Can major amputation rates be decreased in diabetic foot ulcers with hyperbaric oxygen therapy?

A Narrative Review of Diabetic Macroangiopathy: From Molecular Mechanism to Therapeutic Approaches

Diabetic macroangiopathy, a prevalent and severe complication of diabetes mellitus, significantly contributes to the increased morbidity and mortality rates among affected individuals. This complex disorder involves multifaceted molecular mechanisms that lead to the dysfunction and damage of large blood vessels, including atherosclerosis (AS) and peripheral arterial disease. Understanding the intricate pathways underlying the development and progression of diabetic macroangiopathy is crucial for the development of effective therapeutic interventions. This review aims to shed light on the molecular mechanism implicated in the pathogenesis of diabetic macroangiopathy. We delve into the intricate interplay of chronic inflammation, oxidative stress, endothelial dysfunction, and dysregulated angiogenesis, all of which contribute to the vascular complications observed in this disorder. By exploring the molecular mechanism involved in the disease we provide insight into potential therapeutic targets and strategies. Moreover, we discuss the current therapeutic approaches used for treating diabetic macroangiopathy, including glycemic control, lipid-lowering agents, and vascular interventions.

Thermosensitive and antioxidant wound dressings capable of adaptively regulating TGFβ pathways promote diabetic wound healing

Various therapies have been utilized for treating diabetic wounds, yet current regiments do not simultaneously address the key intrinsic causes of slow wound healing, i.e., abnormal skin cell functions (particularly migration), delayed angiogenesis, and chronic inflammation. To address this clinical gap, we develop a wound dressing that contains a peptide-based TGFβ receptor II inhibitor (PTβR2I), and a thermosensitive and reactive oxygen species (ROS)-scavenging hydrogel. The wound dressing can quickly solidify on the diabetic wounds following administration. The released PTβR2I inhibits the TGFβ1/p38 pathway, leading to improved cell migration and angiogenesis, and decreased inflammation. Meanwhile, the PTβR2I does not interfere with the TGFβ1/Smad2/3 pathway that is required to regulate myofibroblasts, a critical cell type for wound healing. The hydrogel's ability to scavenge ROS in diabetic wounds further decreases inflammation. Single-dose application of the wound dressing significantly accelerates wound healing with complete wound closure after 14 days. Overall, using wound dressings capable of adaptively modulating TGFβ pathways provides a new strategy for diabetic wound treatment.

A Systematic Review to Assess the Impact of Hyperbaric Oxygen Therapy on Glycaemia in People with Diabetes Mellitus

Background and Objectives: Hyperbaric oxygen is a recognised treatment for a range of medical conditions, including treatment of diabetic foot disease. A number of studies have reported an impact of hyperbaric oxygen treatment on glycaemic control in patients undergoing treatment for diabetic foot disease. There has been no systematic review considering the impact of hyperbaric oxygen on glycaemia in people with diabetes. Materials and Methods: A prospectively PROSPERO-registered (PROSPERO registration: CRD42021255528) systematic review of eligible studies published in English in the PUBMED, MEDLINE, and EMBASE databases, based on the following search terms: hyperbaric oxygen therapy, HBO2, hyperbaric oxygenation, glycaemic control, diabetes, diabetes Mellitus, diabetic, HbA1c. Data extraction to pre-determined piloted data collection form, with individual assessment of bias. Results: In total, 10 eligible publications were identified after screening. Of these, six articles reported a statistically significant reduction in blood glucose from hyperbaric oxygen treatment, while two articles reported a statistically significant increase in peripheral insulin sensitivity. Two articles also identified a statistically significant reduction in HbA1c following hyperbaric oxygen treatment. Conclusions: There is emerging evidence suggesting a reduction in glycaemia following hyperbaric oxygen treatment in patients with diabetes mellitus, but the existing studies are in relatively small cohorts and potentially underpowered. Additional large prospective clinical trials are required to understand the precise impact of hyperbaric oxygen treatment on glycaemia for people with diabetes mellitus.

Hyperbaric oxygen therapy for nonischemic diabetic ulcers: A systematic review

Diabetic foot ulcers are a common complication of diabetes, which affects 25% of patients and may ultimately lead to amputation of affected limbs. Research suggests hyperbaric oxygen therapy improves healing of these ulcers. However, this has not been reflected in previous reviews, possibly because they did not differentiate between patients with and without peripheral arterial occlusive disease. Therefore, we performed a systematic review of published literature in the MEDLINE, Embase, and Cochrane CENTRAL databases on nonischemic diabetic foot ulcers with outcome measures including complete ulcer healing, amputation rate (major and minor), and mortality. Seven studies were included, of which two were randomized clinical trials. Two studies found no difference in major amputation rate, whereas one large retrospective study found 2% more major amputations in the hyperbaric oxygen group. However, this study did not correct for baseline differences. Two studies showed no significant difference in minor amputation rate. Five studies reporting on complete wound healing showed no significant differences. In conclusion, the current evidence suggests that hyperbaric oxygen therapy does not accelerate wound healing and does not prevent major or minor amputations in patients with a diabetic foot ulcer without peripheral arterial occlusive disease. Based on the available evidence, routine clinical use of this therapy cannot be recommended. However, the available research for this specific subgroup of patients is scarce, and physicians should counsel patients on expected risks and benefits. Additional research, focusing especially on patient selection criteria, is needed to better identify patients that might profit from this therapy modality.

Atypical Wounds; Hyperbaric Oxygen Therapy

Patients with severe diabetic foot ulcerations that fail to heal with standard conventional therapies may be candidates for hyperbaric oxygen therapy; these patients also should be evaluated for atypical wound etiologies. Medical evaluation includes thorough history, physical examination, screening laboratory tests, and ulcer biopsy. During hyperbaric oxygen therapy, patients breathe 100% oxygen at 2 times to 3 times atmospheric pressure while enclosed in a hyperbaric chamber. Over time, administration of hyperbaric oxygen therapy can result in wound neovascularization and enhanced limb salvage. In patients with suspected atypical ulceration, referral to a multidisciplinary wound healing center is considered standard of care.

Efficacy of Hyperbaric Oxygen Therapy in Diabetic Foot Ulcers Based on Wagner Classification

Diabetic foot ulcer is a common chronic complication of diabetes mellitus. In addition to conventional primary therapy, there are adjuvant therapy methods such as hyperbaric oxygen therapy for the healing of diabetic foot ulcer wounds. The present study aimed to determine the efficacy of hyperbaric oxygen therapy in diabetic foot ulcers based on Wagner classification. It was performed retrospectively from prospectively collected data. One hundred thirty patients with diabetic foot ulcers were assessed in 2 groups: 1 group received hyperbaric oxygen therapy; the other group did not. Patients were examined according to age, sex, ulcer grade based on Wagner classification; ulcer healing status; whether hyperbaric oxygen therapy was received; duration of diabetes in years; HbA1C, sedimentation, C-reactive protein levels; and presence of accompanying diseases, including peripheral arterial disease, chronic obstructive pulmonary disease, hypertension, chronic kidney disease, neuropathy, and retinopathy. The mean follow-up period was 19.5 ± 4.45 months (range 12 to 28 months). Seventy-one (54.6%) patients received hyperbaric oxygen therapy, and 59 (45.4%) patients did not. All patients in Wagner grade 2 healed in both groups. In the group that received hyperbaric oxygen therapy for grade 3 and 4 patients, 35 (87.5%) and 11 (84.6%) healed, respectively. In total, 60 (84.5%) patients in the group that received hyperbaric oxygen therapy healed. The subgroup comparison conducted according to Wagner classification revealed no differences between the 2 groups of grades 2 and 5 patients. It also revealed that treatment had higher levels of efficacy in the healing of ulcers in grade 3 and 4 patients.

Adjuvant Lymphatic Osteopathic Manipulative Treatment in Patients With Lower-Extremity Ulcers: Effects on Wound Healing and Edema

Context

In 2012, the US wound registry estimated that the cost of managing chronic wounds in the United States exceeded $50 billion. A large percentage of these wounds are venous stasis ulcers of the lower extremity. Evidence suggests that adjuvant osteopathic manipulative treatment (OMT) may provide a benefit by reducing edema and subsequent healing times in venous stasis ulcers of the lower extremity.

Objective

To determine whether a lymphatic OMT protocol improves wound healing rates among patients with lower-extremity edema.

Methods

This pilot study was a nonrandomized before-after community trial of lymphatic OMT in patients with lower-extremity wounds and edema. Wound surface area measurements for the preliminary phase were obtained retrospectively. During the intervention period, patients received 10 minutes of OMT twice per week. The OMT protocol, which aimed to improve lymphatic flow, included myofascial thoracic outlet release, doming of the diaphragm, pelvic diaphragm release, popliteal release, and pedal pump (2-3 minutes of continuous pump) performed in sequence. Rates of wound healing were compared between the preliminary (standard therapy), intervention (standard therapy plus OMT), and follow-up (standard therapy) phases. Rates of change in edema (measured using leg volume) were evaluated during the intervention phase. A custom-designed questionnaire was used to assess patients’ satisfaction with their treatment and confidence that its effects on their health were good.

Results

Eight patients were included in the study. The wound surface area increased during the preliminary phase by a mean of 10 cm2/wk and decreased during the intervention phase by a mean of 4.9 cm2/wk. Patients’ mean leg volume decreased during the intervention phase. Six patients were “very satisfied” with their treatment.

Conclusion

The adjunctive OMT protocol may have reduced edema and reversed the trend of wound growth in patients with venous stasis ulcers. Edema reduction is a mainstay of current wound therapy, and any modality that decreases edema may subsequently decrease healing times.

Hyperbaric Oxygen Increases Stem Cell Proliferation, Angiogenesis and Wound-Healing Ability of WJ-MSCs in Diabetic Mice

Hyperbaric oxygen therapy (HBOT) is effective for the medical treatment of diverse diseases, infections, and tissue injury. In fact, in recent years there is growing evidence on the beneficial effect of HBOT on non-healing ischemic wounds. However, there is still yet discussion on how this treatment could benefit from combination with regenerative medicine strategies. Here we analyzed the effects of HBOT on three specific aspects of tissue growth, maintenance, and regeneration: (i) modulation of adult rodent (Mus musculus) intestinal stem cell turnover rates; (ii) angiogenesis dynamics during the development of the chorio-allantoic membrane (CAM) in Gallus gallus embryos; (iii) and wound-healing in a spontaneous type II diabetic mouse model with a low capacity to regenerate skin. To analyze these aspects of tissue growth, maintenance, and regeneration, we used HBOT alone or in combination with cellular therapy. Specifically, Wharton Jelly Mesenchymal Stem cells (WJ-MSC) were embedded in a commercial collagen-scaffold. HBOT did not affect the metabolic rate of adult mice nor of chicken embryos. Notwithstanding, HBOT modified the proliferation rate of stem cells in the mice small intestinal crypts, increased angiogenesis in the CAM, and improved wound-healing and tissue repair in diabetic mice. Moreover, our study demonstrates that combining stem cell therapy and HBOT has a collaborative effect on wound-healing. In summary, our data underscore the importance of oxygen tension as a regulator of stem cell biology and support the potential use of oxygenation in clinical treatments.

A Comparative Study of the Effects of Nigella sativa Oil Gel and Aloe Vera Gel on Wound Healing in Diabetic Rats

Clinicians and wound care nurses in Indonesia usually use Nigella sativa oil (NSO) gel and aloe vera (AV) gel to treat diabetic ulcers. However, there are no studies directly comparing the effects of NSO and AV gels on wound healing, so it is unknown which of these 2 plants is better at promoting wound healing in diabetic ulcers. If the comparative efficacy between these 2 gels was known, it would be important evidence favoring the clinical use of one or the other product in Indonesia. The aim of this study was to investigate and compare the effectiveness of NSO and AV gels on wound healing in a rat model of diabetic ulcers. This experimental study involved 3 groups: NSO gel, AV gel, and controls. Our study showed that from day 5 onward, necrotic tissue and inflammation decreased in the AV gel group compared with the other groups. The wound areas on days 6 (P = .020) and 7 (P = .021) were significantly smaller in the AV gel group than in the NSO gel group. Reepithelialization was also better in the AV gel group than in the other groups. This is the first study to compare the effects of AV and NSO gels on wound healing in diabetic ulcers. Our study indicates that the AV gel is better than the NSO gel. Therefore, it is recommended that clinicians and wound care nurses use AV gel instead of NSO gel for the topical treatment of diabetic ulcers.

Hyperbaric oxygen treatment in thromboangiitis obliterans: a retrospective clinical audit

INTRODUCTION

Wounds refractory to standard treatment in patients with thromboangiitis obliterans (TAO, Buerger's disease) are associated with amputation, other morbidity and mortality. The purpose of this study was to investigate the effect of hyperbaric oxygen treatment (HBOT) in patients with TAO.

MATERIALS AND METHODS

Ninety-seven patients with TAO with ischaemic wounds treated between January 2007 and July 2016 were included in this dual-centre, non-randomised, retrospective study. Patients receiving HBOT in addition to conventional treatment were enrolled in an HBOT group (n = 47) and those receiving conventional treatment alone in a non-HBOT group (n = 50). All patients were Rutherford grade III at the time of enrolment.

RESULTS

Significant improvement in the major amputation rate was observed in the HBOT group 10 months after starting treatment (2/47 vs. 13/50, P = 0.007). Numbers of patients progressing to Rutherford grade I (27/47 vs. 17/50, P = 0.035), numbers of patients healing completely (21 vs. 11, P = 0.031 and pain scores (visual analogue scale; 1, range 0-8 vs. 6, range 0-9, P < 0.001) were also significantly improved in the HBOT group.

CONCLUSION

The addition of HBOT to conventional treatment in TAO patients with non-healing ischaemic wounds and severe extremity pain, conferred significant benefits in terms of wound healing and rest pain control. Multi-centre, prospective, randomized studies with blinded outcome analysis are now needed to elicit more reliable results.

Amputation predictors in diabetic foot ulcers treated with hyperbaric oxygen

OBJECTIVE

Although hyperbaric oxygen therapy (HBOT) has long been used for diabetic foot ulcers (DFUs), its effectiveness is still controversial. The aim of this study was to investigate the efficacy of HBOT in the management of DFUs and identify amputation predictors.

METHOD

Patients with chronic DFUs (Wanger grade 2-5) were included in the study, which took place between January 2010 and December 2012. HBOT, 100% oxygen, 2.4 atmosphere absolute (ATA) for 120 minutes, was administered to all patients in addition to standard treatment. DFUs were monitored for at least 3 years, or until healing or amputation occurred.

RESULTS

Patients with a total of 146 chronic DFUswere recruited. Complete healing (69.6%) and significant improvement (17.9%) was observed in 87.5% of the patients. The cases with no improvement resulted in amputation (minor amputation: 15.0%; major amputation: 8.2%). The duration of diabetes (p=0.037), new wound formation (p=0.045), C-reactive protein (p=0.001) and Wagner grade (p=0.0001) were correlated with amputation in multiple regression analysis. Mortality was higher in the amputation group than in the non-amputation group (47.1 % versus 21.4 %, p=0.007).

CONCLUSION

The inclusion of HBOT with standard treatment and a multidisciplinary approach may be useful in the treatment of DFUs. We found the most important predictors of amputation to be Wagner grade and wound infection. Multicentre, prospective, randomised studies are needed to provide more evidence.

Oxygen therapies and their effects on wound healing

Oxygen is an important factor for wound healing. Although several different therapies investigated the use of oxygen to aid wound healing, the results of these studies are not unequivocal. This systematic review summarizes the clinical and experimental studies regarding different oxygen therapies for promoting wound healing, and evaluates the outcomes according the methodological details. A systematic literature search was conducted using Embase, Medline, Web of Science, Cochrane, PubMed publisher, and Google Scholar libraries. Clinical and experimental studies investigating oxygen for wound healing were selected. Included articles were categorized according to the kind of therapy, study design, and wound type. The methodological details were extracted and analyzed. Sixty-five articles were identified and divided in three different oxygen therapies: Local oxygen therapy, hyperbaric oxygen therapy, and supplemental inspired oxygen therapy. More than half of the included local oxygen and hyperbaric oxygen studies had one or more significant positive outcomes, 77 and 63%, respectively. Supplemental inspired oxygen therapy during gastrointestinal and vascular surgery was more likely to have a positive result than during other surgical interventions reducing surgical site infections. These many positive outcomes promote the use of oxygen treatment in the stimulation of wound healing. However, the lack of clinical studies and vast methodological diversity made it impossible to perform a proper comparison within and between the different therapies. Further randomized clinical studies are warranted to examine the value of these therapies, especially studies that investigate the more patient-friendly oxygen dressings and topical wound oxygen therapies. Also, to achieve more solid and consistent data, studies should use more standardized methods and subjects.

Diabetes and Wound Angiogenesis

Diabetes Mellitus Type II (DM2) is a growing international health concern with no end in sight. Complications of DM2 involve a myriad of comorbidities including the serious complications of poor wound healing, chronic ulceration, and resultant limb amputation. In skin wound healing, which has definite, orderly phases, diabetes leads to improper function at all stages. While the etiology of chronic, non-healing diabetic wounds is multi-faceted, the progression to a non-healing phenotype is closely linked to poor vascular networks. This review focuses on diabetic wound healing, paying special attention to the aberrations that have been described in the proliferative, remodeling, and maturation phases of wound angiogenesis. Additionally, this review considers therapeutics that may offer promise to better wound healing outcomes.

Hyperbaric Oxygen Therapy in the Treatment of Fontaine Stage IV Thromboangiitis Obliterans

Ischemic wounds unresponsive to standard treatment in thromboangiitis obliterans are associated with amputation, morbidity, and mortality. In this study, hyperbaric oxygen therapy was added to standard treatment of 36 patients with thromboangiitis obliterans with ischemic ulcerated wounds in the extremities. Full recovery was observed in 52.7% of cases (25% at discharge, 27.7% during follow-up). Resting pain after treatment decreased significantly compared to pretreatment levels based on visual analog scale scores (7.1 ± 1.7 vs 2.2 ± 3.0, P = .0001). Mean wound area also decreased significantly after treatment (22.6 ± 17.5 vs 13.02 ± 16.5, P = .0001). The number of patients requiring no assistance during routine daily activities increased significantly (25% vs 55.5%, P = .001). All patients were at Fontaine stage IV before hyperbaric oxygen therapy. The number of patients at stage IIB increased significantly after treatment, while that of patients at stage IV decreased significantly (0% vs 47.2%, P = .0001, and 100% vs 47.2%, P = .0001, respectively). None of our patients was able to walk without pain before treatment; however, walking distance was significantly extended in 16 patients who were capable of walking (0 vs 190.6 ± 129.4 meters, P = .0001). In addition, 11.1% of patients underwent major amputation during follow-up.

Diabetic Foot Ulcers: The Importance of Patient Comorbidity Recognition and Total Contact Casting in Successful Wound Care

Diabetic foot ulcers (DFUs) are a major burden on the health-care system. The purpose of this study is to investigate factors affecting the healing rate of DFU in a university wound care center. Records of DFU patients treated between July 2013 and February 2015 were reviewed. Demographics, comorbidities, wound characteristics, and treatment modalities including offloading, hyperbaric oxygen treatment, total contact casting, and bioengineered skin were investigated. All patients underwent weekly debridement regardless of treatment modality. A total of 114 patients ages 18 to 98 comprised the study population. Total contact casting was the only treatment associated with increased healing ( P = 0.02). Smoking ( P = 0.004) and deep vein thrombosis history ( P = 0.001) significantly decreased the likelihood of wound healing. Patients with past vascular event trended toward longer healing times ( P = 0.07). Total contact casting in combination with weekly wound debridement showed benefit in DFU wound healing, whereas patients with a history of deep vein thrombosis and smoking were less likely to heal.

Survival evaluation of the patients with diabetic major lower-extremity amputations

PURPOSE

The purpose of this study was to evaluate the survival after major lower-limb amputation, at a level either below (BKA) or above (AKA) the knee, in diabetic patients.

METHODS

A total of 140 diabetic patients who underwent major lower-limb amputation during the period of 2001-2011 were enrolled in the study. The patients were grouped as below-knee and above-knee amputations. The differences in survival by age, gender, amputation level and revision surgery were investigated. The clinical follow-up periods and the results of the patients with major lower-limb amputation were retrospectively assessed.

RESULTS

The mean follow-up period was 24.87 months (range 0.06-120 months). The mortality rate of series was 32.8 % for 1 year and 70 % for 5 years. One-year mortality rate was 24.6 % and 5-year mortality rate was 66.3 % in below-knee group, 1-year mortality rate was 43.3 % and 5-year mortality rate was 83.3 % in above-knee group. The difference between mortality rates of these groups was significant (p: 0.019). There was no statistically significant difference according to age and gender (p: 0.543 and 0.568). The previous minor amputations were found to have no effect on mortality (p: 0.471).

CONCLUSION

Routine utilization of diabetes follow-up, screening and treatment programs with a multidisciplinary approach might be mandatory to handle early multisystem involvement-prevent major amputation, and increase survival rate in diabetic patients.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

What's new in the literature: an update of new research since the original WHS diabetic foot ulcer guidelines in 2006

The objective of the paper was to update the diabetic foot ulcer guidelines that were previously published in 2006. We performed a key word search using MEDLINE and Cochrane reviews for publication between January 2006 and January 2012. Articles that fit the inclusion criteria were reviewed and the previous guidelines were updated.

Hyperbaric oxygen therapy for chronic wounds

BACKGROUND

Chronic wounds are common and present a health problem with significant effect on quality of life. Various pathologies may cause tissue breakdown, including poor blood supply resulting in inadequate oxygenation of the wound bed. Hyperbaric oxygen therapy (HBOT) has been suggested to improve oxygen supply to wounds and therefore improve their healing.

OBJECTIVES

To assess the benefits and harms of adjunctive HBOT for treating chronic ulcers of the lower limb.

SEARCH METHODS

For this second update we searched the Cochrane Wounds Group Specialised Register (searched 18 February 2015); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 1); Ovid MEDLINE (1946 to 17 February 2015); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, 17 February 2015); Ovid EMBASE (1974 to 17 February 2015); and EBSCO CINAHL (1982 to 17 February 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effect on chronic wound healing of therapeutic regimens which include HBOT with those that exclude HBOT (with or without sham therapy).

DATA COLLECTION AND ANALYSIS

Three review authors independently evaluated the risk of bias of the relevant trials using the Cochrane methodology and extracted the data from the included trials. We resolved any disagreement by discussion.

MAIN RESULTS

We included twelve trials (577 participants). Ten trials (531 participants) enrolled people with a diabetic foot ulcer: pooled data of five trials with 205 participants showed an increase in the rate of ulcer healing (risk ratio (RR) 2.35, 95% confidence interval (CI) 1.19 to 4.62; P = 0.01) with HBOT at six weeks but this benefit was not evident at longer-term follow-up at one year. There was no statistically significant difference in major amputation rate (pooled data of five trials with 312 participants, RR 0.36, 95% CI 0.11 to 1.18). One trial (16 participants) considered venous ulcers and reported data at six weeks (wound size reduction) and 18 weeks (wound size reduction and number of ulcers healed) and suggested a significant benefit of HBOT in terms of reduction in ulcer area only at six weeks (mean difference (MD) 33.00%, 95% CI 18.97 to 47.03, P < 0.00001). We identified one trial (30 participants) which enrolled patients with non-healing diabetic ulcers as well as venous ulcers ("mixed ulcers types") and patients were treated for 30 days. For this "mixed ulcers" there was a significant benefit of HBOT in terms of reduction in ulcer area at the end of treatment (30 days) (MD 61.88%, 95% CI 41.91 to 81.85, P < 0.00001). We did not identify any trials that considered arterial and pressure ulcers.

AUTHORS' CONCLUSIONS

In people with foot ulcers due to diabetes, HBOT significantly improved the ulcers healed in the short term but not the long term and the trials had various flaws in design and/or reporting that means we are not confident in the results. More trials are needed to properly evaluate HBOT in people with chronic wounds; these trials must be adequately powered and designed to minimise all kinds of bias.

Clinical Effectiveness of Hyperbaric Oxygen Therapy in Complex Wounds

Hyperbaric Oxygen (HBO, HBO2) Therapy is a non-invasive therapy. It has been applied as adjuvant treatment in many medical conditions over the past 50 years. Different treatment protocols have been proven effective for specifically indicated conditions. To evaluate the clinical effectiveness of Hyperbaric Oxygen (HBO) Therapy as an adjunctive treatment for patients with complex wounds. In this prospective cohort study, 40 patients with complex wounds were included. All patients received HBO. HBO was delivered with 100% oxygen for 90 min at 2.0-2.4 ATA. Wound sizes were assessed by one wound surgeon before, during, and every 2 weeks for a total of 12 months after HBO. An analysis of demographic data, wound size and wound photography was performed. Over the 22-month period ending October 31, 2013, 40 patients (21 men and 19 women) with a mean age of 59.73 (range, 29-88) with complex wounds were included. All complex wounds studied were at least 6 months old. The mean wound size was 16.72 cm(2) in diameter. Thirty-one patients with complex wounds healed after the completion of a series of HBO treatments (77.5%). Two orocutaneous fistulas were completely closed without further surgery. After 5 HBO treatments, the wound size reduced by 29.7% on average (p = 1.24 × 10(-6)). After 10 HBO treatments, the wound size statistically significantly reduced by an additional 16.9% (p = 0.0002). There were no complications in this study. Wound healing process was accelerated by HBO. Significant wound size reduction was noted after 5 HBO treatments. Because the biggest reduction in wound size occurred within the first 10 HBO treatments, it is important to conduct these first treatments without interruption. HBO is an effective and safe treatment modality for complex wounds.

Hyperbaric oxygen treatment outcome for different indications from a single center

BACKGROUND

Hyperbaric oxygen (HBO) is used as an adjunctive therapy for a variety of indications. However, there is a lack of high-quality research evaluating HBO treatment outcomes for different indications available in the current literature.

METHODS

We retrospectively reviewed all patients who underwent HBO therapy at a single hyperbaric center from January 2010 to December 2013 using predetermined criteria to analyze successful, improved, or failed treatment outcomes for the following indications: chronic refractory osteomyelitis, diabetic foot ulcer, failed flap or skin graft, osteoradionecrosis, soft tissue radiation necrosis, and multiple coexisting indications.

RESULTS

Among the included 181 patients treated with adjunctive HBO at our center, 81.8% had either successful or improved treatment outcomes. A successful or improved outcome was observed in 82.6% of patients treated for chronic refractory osteomyelitis (n = 23), 74.1% for diabetic foot ulcer (n = 27), 75.7% for failed flap or skin graft (n = 33), 95.7% for osteoradionecrosis (n = 23), 88.1% for soft tissue radiation necrosis (n = 42), and 72.4% for multiple coexisting indications (n = 29). Among 4 patients treated for other indications, 100% of the cases were either successful or improved.

CONCLUSIONS

This study has provided a comprehensive outcome survey of using HBO for the previously mentioned indications at our center. It supplements the literature with more evidence to support the consideration of HBO in different indications.

Hyperbaric oxygen treatment in the experimental spinal cord injury model

BACKGROUND CONTEXT

Spinal cord trauma is a major cause of mortality and morbidity. Although no known treatment for spinal cord injury exists, a limited number of effective treatment modalities and procedures are available that improve secondary injury. Hyperbaric oxygen (HBO) treatment has been used to assist in neurologic recovery after cranial injury or ischemic stroke.

PURPOSE

To report the findings on the effectiveness of HBO treatment on rats with experimental traumatic spinal cord injury. Improvement was evaluated through motor strength assessment and nitrite level assay testing.

STUDY DESIGN

We randomly distributed 40 rats among 5 groups of 8 rats each: sham incurable trauma, induced trauma, HBO treatment begun at the 1st hour, HBO treatment begun at the 6th hour, and HBO treatment begun at the 24th hour.

METHOD

The HBO treatment was administered to rats in three of the groups and conducted in two 90-minute sessions, under an absolute atmospheric pressure of 2.4 at 100% oxygen for 5 days. In the motor strength evaluations, all the rats were observed during the inclined plane test and clinical motor examination on the first, third, and fifth days. In addition, the nitrite levels of spinal cord tissues on the sixth day were also studied.

RESULTS

Results from the inclined plane levels and motor strength test from all the three groups undergoing HBO treatment were higher than those from Group 2. It was also determined that early HBO treatment resulted in higher recovery rates (groups 3 and 4). The highest levels were seen in the group in which the HBO treatments were started in the first hour (Group 3). It was noted that nitrite levels of rats in the group exposed to trauma increased, compared with the sham group, but increased levels also diminished after HBO treatments. Again, the greatest decrease in nitrite levels was evident in the group where the HBO treatment was started the earliest (Group 3).

CONCLUSIONS

Prompt HBO treatment after trauma significantly contributed to the clinical, histopathologic, and biochemical recovery of the rats.

Treatment of diabetic foot complications with hyperbaric oxygen therapy: a retrospective experience

BACKGROUND

The aim of this study is to evaluate the role of hyperbaric oxygen in the treatment of diabetic foot ulcers.

METHODS

We performed a retrospective observational study of all patients with diabetic foot ulcers treated at the Institution's hyperbaric chamber between January 2010 and August 2012. Patient data was obtained upon patient hospital visit and prospective clinical record consultation.

RESULTS

Twenty-six foot lesions including 13 foot ulcers Wagner grade 2 or greater and 13 amputation stump ulcers were submitted to hyperbaric oxygen therapy between January 2010 and August 2012 in our Institution. Of these, 23 foot lesions completed treatment and complete epithelialization of the primary lesion was achieved in 15 (65%). The mean healing period since the first hyperbaric oxygen therapy session was 16 weeks. Above-ankle amputations were performed in 3 limbs and transmetatarsal amputations in 2 limbs.

CONCLUSION

Hyperbaric oxygen may be associated with ulcer healing in selected diabetic foot ulcers with impaired cicatrization.

Shedding light on a new treatment for diabetic wound healing: a review on phototherapy

Impaired wound healing is a common complication associated with diabetes with complex pathophysiological underlying mechanisms and often necessitates amputation. With the advancement in laser technology, irradiation of these wounds with low-intensity laser irradiation (LILI) or phototherapy, has shown a vast improvement in wound healing. At the correct laser parameters, LILI has shown to increase migration, viability, and proliferation of diabetic cells in vitro; there is a stimulatory effect on the mitochondria with a resulting increase in adenosine triphosphate (ATP). In addition, LILI also has an anti-inflammatory and protective effect on these cells. In light of the ever present threat of diabetic foot ulcers, infection, and amputation, new improved therapies and the fortification of wound healing research deserves better prioritization. In this review we look at the complications associated with diabetic wound healing and the effect of laser irradiation both in vitro and in vivo in diabetic wound healing.

Hyperbaric oxygen therapy as adjunctive treatment of diabetic foot ulcers

The widespread use of HBO as an adjunctive treatment of diabetic foot ulcers has been founded on weak scientific evidence, but the consistency in positive outcomes in trials evaluating HBO on ulcer healing is noteworthy, not least as these results are in concert with data from in vitro and physiologic studies supporting the theoretical framework of HBO reversing hypoxia-induced abnormality. The long-term ulcer-healing rates of the nonrandomized controlled studies before the recent study by Margolis and colleagues, 77% with HBO versus 25% with standard treatment, are in concert with 1-year follow-up data from the 2 double-blind RCTs, 54% versus 25%. These 2 trials have put the use of HBO on firmer ground, but several issues, including health economics, developing robust selection criteria for treatment, optimizing treatment protocols, and identifying standards for when to start and stop treatment, remain to be elucidated. Not least, outcomes from further high-quality studies are needed. At present, HBO may be used as an adjunctive therapy in a select group of patients with diabetic foot ulcers that are difficult to heal.

IGF-1 Increases with Hyperbaric Oxygen Therapy and Promotes Wound Healing in Diabetic Foot Ulcers

Objectives. To investigate insulin-like growth factor I (IGF-1) levels in response to hyperbaric oxygen therapy (HBOT) for diabetic foot ulcers and to determine whether IGF-1 is a predictive indicator of wound healing in patients with diabetic foot ulcers. Design and Methods. We treated 48 consecutive patients with diabetic foot ulcers with HBOT. Alterations of IGF-1 levels in patients whose wound healed with HBOT were compared with those in patients who did not benefit from HBOT. Results. There was no significant difference in initial IGF-1 levels between the two groups (P = 0.399). The mean IGF-1 level increased with HBOT (P < 0.05). In the healed group, the mean IGF-1 increase and the final values were significantly higher (P < 0.05). In the nonhealed group, the mean IGF-1 increase was minus and the final values were not significantly different (P < 0.05). The increase in IGF-1 level with HBOT was significantly higher in the healed group (P < 0.001). Conclusions. IGF-1 increased significantly in the healed group. We believe that HBOT is effective in the treatment of diabetic foot ulcers, with an elevation of IGF-1. This alteration seems to be a predictive factor for wound healing in diabetic foot ulcers treated with HBOT.

The role of hyperbaric oxygen in the treatment of diabetic foot ulcers

Diabetic foot ulcers are still extremely difficult to heal. Therefore, therapeutic options to improve healing rates are continuously being explored. Hyperbaric oxygen (HBO) has been used in addition to standard treatment of the diabetic foot for more than 20 years. Evidence suggests that HBO reduces amputation rates and increases the likelihood of healing in infected diabetic foot ulcers, in association with improved tissue oxygenation, resulting in better quality of life. Nonetheless, HBO represents an expensive modality, which is only available in few centers. Moreover, adverse events necessitate a closer investigation of its safety. Finally, it is not entirely clear which patients stand to benefit from HBO and how these should be selected. In conclusion, HBO appears promising, but more experience is needed before its broad implementation in the routine care of the diabetic foot.

Prospective randomized controlled study of a Chinese herbal medicine compound Tangzu Yuyang Ointment for chronic diabetic foot ulcers: a preliminary report

AIM OF THE STUDY

The purpose of this study was to evaluate the efficacy and safety of a topical Chinese herbal medicine (CHM) compound Tangzu Yuyang Ointment (TYO) for treatment of chronic diabetic foot ulcers.

MATERIALS AND METHODS

This multi-center, prospective, randomized, controlled and add-on clinical trial was conducted at seven centers in the China mainland. Fifty-seven patients with chronic diabetic foot ulcers of Wagner's ulcer grade 1-3 were enrolled in this study. Patients who were randomly assigned to the control group (n=28) received standard wound therapy (SWT), whereas those randomized to the treatment group (n=28) received SWT plus topical TYO. Only 48 patients who finished 24 weeks of observations were entered for data analysis.

RESULTS

The TYO and SWT groups were comparable for baseline characteristics. Ulcer improvement was 79.2% in the TYO group and 41.7% in the SWT group (P=0.017) at 12 weeks, and 91.7% vs. 62.5% (P=0.036) at 24 weeks. The number of ulcers that were completely healed at 4, 12 and 24 weeks was similar in both groups, as were the numbers of adverse events. Healing time was 96±56 days (n=19) in the TYO group and 75±53 days (n=14) in the SWT group (P=0.271).

CONCLUSION

TYO plus SWT is more effective than SWT in the management of chronic diabetic foot ulcers and has few side-effects.

Change in amputation predictors in diabetic foot disease: effect of multidisciplinary approach

Diabetic foot disease causes important morbidity in diabetic population, and amputation due to diabetic foot disease occurs more often than in general population. We have been evaluating patients with diabetic foot disease in a multidisciplinary approach since year 2000. In the current study, we sought to investigate the change in amputation rate and its predictors in diabetic foot with a multidisciplinary team approach. Seventy-four patients (52 male, 22 female) hospitalised between January 2002 and December 2007 were retrospectively analysed. Sixteen out of 74 have undergone amputation. We found overall amputation rate as 21.6%, which is lower than previously reported from our institution (36.7 and 39.4%, respectively). Major amputations (syme, below-knee, above-knee) were applied to 11 patients (14.9%). A logistic regression model including osteomyelitis, peripheral neuropathy, peripheral vascular disease, hypertension, gangrene and age revealed that gangrene is now the only significant predictor for amputation. Our observations confirm that amputation rate has declined after implementation of a multidisciplinary team work, and risk factors apart from presence of gangrene are no longer amputation predictors in our centre.