 28 to 84 years. The perceptions of individuals with diabetic foot ulcers synthesized four overarching themes and their subthemes: perceptions of diabetic foot ulcers (Realization, Reasons), living with diabetic foot ulcers (Change in life, Physical burdens, Emotional burdens, Economic burdens), coping with diabetic foot ulcers (Hospital attendance, Attitude toward amputation, Treatment, Management), and expectations (Expectation of health-personnel, Future expectation).

CONCLUSIONS

Individuals with diabetic foot ulcers suffer greatly in their physical, psychological, and social aspects. Comprehensive and individualized patient-centered care and appropriate families and social support for patients with diabetic foot ulcers should be provided.

Progress and expectation of stem cell therapy for diabetic wound healing

Impaired wound healing presents great health risks to diabetics. Encouragingly, the current clinical successfully found out meaningful method to repair wound tissue, and stem cell therapy could be an effective method for diabetic wound healing with its ability to accelerate wound closure and avoid amputation. This minireview aims at introducing stem cell therapy for facilitating tissue repair in diabetic wounds, discussing the possible therapeutic mechanism and clinical application status and problems.

Exploring the mechanism by which aqueous Gynura divaricata inhibits diabetic foot based on network pharmacology, molecular docking and experimental verification

BACKGROUND

To predict and validate the potential mechanism by which Gynura divaricata (GD) functions in the treatment of diabetic foot (DF).

METHODS

The main chemical constituents of GD were identified by reviewing the literature, the traditional Chinese medicine database platform (TCMIP) and the BATMAN-TCM platform. DF disease targets were identified with the GeneCards database, and the compound-target network was constructed by using the intersection of drugs and disease. The STRING platform was used to construct the protein-protein interaction (PPI) network, and Cytoscape 3.7.2 software was used to visualize the results. Moreover, the Metascape database was used for Gene Ontology (GO) enrichment analyses and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses. Molecular docking of the active ingredients of GD and core protein targets of DF was performed using AutoDock software. Finally, the predicted results were preliminarily verified with experiments.

RESULTS

A total of 140 potential targets of GD were identified and associated with DF. According to the PPI network analysis, GD accelerated DF wound healing, and the mechanism may be related to proteins such as AKT1, TP53, IL6, CASP3, TNF, and VEGFA. GO and KEGG enrichment analyses indicated that GD may play a role in the treatment of diabetic foot by affecting various signaling pathways. Molecular docking results showed that the proteins AKT1, TP53, IL6, CASP3, TNF, and VEGFA were closely associated with the components of GD. The animal experiments showed that GD reduced the levels of IL-6 and TNF-α and increased the mRNA and protein expression of VEGFA in rats with DF.

CONCLUSIONS

GD regulates multiple targets and multiple pathways to promote wound healing in DF.

Factors influencing the use of therapeutic footwear in persons with diabetes mellitus and loss of protective sensation: A focus group study

BACKGROUND

Persons with diabetes mellitus (DM) and loss of protective sensation (LOPS) due to peripheral neuropathy do not use their therapeutic footwear (TF) consistently. TF is essential to prevent foot ulceration. In order to improve compliance in using TF, influencing factors need to be identified and analyzed. Persons with a history of foot ulceration may find different factors important compared with persons without ulceration or persons who have never used TF. Therefore, the objective of this study was to determine factors perceived as important for the use of TF by different groups of persons with DM and LOPS.

METHOD

A qualitative study was performed using focus group discussions. Subjects (n = 24) were divided into 3 focus groups based on disease severity: ulcer history (HoU) versus no ulcer history (no-HoU) and experience with TF (TF) versus no experience (no-TF). For each group of 8 subjects (TF&HoU; TF&no-HoU; no-TF&no-HoU), an online focus group discussion was organized to identify the most important influencing factors. Transcribed data were coded with Atlas.ti. The analysis was performed following the framework approach.

RESULTS

The factors comfort and fit and stability/balance were ranked in the top 3 of all groups. Usability was ranked in the top 3 of group-TF&noHoU and group-noTF&noHoU. Two other factors, reducing pain and preventing ulceration were ranked in the top 3 of group-TF&noHoU and group-TF&HoU, respectively.

CONCLUSION

Experience with TF and a HoU influence which factors are perceived as important for TF use. Knowledge of these factors during the development and prescription process of TF may lead to increased compliance. Although the main medical reason for TF prescription is ulcer prevention, only 1 group gave this factor a high ranking. Therefore, next to focusing on influencing factors, person-centered education on the importance of using TF to prevent ulcers is also required.

Investigating the effects of digital foot self-management program on enhancing self-efficacy and self-care behavior among community-dwelling older adults with type 2 diabetes: A randomized controlled trial

Introduction

Diabetic foot self-management intervention programs have been proven to positively influence individuals' behaviors in preventing diabetic foot ulcers. Using digital technologies to deliver programs can facilitate compliance with diabetes self-management programs. However, few studies have focused on the effects of such digital programs on improving the self-efficacy and behaviors of older adults with type 2 diabetes in the community.

Aim

To evaluate the effects of a digital foot self-management program on self-efficacy, self-care behavior, and Hemoglobin A1c levels.

Design

A single-blinded, randomized controlled trial was conducted.

Methods

The intervention program comprised a 4-week digital foot care program with one face-to-face education session, phone calls once weekly, and LINE messages (social media) three times per research nurse and a follow-up of three months. Patients in the control group received routine care.

Results

A total of 100 participants (n = 50 in the control and n = 50 in the intervention groups) completed the study with a mean age of 67.55 (SD = 11.17). The results showed significant improvements in self-efficacy (F = 2187.24, p < 0.01) and self-care behavior (F = 614.71, p < 0.01) in foot care between the groups. The Hemoglobin A1c levels showed a 0.41% reduction over time in the experimental group (t = -3.759; p < 0.01), whereas the control group showed a 0.06% reduction (t = -0.797, p > 0.05).

Conclusion

The newly developed digital foot self-management program was effective in community-dwelling older adult patients with type 2 diabetes.

Nanomaterials for diabetic wound healing: Visualization and bibliometric analysis from 2011 to 2021

BACKGROUND

Nanomaterials have recently been shown to have a considerable advantage in promoting wound healing in diabetic patients or animal models. However, no bibliometric analysis has been conducted to evaluate global scientific production. Herein, this study aimed to summarize the current characteristics, explore research trends, and clarify the direction of nanomaterials and diabetic wound healing in the future.

METHODS

Relevant publications from 2011 to 2021 were collected from the Web of Science Core Collection on October 3, 2022. VOSviewer, CiteSpace, bibliometrix-R package, Origin 2021, and Microsoft Excel 2019 were used for bibliometric and visualization analyses.

RESULTS

We identified 409 publications relating to nanomaterials and diabetic wound healing. The number of annual productions remarkably increased from 2011 to 2021, with China and Shanghai Jiao Tong University being the most productive. The most prolific authors were Hasan Anwarul. The leading journal was the International Journal of Biological Macromolecules, with 22 publications. The most popular keywords were "nanoparticles," "delivery," "in vitro," "electrospinning," "angiogenesis," and "antibacterial." Keyword burst analysis showed "cerium oxide," "matrix metalloproteinase 9," "composite nanofiber," "hif 1 alpha," and "oxide nanoparticle" were emerging research hotspots.

CONCLUSION

We found there has been a great progress in the application of nanomaterials in diabetic wound healing from 2011 to 2021. Although many researchers and institutions from different countries or regions contributed contributed to publications, it will be helpful or the development of this field if the degree of international cooperation can be enhanced. In the future, nanomaterials with powerful antioxidant and antibacterial qualities and promoting angiogenesis are the research hotspots.