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Slivnik M, Navodnik Preložnik M, Fir M, Jazbar J, Čebron Lipovec N, Locatelli I, Liette Lauzon H, Urbančič Rovan V. A randomized, placebo-controlled study of chitosan gel for the treatment of chronic diabetic foot ulcers (the CHITOWOUND study). BMJ Open Diabetes Res Care 2024; 12:e004195. [PMID: 38909998 DOI: 10.1136/bmjdrc-2024-004195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/07/2024] [Indexed: 06/25/2024] Open
Abstract
INTRODUCTION To assess the efficacy of a chitosan-based gel (ChitoCare) for the treatment of non-healing diabetic foot ulcers (DFUs). RESEARCH DESIGN AND METHODS Forty-two patients with chronic DFUs were randomized to the ChitoCare or placebo gel for a 10-week treatment period and 4-week follow-up. The primary study end point was the rate of complete wound closure at week 10, presented as relative rate. RESULTS Thirty patients completed the 10-week treatment and 28 completed the 4-week follow-up. The ChitoCare arm achieved 16.7% complete wound closure at week 10 vs 4.2% in the placebo arm (p=0.297), 92.0% vs 37.0% median relative reduction in wound surface area from baseline at week 10 (p=0.008), and 4.62-fold higher likelihood of achieving 75% wound closure at week 10 (p=0.012). Based on the results of the Bates-Jensen Wound Assessment Tool, the wound state at week 10 and the relative improvement from the baseline were significantly better (median 20 vs 24 points, p=0.018, and median 29.8% vs 3.6%, p=0.010, respectively). CONCLUSIONS ChitoCare gel increased the rate of the DFU healing process. Several secondary end points significantly favored ChitoCare gel. TRIAL REGISTRATION NUMBER NCT04178525.
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Affiliation(s)
- Matevž Slivnik
- Vizera d.o.o, Ljubljana, Slovenia
- University of Ljubljana Faculty of Pharmacy, Ljubljana, Slovenia
| | | | | | - Janja Jazbar
- University of Ljubljana Faculty of Pharmacy, Ljubljana, Slovenia
| | | | - Igor Locatelli
- University of Ljubljana Faculty of Pharmacy, Ljubljana, Slovenia
| | | | - Vilma Urbančič Rovan
- University Medical Centre Ljubljana, Ljubljana, Slovenia
- University of Ljubljana Faculty of Medicine, Ljubljana, Slovenia
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2
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Thomassen D, Amesz SF, Stol NP, le Cessie S, Steyerberg E. Dynamic prediction of time to wound healing at routine wound care visits. Adv Wound Care (New Rochelle) 2024. [PMID: 38832867 DOI: 10.1089/wound.2024.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
Objective Having a wound decreases patients' quality of life and brings uncertainty, especially if the wound does not show a healing tendency. The objective of this study was to develop and validate a model to dynamically predict time to wound healing at subsequent routine wound care visits. Approach A dynamic prediction model was developed in a cohort of wounds treated by nurse practitioners between 2017-2022. Potential predictors were selected based on literature, expert opinion, and availability in the routine care setting. To assess performance for future wound care visits, the model was validated in a new cohort of wounds visited in early 2023. Reporting followed TRIPOD guidelines. Results We analyzed data from 92,098 visits, corresponding to 14,248 wounds and 7,221 patients. At external validation, discriminative performance of our developed model was comparable to internal validation (c-statistic = 0.70 [95% CI 0.69, 0.71]) and the model remained well-calibrated. Strong predictors were wound-level characteristics and indicators of the healing process so far (e.g., wound surface area). Innovation Going beyond previous prediction studies in the field, the developed model dynamically predicts the remaining time to wound healing for many wound types at subsequent wound care visits, in line with the dynamic nature of wound care. In addition, the model was externally validated and showed stable performance. Conclusion: The developed model can potentially contribute to patient satisfaction and reduce uncertainty around wound healing times when implemented in practice. When the predicted time of wound healing remains high, practitioners can consider adapting their wound management.
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Affiliation(s)
- Doranne Thomassen
- Leiden University Medical Center, Biomedical Data Sciences, Postzone S-05-S, P.O. box 9600, 2300 RC Leiden, Leiden, Netherlands, 2300 RC;
| | - Stella Felicia Amesz
- University Medical Centre Groningen, Department of Health Sciences, Section of Nursing Science, Groningen, Groningen, Netherlands
- QualityZorg, Nieuw-Vennep, Netherlands;
| | | | - Saskia le Cessie
- Leiden University Medical Center, Clinical Epidemiology, Leiden, Zuid-Holland, Netherlands
- Leiden University Medical Center, Biomedical Data Sciences, Leiden, Zuid-Holland, Netherlands;
| | - Ewout Steyerberg
- Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands;
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Hettinger G, Mitra N, Thom SR, Margolis DJ. An Improved Clinical and Genetics-Based Prediction Model for Diabetic Foot Ulcer Healing. Adv Wound Care (New Rochelle) 2024; 13:281-290. [PMID: 38258807 DOI: 10.1089/wound.2023.0194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
Objective: The goal of this investigation was to use comprehensive prediction modeling tools and available genetic information to try to improve upon the performance of simple clinical models in predicting whether a diabetic foot ulcer (DFU) will heal. Approach: We utilized a cohort study (n = 206) that included clinical factors, measurements of circulating endothelial precursor cells (CEPCs), and fine sequencing of the NOS1AP gene. We derived and selected relevant predictive features from this patient-level information using statistical and machine learning techniques. We then developed prognostic models using machine learning approaches and assessed predictive performance. The presentation is consistent with TRIPOD requirements. Results: Models using baseline clinical and CEPC data had an area under the receiver operating characteristic curve (AUC) of 0.73 (0.66-0.80). Models using only single nucleotide polymorphisms (SNPs) of the NOS1AP gene had an AUC of 0.67 (95% confidence interval, CI: [0.59-0.75]). However, models incorporating baseline and SNP information resulted in improved AUC (0.80, 95% CI [0.73-0.87]). Innovation: We provide a rigorous analysis demonstrating the predictive potential of genetic information in DFU healing. In this process, we present a framework for using advanced statistical and bioinformatics techniques for creating superior prognostic models and identify potentially predictive SNPs for future research. Conclusion: We have developed a new benchmark for which future predictive models can be compared against. Such models will enable wound care experts to more accurately predict whether a patient will heal and aid clinical trialists in designing studies to evaluate therapies for subjects likely or unlikely to heal.
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Affiliation(s)
- Gary Hettinger
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stephen R Thom
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David J Margolis
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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4
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Monteiro-Soares M, Hamilton EJ, Russell DA, Srisawasdi G, Boyko EJ, Mills JL, Jeffcoate W, Game F. Classification of foot ulcers in people with diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3645. [PMID: 37132179 DOI: 10.1002/dmrr.3645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Classification and scoring systems can help both clinical management and audit the outcomes of routine care. AIM This study aimed to assess published systems used to characterise ulcers in people with diabetes to determine which should be recommended to (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) characterise people with infection and/or peripheral arterial disease, and (d) audit to compare outcomes in different populations. This systematic review is part of the process of developing the 2023 guidelines to classify foot ulcers from the International Working Group on Diabetic Foot. METHODS We searched PubMed, Scopus and Web of Science for articles published up to December 2021 which evaluated the association, accuracy or reliability of systems used to classify ulcers in people with diabetes. Published classifications had to have been validated in populations of >80% of people with diabetes and a foot ulcer. RESULTS We found 28 systems addressed in 149 studies. Overall, the certainty of the evidence for each classification was low or very low, with 19 (68%) of the classifications being assessed by ≤ 3 studies. The most frequently validated system was the one from Meggitt-Wagner, but the articles validating this system focused mainly on the association between the different grades and amputation. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalisation, limb amputation, mortality, and cost. CONCLUSION Despite the limitations, this systematic review provided sufficient evidence to support recommendations on the use of six particular systems in specific clinical scenarios.
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Affiliation(s)
- Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Emma J Hamilton
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- University of Western Australia, Medical School, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - David A Russell
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gulapar Srisawasdi
- Department of Rehabilitation Medicine, Sirindhorn School of Prosthetics Orthotics, Bangkok, Thailand
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Edward J Boyko
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Joseph L Mills
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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5
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Jais S, Pratama K. A diabetic foot wound healing assessment tool: A scoping review. Heliyon 2023; 9:e15736. [PMID: 37180932 PMCID: PMC10172750 DOI: 10.1016/j.heliyon.2023.e15736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/16/2023] Open
Abstract
Background Indonesia faces a challenge in controlling the burden of diabetic foot ulcers, which necessitates a nursing care management approach to optimize the healing of complications by accurately monitoring wound healing progress using wound assessment tools. Methods This literature review, which is part of a scoping study framework, searched electronic databases including PubMed, ScienceDirect, EBSCOhost, and Google Scholar to find papers relevant to the Indonesian context. Five papers were chosen from a total of 463 papers discovered. Results The diabetic foot ulcer wound assessment tools DFUAS (diabetic foot ulcer assessment scale), DMIST (deep, maceration, infection, size, and tunneling), and MUNGS (maceration, undermining, necrotic, granulation, and symptoms/signs) were identified in the literature review. For leg ulcers, LUMT (leg ulcer measurement tool) and RESVECH 2.0 (Results Expected from Chronic Wound Healing Assessment) were used. DMIST, DFUAS, and MUNGS are used to predict healed and non-healing wounds. LUMT determines the evaluation and documentation of leg ulcers, and RESVECH 2.0 is designed to shorten the duration of chronic wound occurrence. The psychometric properties of the DMIST scale were identified, including reliability, validity, and responsiveness. Conclusions Five tools for assessing chronic wounds were identified. The predictive validity and responsiveness of the DMIST tool were supported by a sufficient rating based on evidence quality. This scoping review provides an overview of the measurement properties of available assessment tools for diabetic foot ulcers.
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Affiliation(s)
- Suriadi Jais
- Corresponding author. Post Graduate School of Nursing, Institute of Technology and Health ,Muhammadiyah Pontianak, Jalan Sei Raya Dalam Gg Ceria V no 19 Kubu Raya, Pontianak, 78117, Indonesia.
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6
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Margolis DJ, Mitra N, Hoffstad O, Malay DS, Mirza ZK, Lantis JC, Lev-Tov HA, Kirsner RS, Ruhela D, Bhopale VM, Thom SR. Circulating endothelial precursor cells are associated with a healed diabetic foot ulcer evaluated in a prospective cohort study. Wound Repair Regen 2023; 31:128-134. [PMID: 36177665 PMCID: PMC10319405 DOI: 10.1111/wrr.13055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/24/2022] [Indexed: 02/01/2023]
Abstract
The goal of this multicentre study was to evaluate whether circulating endothelial precursor cells and microparticles can predict diabetic foot ulcer healing by the 16th week of care. We enrolled 207 subjects, and 40.0% (28.4, 41.5) healed by the 16th week of care. Using flow cytometry analysis, several circulating endothelial precursor cells measured at the first week of care were associated with healing after adjustment for wound area and wound duration. For example, CD34+ CD45dim , the univariate odds ratio was 1.19 (95% confidence interval: 0.88, 1.61) and after adjustment for wound area and wound duration, the odds ratio was (1.67 (1.16, 2.42) p = 0.006). A prognostic model using CD34+ CD45dim , wound area, and wound duration had an area under the curve of 0.75 (0.67, 0.82) and CD34+ CD45dim per initial wound area, an area under the curve of 0.72 (0.64, 0.79). Microparticles were not associated with a healed wound. Previous studies have indicated that circulating endothelial precursor cells measured at the first office visit are associated with a healed diabetic foot ulcer. In this multicentred prospective study, we confirm this finding, show the importance of adjusting circulating endothelial precursor cells measurements by wound area, and show circulating endothelial precursor cells per wound area is highly predictive of a healed diabetic foot ulcer by 16th week of care.
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Affiliation(s)
- David J. Margolis
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ole Hoffstad
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - D. Scot Malay
- Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | | | - John C. Lantis
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Hadar A. Lev-Tov
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida
| | - Robert S. Kirsner
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida
| | - Deepa Ruhela
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Veena M. Bhopale
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Stephan R. Thom
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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7
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Schmidt BM, Holmes CM, Najarian K, Gallagher K, Haus JM, Shadiow J, Ye W, Ang L, Burant A, Baker N, Katona A, Martin CL, Pop-Busui R. On diabetic foot ulcer knowledge gaps, innovation, evaluation, prediction markers, and clinical needs. J Diabetes Complications 2022; 36:108317. [PMID: 36215794 PMCID: PMC10087892 DOI: 10.1016/j.jdiacomp.2022.108317] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/22/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022]
Abstract
Diabetic foot ulcers (DFUs) remain a very prevalent and challenging complication of diabetes worldwide due to high morbidity, high risks of lower extremity amputation and associated mortality. Despite major advances in diabetes treatment in general, there is a paucity of FDA approved technologies and therapies to promote successful healing. Furthermore, accurate biomarkers to identify patients at risk of non-healing and monitor response-to-therapy are significantly lacking. To date, research has been slowed by a lack of coordinated efforts among basic scientists and clinical researchers and confounded by non-standardized heterogenous collection of biospecimen and patient associated data. Novel technologies, especially those in the single and 'multiomics' arena, are being used to advance the study of diabetic foot ulcers but require pragmatic study design to ensure broad adoption following validation. These high throughput analyses offer promise to investigate potential biomarkers across wound trajectories and may support information on wound healing and pathophysiology not previously well understood. Additionally, these biomarkers may be used at the point-of-care. In combination with national scalable research efforts, which seek to address the limitations and better inform clinical practice, coordinated and integrative insights may lead to improved limb salvage rates.
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Affiliation(s)
- Brian M Schmidt
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America.
| | - Crystal M Holmes
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Kayvan Najarian
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, United States of America
| | - Katherine Gallagher
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Abor, MI 48109, United States of America
| | - Jacob M Haus
- School of Kinesiology, University of Michigan, Ann Arbor, MI, United States of America
| | - James Shadiow
- School of Kinesiology, University of Michigan, Ann Arbor, MI, United States of America
| | - Wen Ye
- Biostatistics Department, School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
| | - Lynn Ang
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Aaron Burant
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Nicole Baker
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Aimee Katona
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Catherine L Martin
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Rodica Pop-Busui
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America
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8
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Kerstan A, Dieter K, Niebergall-Roth E, Klingele S, Jünger M, Hasslacher C, Daeschlein G, Stemler L, Meyer-Pannwitt U, Schubert K, Klausmann G, Raab T, Goebeler M, Kraft K, Esterlechner J, Schröder HM, Sadeghi S, Ballikaya S, Gasser M, Waaga-Gasser AM, Murphy GF, Orgill DP, Frank NY, Ganss C, Scharffetter-Kochanek K, Frank MH, Kluth MA. Translational development of ABCB5 + dermal mesenchymal stem cells for therapeutic induction of angiogenesis in non-healing diabetic foot ulcers. Stem Cell Res Ther 2022; 13:455. [PMID: 36064604 PMCID: PMC9444095 DOI: 10.1186/s13287-022-03156-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/25/2022] [Indexed: 11/15/2022] Open
Abstract
Background While rapid healing of diabetic foot ulcers (DFUs) is highly desirable to avoid infections, amputations and life-threatening complications, DFUs often respond poorly to standard treatment. GMP-manufactured skin-derived ABCB5+ mesenchymal stem cells (MSCs) might provide a new adjunctive DFU treatment, based on their remarkable skin wound homing and engraftment potential, their ability to adaptively respond to inflammatory signals, and their wound healing-promoting efficacy in mouse wound models and human chronic venous ulcers. Methods The angiogenic potential of ABCB5+ MSCs was characterized with respect to angiogenic factor expression at the mRNA and protein level, in vitro endothelial trans-differentiation and tube formation potential, and perfusion-restoring capacity in a mouse hindlimb ischemia model. Finally, the efficacy and safety of ABCB5+ MSCs for topical adjunctive treatment of chronic, standard therapy-refractory, neuropathic plantar DFUs were assessed in an open-label single-arm clinical trial. Results Hypoxic incubation of ABCB5+ MSCs led to posttranslational stabilization of the hypoxia-inducible transcription factor 1α (HIF-1α) and upregulation of HIF-1α mRNA levels. HIF-1α pathway activation was accompanied by upregulation of vascular endothelial growth factor (VEGF) transcription and increase in VEGF protein secretion. Upon culture in growth factor-supplemented medium, ABCB5+ MSCs expressed the endothelial-lineage marker CD31, and after seeding on gel matrix, ABCB5+ MSCs demonstrated formation of capillary-like structures comparable with human umbilical vein endothelial cells. Intramuscularly injected ABCB5+ MSCs to mice with surgically induced hindlimb ischemia accelerated perfusion recovery as measured by laser Doppler blood perfusion imaging and enhanced capillary proliferation and vascularization in the ischemic muscles. Adjunctive topical application of ABCB5+ MSCs onto therapy-refractory DFUs elicited median wound surface area reductions from baseline of 59% (full analysis set, n = 23), 64% (per-protocol set, n = 20) and 67% (subgroup of responders, n = 17) at week 12, while no treatment-related adverse events were observed. Conclusions The present observations identify GMP-manufactured ABCB5+ dermal MSCs as a potential, safe candidate for adjunctive therapy of otherwise incurable DFUs and justify the conduct of a larger, randomized controlled trial to validate the clinical efficacy. Trial registration: ClinicalTrials.gov, NCT03267784, Registered 30 August 2017, https://clinicaltrials.gov/ct2/show/NCT03267784 Supplementary Information The online version contains supplementary material available at 10.1186/s13287-022-03156-9.
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Affiliation(s)
- Andreas Kerstan
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | | | | | - Sabrina Klingele
- TICEBA GmbH, Im Neuenheimer Feld 517, 69120, Heidelberg, Germany
| | - Michael Jünger
- Department of Dermatology, University Hospital Greifswald, Greifswald, Germany
| | | | - Georg Daeschlein
- Department of Dermatology, University Hospital Greifswald, Greifswald, Germany.,Clinic of Dermatology, Immunology and Allergology, Medical University Brandenburg "Theodor Fontane" Medical Center Dessau, Dessau, Germany
| | - Lutz Stemler
- Diabetologikum DDG Ludwigshafen, Ludwigshafen, Germany
| | | | | | | | | | - Matthias Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | | | | | | | - Samar Sadeghi
- TICEBA GmbH, Im Neuenheimer Feld 517, 69120, Heidelberg, Germany
| | - Seda Ballikaya
- TICEBA GmbH, Im Neuenheimer Feld 517, 69120, Heidelberg, Germany
| | - Martin Gasser
- Department of Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Ana M Waaga-Gasser
- Department of Surgery, University Hospital Würzburg, Würzburg, Germany.,Division of Renal (Kidney) Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - George F Murphy
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennis P Orgill
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Natasha Y Frank
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA.,Division of Genetics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Transplant Research Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Harvard Stem Cell Institute, Harvard University, Cambridge, MA, USA
| | - Christoph Ganss
- RHEACELL GmbH & Co. KG, Heidelberg, Germany.,TICEBA GmbH, Im Neuenheimer Feld 517, 69120, Heidelberg, Germany
| | | | - Markus H Frank
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Transplant Research Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Harvard Stem Cell Institute, Harvard University, Cambridge, MA, USA.,School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Mark A Kluth
- RHEACELL GmbH & Co. KG, Heidelberg, Germany. .,TICEBA GmbH, Im Neuenheimer Feld 517, 69120, Heidelberg, Germany.
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9
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Landau Z, Whitacre KL, Leewood C, Hawkins J, Wachuku CD. Utilization of a topical autologous blood clot for treatment of pressure ulcers. Int Wound J 2022; 20:806-812. [PMID: 36054532 PMCID: PMC9927894 DOI: 10.1111/iwj.13927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/28/2022] Open
Abstract
Management and treatment of pressure ulcers (PUs) are met with great difficulty due to various factors that cause vulnerability of the soft tissue such as location, limited mobility, increased friction and shearing forces, as well as other comorbidities that may delay or halt wound healing. The topical autologous blood clot therapy (TABCT) is a point-of-care treatment used as a blood clot to assist in recreating and repairing the extracellular matrix (ECM). The mechanism of action consists of reconstruction of the ECM by incorporating into the ulcer, providing protection from further external destruction, while assisting in advancement through the wound healing phases via interaction of necessary growth factors, mediators, and chemokines. This study aims to assess the efficacy of the TABCT in the treatment of PUs in comparison to standard of care (SOC) treatment. Twenty-four patients, 18 years or older, with PUs ranging from stage 1 to 4, were included in this study. TABCT was created by using the patient's own peripheral blood in a point of care setting. Efficacy in percent area reduction (PAR) on weeks 4 and 12 with TABCT over SOC was assessed. Treatment using TABCT in PUs resulted in 77.9% of the patients achieving a 50% PAR on week 4. The mean PAR on week 12 was 96.23% with 45% of the wounds treated with TABCT achieving complete wound closure. TABCT exhibited efficacy in PAR of PUs. In addition, TABCT use prompted granulation tissue formation over vital structures, such as bone, which is often present in later stage PUs. The potential of bringing an affordable, cost-effective, advanced biologic bedside treatment that is efficacious in resolution of these complex wounds has the potential to drastically reduce the burden of treatment on the health system.
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Affiliation(s)
- Zvi Landau
- Medical Nursing and Rehibilitation CenterBeit HadarAshdodIsrael
| | | | - Charles Leewood
- Center for Hyperbarics and Wound CareCandler HospitalSavannahGeorgiaUSA
| | - Jessie Hawkins
- Clinical Research DepartmentFranklin Health Research CenterFranklinTennesseeUSA
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10
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Margolis DJ, Mitra N, Malay DS, Mirza ZK, Lantis JC, Lev-Tov HA, Kirsner RS, Thom SR. Further evidence that wound size and duration are strong prognostic markers of diabetic foot ulcer healing. Wound Repair Regen 2022; 30:487-490. [PMID: 35470507 DOI: 10.1111/wrr.13019] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/25/2022] [Accepted: 04/23/2022] [Indexed: 11/29/2022]
Abstract
Diabetic foot ulcers (DFU) are a critical problem for those with diabetes mellitus. Predicting the healing likelihood of a DFU is important to implementing appropriate care, allocating resources, having access to advanced therapies, having successful clinical trials, calibrating clinical trial results, and providing information to administrative entities on patient and provider outcomes. Prognostic modeling can also be important when attempting to compare results across trials or care centers. In a prospective cohort study, we demonstrate and replicate that simple wound characteristics like wound area and wound duration can be used to predict wound healing by the 16th week of care. The models were based on previous literature and replicated using a machine learning algorithm. The use of wound duration and wound area in a prognostic model continues to be important when comparing study results, center-based outcomes, as well as designing clinical trials.
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Affiliation(s)
- David J Margolis
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - D Scott Malay
- Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | | | - John C Lantis
- Department of Surgery, Icahn School of Medicine at Mount Sinaim, New York City, New York
| | - Hadar A Lev-Tov
- Department of Dermatology, University of Miami School of Medicine, Miami, Florida
| | - Robert S Kirsner
- Department of Dermatology, University of Miami School of Medicine, Miami, Florida
| | - Stephan R Thom
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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11
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Wang S, Xia C, Zheng Q, Wang A, Tan Q. Machine Learning Models for Predicting the Risk of Hard-to-Heal Diabetic Foot Ulcers in a Chinese Population. Diabetes Metab Syndr Obes 2022; 15:3347-3359. [PMID: 36341229 PMCID: PMC9628710 DOI: 10.2147/dmso.s383960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Early detection of hard-to-heal diabetic foot ulcers (DFUs) is vital to prevent a poor prognosis. The purpose of this work was to employ clinical characteristics to create an optimal predictive model of hard-to-heal DFUs (failing to decrease by >50% at 4 weeks) based on machine learning algorithms. METHODS A total of 362 DFU patients hospitalized in two tertiary hospitals in eastern China were enrolled in this study. The training dataset and validation dataset were split at a ratio of 7:3. Univariate logistic analysis and clinical experience were utilized to screen clinical characteristics as predictive features. The following six machine learning algorithms were used to build prediction models for differentiating hard-to-heal DFUs: support vector machine, the naïve Bayesian (NB) model, k-nearest neighbor, general linear regression, adaptive boosting, and random forest. Five cross-validations were employed to realize the model's parameters. Accuracy, precision, recall, F1-scores, and AUCs were utilized to compare and evaluate the models' efficacy. On the basis of the best model identified, the significance of each characteristic was evaluated, and then an online calculator was developed. RESULTS Independent predictors for model establishment included sex, insulin use, random blood glucose, wound area, diabetic retinopathy, peripheral arterial disease, smoking history, serum albumin, serum creatinine, and C-reactive protein. After evaluation, the NB model was identified as the most generalizable model, with an AUC of 0.864, a recall of 0.907, and an F1-score of 0.744. Random blood glucose, C-reactive protein, and wound area were determined to be the three most important influencing factors. A corresponding online calculator was created (https://predicthardtoheal.azurewebsites.net/). CONCLUSION Based on clinical characteristics, machine learning algorithms can achieve acceptable predictions of hard-to-heal DFUs, with the NB model performing the best. Our online calculator can assist doctors in identifying the possibility of hard-to-heal DFUs at the time of admission to reduce the likelihood of a dismal prognosis.
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Affiliation(s)
- Shiqi Wang
- Department of Burns and Plastic Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, People’s Republic of China
| | - Chao Xia
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Nanjing, People’s Republic of China
| | - Qirui Zheng
- Software Institute, Nanjing University, Nanjing, People's Republic of China
| | - Aiping Wang
- Department of Endocrinology, Air Force Hospital of Eastern Theater Command, Nanjing, People's Republic of China
- Aiping Wang, Department of Endocrinology, Air Force Hospital of Eastern Theater Command, Nanjing, 210002, People’s Republic of China, Email
| | - Qian Tan
- Department of Burns and Plastic Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, People’s Republic of China
- Correspondence: Qian Tan, Department of Burns and Plastic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China, Tel +86 25 83106666, Email
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12
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Foomani FH, Anisuzzaman DM, Niezgoda J, Niezgoda J, Guns W, Gopalakrishnan S, Yu Z. Synthesizing time-series wound prognosis factors from electronic medical records using generative adversarial networks. J Biomed Inform 2021; 125:103972. [PMID: 34920125 DOI: 10.1016/j.jbi.2021.103972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/20/2021] [Accepted: 12/03/2021] [Indexed: 11/26/2022]
Abstract
Wound prognostic models not only provide an estimate of wound healing time to motivate patients to follow up their treatments but also can help clinicians to decide whether to use a standard care or adjuvant therapies and to assist them with designing clinical trials. However, collecting prognosis factors from Electronic Medical Records (EMR) of patients is challenging due to privacy, sensitivity, and confidentiality. In this study, we developed time series medical generative adversarial networks (GANs) to generate synthetic wound prognosis factors using very limited information collected during routine care in a specialized wound care facility. The generated prognosis variables are used in developing a predictive model for chronic wound healing trajectory. Our novel medical GAN can produce both continuous and categorical features from EMR. Moreover, we applied temporal information to our model by considering data collected from the weekly follow-ups of patients. Conditional training strategies were utilized to enhance training and generate classified data in terms of healing or non-healing. The ability of the proposed model to generate realistic EMR data was evaluated by TSTR (test on the synthetic, train on the real), discriminative accuracy, and visualization. We utilized samples generated by our proposed GAN in training a prognosis model to demonstrate its real-life application. Using the generated samples in training predictive models improved the classification accuracy by 6.66-10.01% compared to the previous EMR-GAN. Additionally, the suggested prognosis classifier has achieved the area under the curve (AUC) of 0.875, 0.810, and 0.647 when training the network using data from the first three visits, first two visits, and first visit, respectively. These results indicate a significant improvement in wound healing prediction compared to the previous prognosis models.
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Affiliation(s)
- Farnaz H Foomani
- Department of Electrical Engineering, University of Wisconsin-Milwaukee, Milwaukee, WI, United States
| | - D M Anisuzzaman
- Department of Computer Science, University of Wisconsin-Milwaukee, Milwaukee, WI, United States
| | | | | | - William Guns
- AZH Wound and Vascular Center, Milwaukee, WI, United States
| | | | - Zeyun Yu
- Department of Electrical Engineering, University of Wisconsin-Milwaukee, Milwaukee, WI, United States; Department of Computer Science, University of Wisconsin-Milwaukee, Milwaukee, WI, United States.
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13
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Bender C, Cichosz SL, Pape-Haugaard L, Hartun Jensen M, Bermark S, Laursen AC, Hejlesen O. Assessment of Simple Bedside Wound Characteristics for a Prediction Model for Diabetic Foot Ulcer Outcomes. J Diabetes Sci Technol 2021; 15:1161-1167. [PMID: 32696655 PMCID: PMC8442191 DOI: 10.1177/1932296820942307] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Evidence-based learning systems built on prediction models can support wound care community nurses (WCCNs) during diabetic foot ulcer care sessions. Several prediction models in the area of diabetic foot ulcer healing have been developed, most built on cardiovascular measurement data. Two other data types are patient information (i.e. sex and hemoglobin A1c) and wound characteristics (i.e. wound area and wound duration); these data relate to the status of the diabetic foot ulcer and are easily accessible for WCCNs. The aim of the study was to assess simple bedside wound characteristics for a prediction model for diabetic foot ulcer outcomes. METHOD Twenty predictor variables were tested. A pattern prediction model was used to forecast whether a given diabetic foot ulcer would (i) increase in size (or not) or (ii) decrease in size. Sensitivity, specificity, and area under the curve (AUC) in a receiver-operating characteristics curve were calculated. RESULTS A total of 162 diabetic foot ulcers were included. In combination, the predictor variables necrosis, wound size, granulation, fibrin, dry skin, and age were most informative, in total an AUC of 0.77. CONCLUSIONS Wound characteristics have potential to predict wound outcome. Future research should investigate implementation of the prediction model in an evidence-based learning system.
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Affiliation(s)
- Clara Bender
- Department of Health Science and
Technology, Aalborg University, Denmark
| | | | | | | | - Susan Bermark
- Copenhagen Wound Healing Centre,
Bispebjerg Hospital, Capital Region, Denmark
| | | | - Ole Hejlesen
- Department of Health Science and
Technology, Aalborg University, Denmark
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14
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Lantis JC, Snyder R, Reyzelman AM, Van Gils CC, Sigal F, Vayser D, Caporusso JM, Cazzell S, Lavery LA. Fetal bovine acellular dermal matrix for the closure of diabetic foot ulcers: a prospective randomised controlled trial. J Wound Care 2021; 30:S18-S27. [PMID: 34256588 DOI: 10.12968/jowc.2021.30.sup7.s18] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIM The purpose of this clinical trial was to evaluate the safety and efficacy of a fetal bovine acellular dermal matrix (FBADM) plus standard of care (SOC) for treating hard-to-heal diabetic foot ulcers (DFUs). METHOD A prospective, multi-centre, randomised controlled trial was carried out. The study included a 2-week run-in period, a 12-week treatment phase and a 4-week follow-up phase. The primary endpoint was complete wound closure at 12 weeks. RESULTS Twenty-one US sites enrolled and randomised 226 patients with hard-to-heal DFUs. The study was terminated early due to the COVID-19 pandemic, which led to a modified intent-to-treat (mITT) population of 207 patients, with 103 in the FBADM group and 104 in the SOC group. Of these participants, 161 completed the study per protocol (mPP population), with 79 receiving FBADM, and 82 without. At the first analysis point, patients treated with FBADM were found to be significantly more likely to achieve complete wound closure compared with SOC alone (mITT: 45.6% versus 27.9% p=0.008; mPP: 59.5% versus 35.6% p=0.002). The difference in outcome yielded an odds ratio of 2.2 (95% confidence interval (CI): 1.2, 3.9; p=0.008). Median time to closure within 12 weeks was 43 days for the FBADM group compared to 57 days for the SOC group (p=0.36). The median number of applications of FBADM to achieve closure was one. Adverse events were similar between groups and no product-related serious adverse events occurred. CONCLUSIONS These results indicate that in many cases a single application of FBADM in conjunction with SOC offers a safe, faster and more effective treatment of DFUs than SOC alone.
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Affiliation(s)
- John C Lantis
- Mount Sinai West Hospital, Icahn School of Medicine, New York, NY, US
| | - Robert Snyder
- Barry University School of Podiatric Medicine, Miami, FL, US
| | - Alexander M Reyzelman
- Department of Medicine, California School of Podiatric Medicine and UCSF Center for Limb Preservation, California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA, US
| | | | | | | | | | - Shawn Cazzell
- Limb Preservation Platform, Valley Vascular Surgical Associates, Fresno, CA, US
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15
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Campitiello F, Mancone M, Cammarota M, D’Agostino A, Ricci G, Stellavato A, Della Corte A, Pirozzi AVA, Scialla G, Schiraldi C, Canonico S. Acellular Dermal Matrix Used in Diabetic Foot Ulcers: Clinical Outcomes Supported by Biochemical and Histological Analyses. Int J Mol Sci 2021; 22:7085. [PMID: 34209306 PMCID: PMC8267704 DOI: 10.3390/ijms22137085] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/10/2021] [Accepted: 06/23/2021] [Indexed: 01/21/2023] Open
Abstract
Diabetic foot ulcer (DFU) is a diabetes complication which greatly impacts the patient's quality of life, often leading to amputation of the affected limb unless there is a timely and adequate management of the patient. DFUs have a high economic impact for the national health system. Data have indeed shown that DFUs are a major cause of hospitalization for patients with diabetes. Based on that, DFUs represent a very important challenge for the national health system. Especially in developed countries diabetic patients are increasing at a very high rate and as expected, also the incidence of DFUs is increasing due to longevity of diabetic patients in the western population. Herein, the surgical approach focused on the targeted use of the acellular dermal matrix has been integrated with biochemical and morphological/histological analyses to obtain evidence-based information on the mechanisms underlying tissue regeneration. In this research report, the clinical results indicated decreased postoperative wound infection levels and a short healing time, with a sound regeneration of tissues. Here we demonstrate that the key biomarkers of wound healing process are activated at gene expression level and also synthesis of collagen I, collagen III and elastin is prompted and modulated within the 28-day period of observation. These analyses were run on five patients treated with Integra® sheet and five treated with the injectable matrix Integra® Flowable, for cavitary lesions. In fact, clinical evaluation of improved healing was, for the first time, supported by biochemical and histological analyses. For these reasons, the present work opens a new scenario in DFUs treatment and follow-up, laying the foundation for a tailored protocol towards complete healing in severe pathological conditions.
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Affiliation(s)
- Ferdinando Campitiello
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Miraglia 2, 80138 Naples, Italy; (F.C.); (A.D.C.); (G.S.); (S.C.)
| | - Manfredi Mancone
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Miraglia 2, 80138 Naples, Italy; (F.C.); (A.D.C.); (G.S.); (S.C.)
| | - Marcella Cammarota
- Department of Experimental Medicine, Section of Biotechnology, Medical Histology and Molecular Biology, University of Campania Luigi Vanvitelli, Via L. De Crecchio 7, 80138 Naples, Italy; (M.C.); (A.D.); (G.R.); (A.S.); (A.V.A.P.); (C.S.)
| | - Antonella D’Agostino
- Department of Experimental Medicine, Section of Biotechnology, Medical Histology and Molecular Biology, University of Campania Luigi Vanvitelli, Via L. De Crecchio 7, 80138 Naples, Italy; (M.C.); (A.D.); (G.R.); (A.S.); (A.V.A.P.); (C.S.)
| | - Giulia Ricci
- Department of Experimental Medicine, Section of Biotechnology, Medical Histology and Molecular Biology, University of Campania Luigi Vanvitelli, Via L. De Crecchio 7, 80138 Naples, Italy; (M.C.); (A.D.); (G.R.); (A.S.); (A.V.A.P.); (C.S.)
| | - Antonietta Stellavato
- Department of Experimental Medicine, Section of Biotechnology, Medical Histology and Molecular Biology, University of Campania Luigi Vanvitelli, Via L. De Crecchio 7, 80138 Naples, Italy; (M.C.); (A.D.); (G.R.); (A.S.); (A.V.A.P.); (C.S.)
| | - Angela Della Corte
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Miraglia 2, 80138 Naples, Italy; (F.C.); (A.D.C.); (G.S.); (S.C.)
| | - Anna Virginia Adriana Pirozzi
- Department of Experimental Medicine, Section of Biotechnology, Medical Histology and Molecular Biology, University of Campania Luigi Vanvitelli, Via L. De Crecchio 7, 80138 Naples, Italy; (M.C.); (A.D.); (G.R.); (A.S.); (A.V.A.P.); (C.S.)
| | - Gianluca Scialla
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Miraglia 2, 80138 Naples, Italy; (F.C.); (A.D.C.); (G.S.); (S.C.)
| | - Chiara Schiraldi
- Department of Experimental Medicine, Section of Biotechnology, Medical Histology and Molecular Biology, University of Campania Luigi Vanvitelli, Via L. De Crecchio 7, 80138 Naples, Italy; (M.C.); (A.D.); (G.R.); (A.S.); (A.V.A.P.); (C.S.)
| | - Silvestro Canonico
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Miraglia 2, 80138 Naples, Italy; (F.C.); (A.D.C.); (G.S.); (S.C.)
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16
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Leese GP, Soto-Pedre E, Schofield C. Independent Observational Analysis of Ulcer Outcomes for SINBAD and University of Texas Ulcer Scoring Systems. Diabetes Care 2021; 44:326-331. [PMID: 33288650 DOI: 10.2337/dc20-1817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/02/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to compare the University of Texas (UT) and Site, Ischemia, Neuropathy, Bacterial Infection, and Depth (SINBAD) foot ulcer scores in predicting ulcer outcome within a routine diabetes foot clinic. RESEARCH DESIGN AND METHODS From 2006 to 2018, data were collected from all patients attending an outpatient diabetes foot clinic with an active ulcer not healed within 4 weeks. UT and SINBAD were compared in predicting ulcer outcome. A unified numerical score for UT was constructed and compared with UT grade (depth) and stage scores. Outcomes included death, a healed ulcer, or a nonhealed ulcer, which included major or minor amputation and nonhealing chronic ulcers. RESULTS Outcomes were available from 1,645 ulcer outcomes in 1,068 patients (mean [SD] age 65.4 [4] years, 72% male), of which 1,108 (67%) healed. With exclusion of death as an adverse outcome, the c-statistic (area under operator curve) was 0.67 (95% CI 0.65-0.71) for UT grade/depth and 0.64 (0.61-0.67) for UT stage. The new unified UT score had an improved c-statistic of 0.71 (0.68-0.74). The c-statistic was 0.72 (0.69-0.75) for SINBAD. There was a stepwise decrease in the proportion of ulcers healed for each increased score on ulcer grading for both grading schemes. CONCLUSIONS This large and independent observational comparison, in a real-world clinical setting, demonstrated that the UT and SINBAD diabetes foot ulcer grading schemes had similar prognostic ability for predicting foot ulcer outcomes. We have devised and validated a unified numerical scoring system for UT.
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Affiliation(s)
- Graham P Leese
- Strathmore Diabetes Centre, Ninewells Hospital, Dundee, U.K.
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17
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Yammine K, Kheir N, Assi C. A Meta-Analysis of the Outcomes of Metatarsal Head Resection for the Treatment of Neuropathic Diabetic Foot Ulcers. Adv Wound Care (New Rochelle) 2021; 10:81-90. [PMID: 32870773 DOI: 10.1089/wound.2020.1261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Significance: Diabetic foot ulcers (DFUs) are associated with high morbidity, mortality, and health costs. Standard care (SC) associated with nonsurgical offloading is the mainstay treatment for DFUs, but it has high recurrence and infection rates. Metatarsal head resection (MHR) has been proposed as an effective surgical offloading technique for the treatment of plantar neuropathic DFUs, but with no evidence synthesis yet. Recent Advances: Based on PRISMA guidelines, a meta-analysis was conducted to assess the efficacy of MHR. Four electronic databases were searched for. Eleven studies met the inclusion criteria with a total of 477 patients (494 feet and 593 neuropathic forefoot ulcers). The studies included three retrospective comparative studies and eight case series. Critical Issues: Meta-analytical results of comparative studies on recent noninfected DFUs showed MHR having significantly better rates of healing, time to healing, ulcer recurrence, and infection than SC. Failure to heal, recurrence, and infection rates were 4 times higher in the SC group than in the MHR group, and the amputation rate was two times higher in the SC group than in the MHR group. The outcomes of the meta-analysis of case series on chronic and recalcitrant ulcers treated with MHR were similar. Future Directions: Considering the natural history of DFUs treated conservatively and the satisfactory outcomes with a significantly low complication rate of MHR, physicians should consider the use of MHR more often and include this technique in the early management of DFUs. Scope and Significance: DFU impose great public health burden around the globe. Standard of care using in-office debridement and topical agents is the usual mainstay of treatment. However, such conservative care is known to result in high rates of ulcer recurrence and complications. In this systematic review, we quantitatively investigate the outcomes of a surgical off-loading technique, the MHR in the treatment of chronic plantar neuropathic wounds. Translational Relevance: Many biochemical factors are implicated in the complex process of wound healing. In the case of diabetic neuropathic ulcers of the forefoot, additional mechanical factors induced by the presence of diabetic neuropathy lead to high pressure loads of the metatarsal heads on the plantar skin. With time, such chronic loads could favor ulcer formation. Removal of the causal mechanical factor could alleviate the pressure and allow wound healing. Clinical Relevance: Neuropathic plantar ulcers are difficult-to-heal wounds and chronicity is associated to frequent hospitalizations, higher rates of amputation, and mortality. Early removal of the indirect causal agent, the resection of the metatarsal head, after failure of a well-conducted conservative standard of care could be a needed solution for wound healing and consequently a potential for reducing complications and costs.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon
- Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
| | - Nadim Kheir
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
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Subhan BS, Kwong J, Kuhn JF, Monas A, Sharma S, Rabbani PS. Amniotic fluid-derived multipotent stromal cells drive diabetic wound healing through modulation of macrophages. J Transl Med 2021; 19:16. [PMID: 33407615 PMCID: PMC7789548 DOI: 10.1186/s12967-020-02674-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 12/11/2020] [Indexed: 01/13/2023] Open
Abstract
Background Cutaneous wounds in patients with diabetes exhibit impaired healing due to physiological impediments and conventional care options are severely limited. Multipotent stromal cells (MSCs) have been touted as a powerful new therapy for diabetic tissue repair owing to their trophic activity and low immunogenicity. However, variations in sources and access are limiting factors for broader adaptation and study of MSC-based therapies. Amniotic fluid presents a relatively unexplored source of MSCs and one with wide availability. Here, we investigate the potential of amniotic fluid-derived multipotent stromal cells (AFMSCs) to restore molecular integrity to diabetic wounds, amend pathology and promote wound healing. Method We obtained third trimester amniotic fluid from term cesarean delivery and isolated and expanded MSCs in vitro. We then generated 10 mm wounds in Leprdb/db diabetic mouse skin, and splinted them open to allow for humanized wound modeling. Immediately after wounding, we applied AFMSCs topically to the sites of injuries on diabetic mice, while media application only, defined as vehicle, served as controls. Post-treatment, we compared healing time and molecular and cellular events of AFMSC-treated, vehicle-treated, untreated diabetic, and non-diabetic wounds. A priori statistical analyses measures determined significance of the data. Result Average time to wound closure was approximately 19 days in AFMSC-treated diabetic wounds. This was significantly lower than the vehicle-treated diabetic wounds, which required on average 27.5 days to heal (p < 0.01), and most similar to time of closure in wild type untreated wounds (an average of around 18 days). In addition, AFMSC treatment induced changes in the profiles of macrophage polarizing cytokines, resulting in a change in macrophage composition in the diabetic wound bed. We found no evidence of AFMSC engraftment or biotherapy induced immune response. Conclusion Treatment of diabetic wounds using amniotic fluid-derived MSCs encourages cutaneous tissue repair through affecting inflammatory cell behavior in the wound site. Since vehicle-treated diabetic wounds did not demonstrate accelerated healing, we determined that AFMSCs were therapeutic through their paracrine activities. Future studies should be aimed towards validating our observations through further examination of the paracrine potential of AFMSCs. In addition, investigations concerning safety and efficacy of this therapy in clinical trials should be pursued.
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Affiliation(s)
- Bibi S Subhan
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, 540 First Avenue, New York, 10016, USA
| | - Jennifer Kwong
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, 540 First Avenue, New York, 10016, USA
| | - Joseph F Kuhn
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, 540 First Avenue, New York, 10016, USA
| | - Arie Monas
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, 540 First Avenue, New York, 10016, USA
| | - Sonali Sharma
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, 540 First Avenue, New York, 10016, USA
| | - Piul S Rabbani
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, 540 First Avenue, New York, 10016, USA.
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19
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Kim RB, Gryak J, Mishra A, Cui C, Soroushmehr SMR, Najarian K, Wrobel JS. Utilization of smartphone and tablet camera photographs to predict healing of diabetes-related foot ulcers. Comput Biol Med 2020; 126:104042. [PMID: 33059239 DOI: 10.1016/j.compbiomed.2020.104042] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/21/2020] [Accepted: 10/03/2020] [Indexed: 12/15/2022]
Abstract
The objective of this study was to build a machine learning model that can predict healing of diabetes-related foot ulcers, using both clinical attributes extracted from electronic health records (EHR) and image features extracted from photographs. The clinical information and photographs were collected at an academic podiatry wound clinic over a three-year period. Both hand-crafted color and texture features and deep learning-based features from the global average pooling layer of ResNet-50 were extracted from the wound photographs. Random Forest (RF) and Support Vector Machine (SVM) models were then trained for prediction. For prediction of eventual wound healing, the models built with hand-crafted imaging features alone outperformed models built with clinical or deep-learning features alone. Models trained with all features performed comparatively against models trained with hand-crafted imaging features. Utilization of smartphone and tablet photographs taken outside of research settings hold promise for predicting prognosis of diabetes-related foot ulcers.
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Affiliation(s)
- Renaid B Kim
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, 48109, USA.
| | - Jonathan Gryak
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, 48109, USA
| | - Abinash Mishra
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Can Cui
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, 48109, USA
| | - S M Reza Soroushmehr
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, 48109, USA
| | - Kayvan Najarian
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, 48109, USA; Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, 48109, USA; Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - James S Wrobel
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
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20
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Cho SK, Mattke S, Gordon H, Sheridan M, Ennis W. Development of a Model to Predict Healing of Chronic Wounds Within 12 Weeks. Adv Wound Care (New Rochelle) 2020; 9:516-524. [PMID: 32941121 PMCID: PMC7522633 DOI: 10.1089/wound.2019.1091] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective: Chronic wounds represent a highly prevalent but little recognized condition with substantial implications for patients and payers. While better wound care products and treatment modalities are known to improve healing rates, they are inconsistently used in real-world practice. Predicting healing rates of chronic wounds and comparing to actual rates could be used to detect and reward better quality of care. We developed a prediction model for chronic wound healing. Approach: We analyzed electronic medical records (EMRs) for 620,356 chronic wounds of various etiologies in 261,398 patients from 532 wound care clinics in the United States. Patient-level and wound-level parameters influencing wound healing were identified from prior research and clinician input. Logistic regression and classification tree models to predict the probability of wound healing within 12 weeks were developed using a random sample of 70% of the wounds and validated in the remaining data. Results: A total of 365,659 (58.9%) wounds were healed by week 12. The logistic and classification tree models predicted healing with an area under the curve of 0.712 and 0.717, respectively. Wound-level characteristics, such as location, area, depth, and etiology, were more powerful predictors than patient demographics and comorbidities. Innovation: The probability of wound healing can be predicted with reasonable accuracy in real-world data from EMRs. Conclusion: The resulting severity adjustment model can become the basis for applications like quality measure development, research into clinical practice and performance-based payment.
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Affiliation(s)
- Sang Kyu Cho
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California
| | - Soeren Mattke
- Center for Economic and Social Research, University of Southern California, Los Angeles, California
| | | | | | - William Ennis
- Healogics, Inc., Jacksonville, Florida
- Department of Surgery, Wound Healing and Tissue Repair Program, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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Diab J, O'Hara J, Pye M, Parker C, Maitz PKM, Issler-Fisher A. Foot burns: A comparative analysis of diabetic and non-diabetic patients. Burns 2020; 47:705-713. [PMID: 32863067 DOI: 10.1016/j.burns.2020.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Foot burns represent a small part of the body with many challenges. The impact of diabetes on clinical outcomes adds further issues in management that clinicians must consider in their management. These factors have serious implications on morbidity and long term sequelae. Our aim is to analyse epidemiological trends of foot burns and examine the differences between diabetic and non-diabetics at Concord hospital from 2014 to 2019. METHODS A retrospective audit from 2014-19 at Concord General Repatriation Hospital Burns Unit summarised patient demographics, burn injury, diabetic status, operations and length of stay. All foot burn injuries from 2014-19 of all ages and gender that attended Concord burns hospital were included in this study. RESULTS We treated 797 patients who presented with foot burns, of which 16.2% were diabetic. The average age was higher in diabetics (60.72 years) than non-diabetics (39.72 years) and more males suffered burns compared to females in both groups (p < 0.001). There was a larger portion of elderly patients (greater than 65 years old, 15.1% of total) who sustained foot burns in the diabetic group compared to the non-diabetic group (p < 0.001). The most affected season was summer (27.0%), but diabetic patients were 1.7 times more likely to sustain injury in winter than non-diabetics. Diabetics were 3.8 times more likely to have contact burns compared to non-diabetic patients (p < 0.001). In a multivariable linear regression analysis, factors that contributed to increased length of stay included elderly status, place of event, diabetic status, number of operations, ICU admission, wound infection, amputation, and admission [F (16, 757 = 41.149, p < 0.001, R2 = 0.465]. CONCLUSIONS With the increase of diabetes, our multidisciplinary approach to diabetic foot care should include nursing, medical and surgical disciplines to identify patients at risk. The data highlights that a focus on prevention and education for diabetes is central to optimize glycaemic control and burn management, whilst providing a multidisciplinary network on discharge.
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Affiliation(s)
- Jason Diab
- Concord Repatriation General Hospital, Burns Unit, Australia; Concord Clinical School, University of Sydney, Sydney, Australia; School of Medicine, University of Notre Dame, Sydney, Australia.
| | - Justine O'Hara
- Concord Repatriation General Hospital, Burns Unit, Australia; Concord Clinical School, University of Sydney, Sydney, Australia
| | - Miranda Pye
- Concord Repatriation General Hospital, Burns Unit, Australia
| | | | - Peter K M Maitz
- Concord Repatriation General Hospital, Burns Unit, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; Concord Clinical School, University of Sydney, Sydney, Australia
| | - Andrea Issler-Fisher
- Concord Repatriation General Hospital, Burns Unit, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; Concord Clinical School, University of Sydney, Sydney, Australia
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22
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Clinician Assessment Tools for Patients with Diabetic Foot Disease: A Systematic Review. J Clin Med 2020; 9:jcm9051487. [PMID: 32429068 PMCID: PMC7291260 DOI: 10.3390/jcm9051487] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 12/22/2022] Open
Abstract
The amputation rate in patients with diabetes is 15 to 40 times higher than in patients without diabetes. To avoid major complications, the identification of high-risk in patients with diabetes through early assessment highlights as a crucial action. Clinician assessment tools are scales in which clinical examiners are specifically trained to make a correct judgment based on patient outcomes that helps to identify at-risk patients and monitor the intervention. The aim of this study is to carry out a systematic review of valid and reliable Clinician assessment tools for measuring diabetic foot disease-related variables and analysing their psychometric properties. The databases used were PubMed, Scopus, SciELO, CINAHL, Cochrane, PEDro, and EMBASE. The search terms used were foot, ankle, diabetes, diabetic foot, assessment, tools, instruments, score, scale, validity, and reliability. The results showed 29 validated studies with 39 Clinician assessment tools and six variables. There is limited evidence on all of the psychometric characteristics of the Clinician assessment tools included in this review, although some instruments have been shown to be valid and reliable for the assessment of diabetic neuropathy (Utah Early Neuropathy Scale or UENS); ulceration risk (Queensland High Risk Foot Form or QHRFF); diabetic foot ulcer assessment, scoring, and amputation risk (Perfusion, extent, depth, infection and sensation scale or PEDIS and Site, Ischemia, Neuropathy, Bacterial Infection, and Depth score or SINBAD); and diabetic foot ulcer measurement (Leg Ulcer Measurement Tool LUMT).
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23
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Monteiro-Soares M, Boyko EJ, Jeffcoate W, Mills JL, Russell D, Morbach S, Game F. Diabetic foot ulcer classifications: A critical review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3272. [PMID: 32176449 DOI: 10.1002/dmrr.3272] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Classification and scoring systems can help both clinical management and audit outcomes of routine care. The aim of this study was to assess published systems of diabetic foot ulcers (DFUs) to determine which should be recommended for a given clinical purpose. Published classifications had to have been validated in populations of > 75% people with diabetes and a foot ulcer. Each study was assessed for internal and external validity and reliability. Eight key factors associated with failure to heal were identified from large clinical series and each classification was scored on the number of these key factors included. Classifications were then arranged according to their proposed purpose into one or more of four groups: (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) aid clinical management decision making for an individual case, and (d) audit to compare outcome in different populations. Thirty-seven classification systems were identified of which 18 were excluded for not being validated in a population of >75% DFUs. The included 19 classifications had different purposes and were derived from different populations. Only six were developed in multicentre studies, just 13 were externally validated, and very few had evaluated reliability.Classifications varied in the number (4 - 30), and definition of individual items and the diagnostic tools required. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalization, limb amputation, mortality, and cost. Despite the limitations, there was sufficient evidence to make recommendations on the use of particular classifications for the indications listed above.
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Affiliation(s)
- Matilde Monteiro-Soares
- Departamento de Medicina da Comunidade, Informação e Decisão em Saúde (MEDCIDS), Faculdade de Medicina da Universidade do Porto, Oporto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Faculdade de Medicina da Universidade do Porto, Oporto, Portugal
| | | | - William Jeffcoate
- Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - David Russell
- Department of Vascular Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Stephan Morbach
- Department of Diabetes and Angiology, Marienkrankenhaus gGmbH, Soest, Germany
- Institute for Health Services Research and Health Economics, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Yammine K, Nahed M, Assi C. Metatarsal Osteotomies for Treating Neuropathic Diabetic Foot Ulcers: A Meta-analysis. Foot Ankle Spec 2019; 12:555-562. [PMID: 30565498 DOI: 10.1177/1938640018819784] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diabetic foot ulcers (DFUs) are usually treated with conservative management based on debridement, topical agents, and nonsurgical off-loading; however, the recurrence rate following such standard care is reported to be high. In the case of recalcitrant or recurrent ulcers, a surgical off-loading technique such as the metatarsal osteotomy (MO) is indicated. Thus, the aim of this study is to conduct a meta-analysis evaluating the efficacy of MO in treating DFUs. Four relevant studies were identified, including 119 patients with 129 DFUs; all wounds were refractory to a previous conservative treatment of a mean duration of 10.9 ± 4.2 months. With a mean follow-up period of 18.2 ± 5.7 months, the weighted pooled rates were as follows: 98.7% for ulcer healing (in a mean time to heal of 6.5 ± 1.2 weeks), 4.3% for ulcer recurrence, 10.3% for ulcer transfer, 3.7% for infection, and 3.4% for nonunion. These findings were found to be noticeably better than those reported in the literature following standard care, whether associated or not to nonsurgical off-loading methods and that for all the studied outcomes. Knowing the dismal natural history of recalcitrant DFUs treated conservatively, the results of the MO techniques seems to offer a promising alternative in terms of ulcer healing and ulcer complications. In addition to complicated wounds, the indications for MO could include noncomplicated ulcers with healing delay. Level of Evidence: Level IV.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center, Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon (KY, MN, CA).,Diabetic Foot Clinic, Lebanese American University Medical Center, Rizk Hospital, Beirut, Lebanon (KY).,Center for Evidence-Based Anatomy, Sport and Orthopedics Research (KY, MN, CA)
| | - Marc Nahed
- Department of Orthopedic Surgery, Lebanese American University Medical Center, Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon (KY, MN, CA).,Diabetic Foot Clinic, Lebanese American University Medical Center, Rizk Hospital, Beirut, Lebanon (KY).,Center for Evidence-Based Anatomy, Sport and Orthopedics Research (KY, MN, CA)
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center, Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon (KY, MN, CA).,Diabetic Foot Clinic, Lebanese American University Medical Center, Rizk Hospital, Beirut, Lebanon (KY).,Center for Evidence-Based Anatomy, Sport and Orthopedics Research (KY, MN, CA)
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25
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Woods JS, Saxena M, Nagamine T, Howell RS, Criscitelli T, Gorenstein S, M Gillette B. The Future of Data-Driven Wound Care. AORN J 2019; 107:455-463. [PMID: 29595902 DOI: 10.1002/aorn.12102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Care for patients with chronic wounds can be complex, and the chances of poor outcomes are high if wound care is not optimized through evidence-based protocols. Tracking and managing every variable and comorbidity in patients with wounds is difficult despite the increasing use of wound-specific electronic medical records. Harnessing the power of big data analytics to help nurses and physicians provide optimized care based on the care provided to millions of patients can result in better outcomes. Numerous applications of machine learning toward workflow improvements, inpatient monitoring, outpatient communication, and hospital operations can improve overall efficiency and efficacy of care delivery in and out of the hospital, while reducing adverse events and complications. This article provides an overview of the application of big data analytics and machine learning in health care, highlights important recent advances, and discusses how these technologies may revolutionize advanced wound care.
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26
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Ananian CE, Davis RD, Johnson EL, Regulski MJ, Reyzelman AM, Saunders MC, Danilkovitch A. Wound Closure Outcomes Suggest Clinical Equivalency Between Lyopreserved and Cryopreserved Placental Membranes Containing Viable Cells. Adv Wound Care (New Rochelle) 2019; 8:546-554. [PMID: 31637101 PMCID: PMC6798798 DOI: 10.1089/wound.2019.1028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
Objective: To evaluate the clinical outcomes of lyopreserved placental membrane containing viable cells (vLPM) in the treatment of nonhealing wounds of various etiologies, and to compare them to those previously reported for cryopreserved placental membrane containing viable cells (vCPM). Approach: Patients with nonhealing wounds who qualified to receive advanced wound therapies were consecutively enrolled and treated weekly with vLPM plus standard of care (SOC) at five centers. Data were de-identified and retrospectively analyzed. Outcomes included closure, time to closure, number of vLPM applications, and adverse events (AEs). Results: Seventy-eight patients with 98 wounds (41 diabetic foot ulcers [DFUs], 19 venous leg ulcers [VLUs], 10 surgical, and 28 others) with an average size of 13.3 cm2 and 8.7 months duration were treated. Fifty-eight of the 98 wounds (59.2%) achieved complete closure with median time to closure of 63 days and 6 vLPM applications. The closure by wound etiology was 63% for DFUs, 47% for VLUs, 70% for surgical wounds, and 57% for other types of wounds. Similar closure rates have been previously demonstrated for vCPM. Wound duration was the main predictor of closure: 65.8% versus 30.0% (p = 0.004) closure was achieved for wounds of ≤12 and >12 months duration, respectively. There were no AEs related to vLPM application. Innovation: This is the first multicenter case series evaluating the clinical outcomes of vLPM in a real-world setting. Conclusion: These results support clinical equivalency between the two placental membrane formulations with the added convenience of room-temperature storage for vLPM, allowing it to be used in any wound-care setting.
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Affiliation(s)
| | | | - Eric L. Johnson
- Bozeman Health Deaconess Hospital, Wound and Hyperbaric Center, Bozeman, Montana
| | - Matthew J. Regulski
- Ocean County Foot & Ankle Surgical Associates, P.C., Forked River, New Jersey
| | - Alexander M. Reyzelman
- California School of Podiatric Medicine at Samuel Merritt University, Oakland, California
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Trøstrup H, Holstein P, Karlsmark T, Moser C, Ågren MS. Uncontrolled gelatin degradation in non-healing chronic wounds. J Wound Care 2019; 27:724-734. [PMID: 30398935 DOI: 10.12968/jowc.2018.27.11.724] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To compare matrix metalloproteinase (MMP)-9 and the antiproteinase tissue inhibitor of metalloproteinases (TIMP)-1 in wound fluids and sera from patients with chronic non-healing or acute healing wounds. In addition, the functional consequences on MMP-9 activity and general gelatinase activity were assessed. METHOD In this observational study, samples were collected from patients with venous leg ulcers (VLUs), patients with type 2 diabetes with neuropathic foot ulcers (DFUs), and from another cohort of VLU patients with sterile split-thickness skin graft donor sites after autologous skin grafting, serving as healing control wounds. MMP-9 and TIMP-1 concentrations were determined by enzyme-linked immunosorbent assays. MMP-9 and gelatinase activities were determined in wound fluids in subsets of the patients. RESULTS A total of 24 patients took part in the study. No significant differences in MMP-9 wound fluid levels were found among the three groups. TIMP-1 levels were markedly and significantly lower in the two chronic wound groups resulting in a severely unbalanced MMP-9/TIMP-1 ratio, especially notable in the VLU group and possibly in the elevated endogenous MMP-9 activity (p<0.01) compared with the acute wound fluids. At least 20% of the chronic wound fluids displayed atypical patterns on gelatin zymography and showed high general gelatinase activity that was not inhibited by either TIMP-1 or by a gelatinase inhibitor (AG3340). MMP-9 levels were higher in the sera of the patients with type 2 diabetes. CONCLUSION We hypothesise that non-MMP proteinases contribute to matrix destruction in a significant number of chronic wounds. Blocking the excessive MMP-9 activity may be insufficient to normalise wound healing. The reasons and effects of the very low TIMP-1 levels in chronic wounds need further clarification.
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Affiliation(s)
- Hannah Trøstrup
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Per Holstein
- Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Tonny Karlsmark
- Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Magnus S Ågren
- Professor, Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark. Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark. Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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28
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Jenkins DA, Mohamed S, Taylor JK, Peek N, van der Veer SN. Potential prognostic factors for delayed healing of common, non-traumatic skin ulcers: A scoping review. Int Wound J 2019; 16:800-812. [PMID: 30821117 PMCID: PMC6563199 DOI: 10.1111/iwj.13100] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/04/2019] [Indexed: 01/08/2023] Open
Abstract
Healing of non-traumatic skin ulcers is often suboptimal. Prognostic tools that identify people at high risk of delayed healing within the context of routine ulcer assessments may improve this, but robust evidence on which factors to include is lacking. Therefore, we scoped the literature to identify which potentially prognostic factors may warrant future systematic reviews and meta-analyses. We conducted electronic searches in MEDLINE and Embase to identify studies in English published between 1997 and 2017 that tested the association between healing of the three most common non-traumatic skin ulcers encountered by health care professionals (venous leg, diabetic foot, and pressure ulcers) and patient characteristics, ulcer characteristics, and results from clinical investigations. We included 42 studies that investigated factors which may be associated with the healing of venous leg ulcers (n = 17), diabetic foot ulcers (n = 15), and pressure ulcers (n = 10). Across ulcer types, ulcer characteristics were most commonly reported as potential prognostic factors for healing (n = 37), including the size of the ulcer area (n = 29) and ulcer duration at first assessment (n = 16). A total of 35 studies investigated the prognostic value of patient characteristics (n = 35), including age (n = 31), gender (n = 30), diabetes (n = 22), smoking status (n = 15), and history of deep vein thrombosis (DVT) (n = 13). Of these studies, 23 reported results from clinical investigations as potential prognostic factors, with the majority regarding vessel quality. Age, gender, diabetes, smoking status, history of DVT, ulcer area, and ulcer duration at time of first assessment warrant a systematic review and meta-analysis to quantify their prognostic value for delayed ulcer healing.
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Affiliation(s)
- David A. Jenkins
- NIHR Greater Manchester Patient Safety Translational Research CentreThe University of ManchesterManchesterUK
- Health e‐Research Centre, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
| | - Sundus Mohamed
- Health e‐Research Centre, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
| | - Joanne K. Taylor
- Health e‐Research Centre, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
- Manchester University NHS Foundation TrustManchesterUK
| | - Niels Peek
- NIHR Greater Manchester Patient Safety Translational Research CentreThe University of ManchesterManchesterUK
- Health e‐Research Centre, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
- NIHR Manchester Biomedical Research Centre, Faculty of Biology Medicine and HealthThe University of ManchesterManchesterUK
| | - Sabine N. van der Veer
- NIHR Greater Manchester Patient Safety Translational Research CentreThe University of ManchesterManchesterUK
- Health e‐Research Centre, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
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29
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Vas PRJ, Edmonds ME, Papanas N. Nutritional Supplementation for Diabetic Foot Ulcers: The Big Challenge. INT J LOW EXTR WOUND 2017; 16:226-229. [DOI: 10.1177/1534734617740254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Diabetic foot ulcers remain difficult to heal and nutritional supplementation may be an important complementary therapeutic measure. However, we need to clarify many issues before such supplementation is more widely used. Indeed, improvements are needed in the following areas: evaluation of nutritional inadequacy, completion of randomized controlled trials, understanding of patient and ulcer characteristics that favor response to nutritional supplementation, optimal duration of supplementation therapy, and evaluation of patient adherence. The challenge is now to acquire more knowledge in the aforementioned areas.
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30
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Adipose-derived stem cells for treatment of chronic cutaneous ulcers in patients with critical limb ischemia: a pilot study. EUROPEAN JOURNAL OF PLASTIC SURGERY 2017. [DOI: 10.1007/s00238-017-1383-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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31
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Novelli G, Daleffe F, Birra G, Canzi G, Mazzoleni F, Boni P, Maino C, Giussani C, Sozzi D, Bozzetti A. Negative pressure wound therapy in complex cranio-maxillofacial and cervical wounds. Int Wound J 2017; 15:16-23. [PMID: 29171161 DOI: 10.1111/iwj.12802] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/03/2017] [Accepted: 07/07/2017] [Indexed: 02/06/2023] Open
Abstract
The care and the management of the healing of difficult wounds at the level of the skull-facial face many problems related to patient compliance and the need to perform multiple dressings, with long periods of healing and, occasionally, a very long hospitalisation period. The introduction and evolution of negative pressure wound therapy (NPWT) in the treatment of difficult wounds has resulted in better healing, with a drastic reduction in terms of time and biological costs to the patient and cost to the health care system. The main aim of this study is to describe and discuss, using out our experience, the usefulness of NPWT in the cranial-facial-cervical region. We studied 16 patients with complex wounds of the cranial-facial-cervical region treated with NPWT. We divided clinical cases in four groups: cervicofacial infectious disease, healing complications in oncological-reconstructive surgery, healing complications of injury with exposure of bone and/or internal fixations and healing complications in traumatic injury with loss of substance. We evaluated complete or incomplete wound healing; application time, related also to hospitalisation time; days of intensive care unit (ICU) stay; management of the upper airways; timing of medication renewal; and patient comfort and compliance (on a scale of 1-5). Depression values were always between -75 and -125 mmHg in a continuous aspiration pattern. For every patient, we used the ActiVAC Therapy Unit, derived from the vacuum-assisted closure system (Kinetic Concepts Inc., San Antonio, TX). Medication renewals were performed every 48-72 hours. The NPWT application time ranged from 4 to 22 days (mean of 11·57 day). Therapy was effective to gain a complete restitutio ad integrum in every patient included in the group of cervicofacial infectious disease. Therapy has, however, been well tolerated in our series; this is probably due to the decreased number of applications, the ease of use and the comfort of the system relative to traditional dressing. Results were satisfactory for most of cases treated; faster and more effective wound healing was achieved. The lower number of NPWT applications, relating to standard dressings, led to an increase in patient comfort and compliance and a decrease in the use of medical, and in some cases economic, resources according to international literature.
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Affiliation(s)
- Giorgio Novelli
- Department of Maxillofacial Surgery, University of Milano-Bicocca, Asst- San Gerardo Hospital, Monza, Italy
| | - Francesco Daleffe
- Department of Maxillofacial Surgery, University of Milano-Bicocca, Asst- San Gerardo Hospital, Monza, Italy
| | - Gisella Birra
- Department of Maxillofacial Surgery, University of Milano-Bicocca, Asst- San Gerardo Hospital, Monza, Italy
| | - Gabriele Canzi
- Department of Maxillofacial Surgery, Niguarda Hospital, Milano, Italy
| | - Fabio Mazzoleni
- Department of Maxillofacial Surgery, University of Milano-Bicocca, Asst- San Gerardo Hospital, Monza, Italy
| | - Pietro Boni
- Department of Maxillofacial Surgery, University of Milano-Bicocca, Asst- San Gerardo Hospital, Monza, Italy
| | - Clara Maino
- Outpatient clinic - Advanced Wound Care, Department of Professional Health, Asst-San Gerardo Hospital, Monza, Italy
| | - Carlo Giussani
- Department of Neurosurgery, University of Milano-Bicocca, Asst-San Gerardo Hospital, Monza, Italy
| | - Davide Sozzi
- Department of Maxillofacial Surgery, University of Milano-Bicocca, Asst- San Gerardo Hospital, Monza, Italy
| | - Alberto Bozzetti
- Department of Maxillofacial Surgery, University of Milano-Bicocca, Asst- San Gerardo Hospital, Monza, Italy
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Ferraro NM, Dampier W, Weingarten MS, Spiller KL. Deconvolution of heterogeneous wound tissue samples into relative macrophage phenotype composition via models based on gene expression. Integr Biol (Camb) 2017; 9:328-338. [PMID: 28290581 DOI: 10.1039/c7ib00018a] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Macrophages, the primary cell of the innate immune system, act on a spectrum of phenotypes that correspond to diverse functions. Dysregulation of macrophage phenotype is associated with many diseases. In particular, defective transition from pro-inflammatory (M1) to anti-inflammatory (M2) behavior has been implicated as a potential source of sustained inflammation that prevents healing of chronic wounds such as diabetic ulcers. In order to design effective treatments, an understanding of the relative presence of macrophage phenotypes during tissue repair is necessary. Inferring the relative phenotype composition is currently challenging due to the heterogeneous nature of the macrophages themselves and also of tissue samples. We propose here a method to deconvolute gene expression from heterogeneous tissue samples into the composition of two primary macrophage phenotypes (M1 and M2). Our final method uses gene expression signatures for each phenotype cultivated in vitro as input to a predictive model that infers sample composition with an average error of 0.16, and whose predictions fit known compositions prepared in vitro with an R2 value of 0.90. Finally, we apply this model to describe macrophage behavior in human diabetic ulcer healing using clinically isolated ulcer tissue samples. The model predicted that non-healing diabetic ulcers contained higher proportions of M1 macrophages compared to healing diabetic ulcers, in agreement with numerous studies that have implicated a dysfunctional M1-to-M2 transition in the impaired healing of diabetic ulcers. These results show proof of concept that the model holds utility in making predictions regarding macrophage behavior in heterogeneous samples, with potential application as a wound healing diagnostic.
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Affiliation(s)
- Nicole M Ferraro
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, USA.
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Diabetic foot ulcers—comparison of performance of ankle-brachial index and transcutaneous partial oxygen pressure in predicting outcome. Int J Diabetes Dev Ctries 2017. [DOI: 10.1007/s13410-017-0580-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Monami M, Mirabella C, Scatena A, Nreu B, Zannoni S, Aleffi S, Giannoni L, Mannucci E. CO 2 laser for the treatment of diabetic foot ulcers with exposed bone. A consecutive series of type 2 diabetic patients. J Endocrinol Invest 2017; 40:819-822. [PMID: 28260184 DOI: 10.1007/s40618-017-0642-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 02/13/2017] [Indexed: 11/30/2022]
Abstract
AIM The treatment of foot ulcers with exposed bone is challenging, because of the risk of infection and of difficulties in the development of granulation tissue. A CO2 laser beam could be used to produce discontinuities in periosteum, allowing the exposure of blood containing multipotent stem cells, capable of initiating the healing process. The local application of platelet-rich plasma (PRP) has been proposed as a therapeutic tool for accelerating healing in foot ulcers, including those in patients with diabetes. Aim of the present pilot, proof-of-concept study is the assessment of the therapeutic potential of CO2 laser treatment, either alone or combined with PRP, in the treatment of diabetic foot ulcers with exposed bone. METHODS We performed a pilot, uncontrolled 3-month observation study on a consecutive series of 9 type two diabetic patients and foot ulcers with exposed bone. A CO2-laser was used for producing nine discontinuities on periosteum for each cm2, by directing the focused laser beam on the bone until bleeding. The procedure was repeated up to 6 times, at a distance of 1 week and ulcers assessed weekly until the end of the study (3 months). In the last 5 of the 14 patients, the treatment described above was associated with PRP. RESULTS Of the nine patients treated, four healed, and one more patient developed granulation tissue covering entirely bone surface. Out of the four patients who did not heal, one underwent minor amputation. Among the five patients treated with a combination of CO2 laser and PRP, two healed within 3 months, and two more patients developed granulation tissue covering entirely bone surface; the fifth patient did not show any improvement and underwent amputation. CONCLUSIONS The present pilot experience represents a novelty in this field showing a possible use of CO2-laser in the treatment of diabetic foot ulcers.
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Affiliation(s)
- M Monami
- Diabetology, Azienda Ospedaliero Universitaria Careggi, University of Florence, SOD Diabetologia - AOU Careggi, Via delle Oblate n. 4, 50141, Florence, Italy.
| | - C Mirabella
- Immunohematology and Transfusion Medicine, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
| | - A Scatena
- Diabetology Unit, Ospedale San Donato Arezzo, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
| | - B Nreu
- Geriatric Medicine, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
| | - S Zannoni
- Diabetology, Azienda Ospedaliero Universitaria Careggi, University of Florence, SOD Diabetologia - AOU Careggi, Via delle Oblate n. 4, 50141, Florence, Italy
| | - S Aleffi
- Diabetology, Azienda Ospedaliero Universitaria Careggi, University of Florence, SOD Diabetologia - AOU Careggi, Via delle Oblate n. 4, 50141, Florence, Italy
| | - L Giannoni
- Diabetology, Azienda Ospedaliero Universitaria Careggi, University of Florence, SOD Diabetologia - AOU Careggi, Via delle Oblate n. 4, 50141, Florence, Italy
| | - E Mannucci
- Diabetology, Azienda Ospedaliero Universitaria Careggi, University of Florence, SOD Diabetologia - AOU Careggi, Via delle Oblate n. 4, 50141, Florence, Italy
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Systematic review of complications and outcomes of diabetic patients with burn trauma. Burns 2016; 42:1644-1651. [DOI: 10.1016/j.burns.2016.06.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/27/2016] [Accepted: 06/15/2016] [Indexed: 01/02/2023]
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Pua BB, Muhs BE, Maldonado T, Ben-Arie E, Sheehan P, Gagne PJ. Total-Contact Casting as an Adjunct to Promote Healing of Pressure Ulcers in Amputees. Vasc Endovascular Surg 2016; 40:135-40. [PMID: 16598362 DOI: 10.1177/153857440604000208] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Partial foot amputations have become increasingly prevalent among long-lived diabetic patients. These patients have lower extremity neuropathy and are prone to ulceration at their amputation site. These ulcers are difficult to heal, and they place a significant financial and resource burden on the healthcare system. We examined the efficacy of total-contact casts (TCC) in diabetic amputees with nonhealing partial foot amputation site neuropathic ulcers. Data were collected retrospectively on all patients with amputations who were treated with a total-contact cast between December 2000 and December 2003. Seventeen patients (13 men, 4 women) with amputation site ulceration were identified. All patients were diagnosed with neuropathy secondary to diabetes and none had wound healing compromised by ischemia. The initial ulcer averaged 1,169 mm2 with a depth of 2.77 mm. Patients were treated with an average of 7.9 cast applications over 8.4 weeks; 47% (8/17) of ulcers healed, but 29% (5/17) of patients were unable to complete their recommended treatment course secondary to complications from the TCC. Of the patients who were able to complete their treatment course, the healing rate was 66.7% (8/12). The recurrence rate for healed ulcers was 63% (5/8). Partial foot amputations with neuropathic ulcers present a very difficult problem to the vascular surgeon. Patient compliance and underlying medical comorbidities limit the success rate. In patients who can complete a TCC treatment course, good short term results can be expected. However, recurrence rates are high following discontinuation of mechanical TCC off-loading.
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Affiliation(s)
- Bradley B Pua
- Department of Surgery, New York University School of Medicine, New York, NY 10016, USA
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Cullum N, Buckley H, Dumville J, Hall J, Lamb K, Madden M, Morley R, O’Meara S, Goncalves PS, Soares M, Stubbs N. Wounds research for patient benefit: a 5-year programme of research. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04130] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BackgroundComplex wounds are those that heal by secondary intention and include lower-limb ulcers, pressure ulcers and some surgical wounds. The care of people with complex wounds is costly, with care mainly being delivered by community nurses. There is a lack of current, high-quality data regarding the numbers and types of people affected, care received and outcomes achieved.ObjectivesTo (1) assess how high-quality data about complex wounds can be captured effectively for use in both service planning and research while ensuring integration with current clinical data collection systems and minimal impact on staff time; (2) investigate whether or not a clinical register of people with complex wounds could give valid estimates of treatment effects, thus reducing dependence on large-scale randomised controlled trials (RCTs); (3) identify the most important research questions and outcomes for people with complex wounds from the perspectives of patients, carers and health-care professionals; (4) evaluate the potential contributions to decision-making of individual patient data meta-analysis and mixed treatment comparison meta-analysis; and (5) complete and update systematic reviews in topic areas of high priority.MethodsTo meet objectives 1 and 2 we conducted a prevalence survey and developed and piloted a longitudinal disease register. A consultative, deliberative method and in-depth interviews were undertaken to address objective 3. To address objectives 4 and 5 we conducted systematic reviews including mixed treatment comparison meta-analysis.ResultsFrom the prevalence survey we estimated the point prevalence of all complex wounds to be 1.47 per 1000 people (95% confidence interval 1.38 to 1.56 per 1000 people). Pressure ulcers and venous leg ulcers were the most common type of complex wound. A total of 195 people with a complex wound were recruited to a complex wounds register pilot. We established the feasibility of correctly identifying, extracting and transferring routine NHS data into the register; however, participant recruitment, data collection and tracking individual wounds in people with multiple wounds were challenging. Most patients and health professionals regarded healing of the wound as the primary treatment goal. Patients were greatly troubled by the social consequences of having a complex wound. Complex wounds are frequently a consequence of, and are themselves, a long-term condition but treatment is usually focused on healing the wound. Consultative, deliberative research agenda setting on pressure ulcer prevention and treatment with patients, carers and clinicians yielded 960 treatment uncertainties and a top 12 list of research priorities. Of 167 RCTs of complex wound treatments in a systematic review of study quality, 41% did not specify a primary outcome and the overall quality of the conduct and reporting of the research was poor. Mixed-treatment comparison meta-analysis in areas of high priority identified that matrix hydrocolloid dressings had the highest probability (70%) of being the most effective dressing for diabetic foot ulcers, whereas a hyaluronan fleece dressing had the highest probability (35%) of being the most effective dressing for venous ulcers; however, the quality of this evidence was low and uncertainty is high.ConclusionsComplex wounds are common and costly with a poor evidence base for many frequent clinical decisions. There is little routine clinical data collection in community nursing. A prospective complex wounds register has the potential to both assist clinical decision-making and provide important research evidence but would be challenging to implement without investment in information technology in NHS community services. Future work should focus on developing insights into typical wound healing trajectories, identifying factors that are prognostic for healing and assessing the cost-effectiveness of selected wound treatments.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Nicky Cullum
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Hannah Buckley
- Department of Health Sciences, University of York, York, UK
| | - Jo Dumville
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Jill Hall
- Department of Health Sciences, University of York, York, UK
| | - Karen Lamb
- Leeds Community Healthcare NHS Trust, Leeds, UK
| | - Mary Madden
- Department of Health Sciences, University of York, York, UK
| | - Richard Morley
- Department of Health Sciences, University of York, York, UK
| | - Susan O’Meara
- Department of Health Sciences, University of York, York, UK
| | | | - Marta Soares
- Centre for Health Economics, University of York, York, UK
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Guihan M, Sohn MW, Bauman WA, Spungen AM, Powell-Cope GM, Thomason SS, Collins JF, Bates-Jensen BM. Difficulty in Identifying Factors Responsible for Pressure Ulcer Healing in Veterans With Spinal Cord Injury. Arch Phys Med Rehabil 2016; 97:2085-2094.e1. [PMID: 27373743 DOI: 10.1016/j.apmr.2016.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 04/29/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To identify characteristics associated with pressure ulcer (PrU) healing for individuals with spinal cord injury (SCI). DESIGN Secondary analysis of a large clinical trial's data for healing PrUs in individuals with SCI; prospective Delphi process was conducted with SCI and/or PrU experts. SETTING Spinal cord injury centers. PARTICIPANTS There were 629 screening and 162 treatment participants (N=791); 185 SCI clinicians/national PrU/wound care experts participated in the Delphi process. INTERVENTIONS None. MAIN OUTCOME MEASURE PrU healing of 50% and 100% at weeks 4 and 12. RESULTS Poisson regression models using the top Delphi-recommended factors found that only ulcer stage consistently predicted 50% and 100% healing at weeks 4 and 12. Additionally, ischial/perineal location was associated with 33% higher likelihood of 50% healing at week 4. Patient noncompliance with treatment recommendations, the top-ranked Delphi factor, did not predict healing at week 4 or 12. Expanded models found that at week 4, baseline PrU size, PrU stage IV, PrU pain, and American Spinal Injury Association grade A significantly predicted 100% healing, while at week 12, only PrU stage (IV) significantly predicted 100% healing. Significant predictors of 50% healing at week 4 included baseline PrU size, stage, ischial/perianal location body mass index >30kg/m2, foul odor, and signs of infection. At week 12, PrU duration, paraplegia predicted 50% healing. SCI center identifiers consistently showed 2- to 5-fold variation in predicting 50% PrU healing at weeks 4 and 12. CONCLUSIONS Delphi panel-recommended factors (eg, patient compliance) did not predict PrU healing. Reducing center-level variability in wound healing by learning from best practices should be a health system goal. PrU healing in SCI is still poorly understood, and future studies should focus on as yet unidentified or underappreciated factors.
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Affiliation(s)
- Marylou Guihan
- Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr Veterans Administration Hospital, Hines, IL; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Min-Woong Sohn
- Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - William A Bauman
- Veterans Administration Rehabilitation Research and Development National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Administration Medical Center, Bronx, NY; Department of Medicine and Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ann M Spungen
- Veterans Administration Rehabilitation Research and Development National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Administration Medical Center, Bronx, NY; Department of Medicine and Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gail M Powell-Cope
- Center of Innovation for Disability and Rehabilitation Research, Tampa, FL; School of Nursing, University of South Florida, Tampa, FL
| | - Susan S Thomason
- Center of Innovation for Disability and Rehabilitation Research, Tampa, FL
| | - Joseph F Collins
- Cooperative Studies Program Coordinating Center, Perry Point Veterans Administration Medical Center, Perry Point, MD
| | - Barbara M Bates-Jensen
- Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr Veterans Administration Hospital, Hines, IL; School of Nursing, University of California at Los Angeles, Los Angeles, CA; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA
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Fife CE, Horn SD, Smout RJ, Barrett RS, Thomson B. A Predictive Model for Diabetic Foot Ulcer Outcome: The Wound Healing Index. Adv Wound Care (New Rochelle) 2016; 5:279-287. [PMID: 27366589 PMCID: PMC4900227 DOI: 10.1089/wound.2015.0668] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: To develop a healing index for patients with diabetic foot ulcers (DFUs) for use in clinical practice, research analysis, and clinical trials. Approach: U.S. Wound Registry data were examined retrospectively and assigned a clear outcome (healed, amputated, etc.). Significant variables were identified with bivariate analyses. A multivariable logistic regression model was created based on significant factors (p < 0.05) and tested on a hold-out sample of data. Out of 13,266 DFUs from the original dataset, 6,440 were eligible for analysis. The logistic regression model included 5,239 ulcers, of which 3,462 healed (66.1%). The 10% validation sample utilized 555 ulcers, of which 377 healed (67.9%). Results: Variables that significantly predicted healing were as follows: wound age (duration in days), wound size, number of concurrent wounds of any etiology, evidence of bioburden/infection, patient age, Wagner grade, being nonambulatory, renal dialysis, renal transplant, peripheral vascular disease, and patient hospitalization for any reason. Innovation: We present a validated stratification system, previously described as the Wound Healing Index (WHI), which predicts healing likelihood of patients with DFUs, incorporating patient- and wound-specific variables. Conclusion: The DFU WHI is a comprehensive and user-friendly validated predictive model for DFU healing. It can risk stratify patients enrolled in clinical research trials, stratify patient data for quality reporting and benchmarking activities, and identify patients most likely to require costly therapy to heal.
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Affiliation(s)
| | - Susan D. Horn
- Institute for Clinical Outcomes Research, Salt Lake City, Utah
- University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Ryan S. Barrett
- Institute for Clinical Outcomes Research, Salt Lake City, Utah
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Margolis DJ. The Swings and Roundabouts of Randomized Controlled Studies in Wound Healing. INT J LOW EXTR WOUND 2016; 3:4-6. [PMID: 15866781 DOI: 10.1177/153473460431002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ooi GS, Rodrigo C, Cheong WK, Mehta RL, Bowen G, Shearman CP. An Evaluation of the Value of Group Education in Recently Diagnosed Diabetes Mellitus. INT J LOW EXTR WOUND 2016; 6:28-33. [PMID: 17344199 DOI: 10.1177/1534734606297295] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diabetic patients have a 12% to 25% lifetime risk of developing foot complications leading to significant morbidity and mortality. The objective of this study was to assess the effectiveness of group education in improving patient awareness of foot care. The authors evaluated the effect of group size and areas in which knowledge seemed to be most affected. Patients attending a 2-hour teaching session between November 2005 and March 2006 were recruited. Patients filled in an 18-part questionnaire before and after the teaching session to assess knowledge. Fifty-nine patients recently diagnosed with diabetes mellitus or foot complications were recruited for 7 sessions. Analysis of the data showed a statistically significant improvement in foot care knowledge after the teaching session compared with before (69% to 85%,P < .001). Patients in the smaller group (n< 10) had significantly higher scores compared with the bigger groups (n> 10;P < .025). These data show the benefit of group education about foot care for patients with diabetes. Smaller groups benefited more than larger ones did, which could be attributed to the sizes allowing for better interaction between the tutor and patient. As patient knowledge is variable from individual to individual, smaller teaching sessions may allow patients to address specific concerns.
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Affiliation(s)
- G S Ooi
- Southampton University Hospital NHS Trust, Southampton, UK.
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Gallagher KA, Goldstein LJ, Thom SR, Velazquez OC. Hyperbaric Oxygen and Bone Marrow–Derived Endothelial Progenitor Cells in Diabetic Wound Healing. Vascular 2016; 14:328-37. [PMID: 17150153 DOI: 10.2310/6670.2006.00057] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Endothelial progenitor cells (EPCs) are the key cellular effectors of postnatal vasculogenesis and play a central role in wound healing. In diabetes, there is a significant impairment in the number and function of circulating and wound-tissue EPC. Recent evidence indicates, that tissue-level hyperoxia achieved by therapeutic hyperbaric oxygen protocols (HBO2) can increase the mobilization of EPC from the bone marrow into peripheral blood. In this paper we review the recent reports on hyperoxia-mediated mobilization of bone marrow-derived EPC and postulate avenues of future research in this area as it applies to improving healing in chronic wounds affected by diabetes and peripheral arterial disease (PAD).
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Affiliation(s)
- Katherine A Gallagher
- Department of Surgery, Institute for Environmental Medicine, University of Pennsylvania Medical Center, Philadelphia 19124, USA
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Monteiro-Soares M, Dinis-Ribeiro M. A new diabetic foot risk assessment tool: DIAFORA. Diabetes Metab Res Rev 2016; 32:429-35. [PMID: 27094098 DOI: 10.1002/dmrr.2785] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 12/16/2015] [Accepted: 01/24/2016] [Indexed: 11/09/2022]
Abstract
AIMS This study aimed to derive a new model to classify subjects with diabetes and active diabetic foot ulcer by their risk of lower extremity amputation. METHODS A prospective cohort study was conducted that included all subjects with diabetic foot ulcer attending our Hospital Diabetic Foot Clinic from 2010 to 2013. Variables were collected at baseline. Subjects were followed up until healing, lower extremity amputation, death or for at least 3 months. Logistic regression was used to derive the new model, and the area under the receiver operating characteristic curve was assessed to propose the model with the greatest discrimination. RESULTS A total of 293 participants were included and followed for a median of 91 days. In 23.2% amputation was required, 5.1% died and 3.1% were lost. Our final model included the variables most commonly used in clinical practice for diabetic foot risk assessment (presence of neuropathy, foot deformity, peripheral arterial disease and previous foot complications) in addition to multiple diabetic foot ulcer, infection, gangrene and bone involvement. This model had an area under the receiver operating characteristic curve of 0.91 [95% confidence interval (CI) 0.87-0.95] and as classification of 0.89 (95% CI 0.84-0.93) for lower extremity amputation prediction. The high-risk group presented a positive likelihood ratio of 5 (95% CI 3-8) and predictive value of 58 (46-71). Only one minor lower extremity amputation occurred in the low-risk group. CONCLUSIONS We propose a new classification: diabetic foot risk assessment (DIAFORA). This classification was equally or more accurate for lower extremity amputation prediction in diabetic foot ulcer patients when compared with the existing ones.
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Affiliation(s)
- M Monteiro-Soares
- CIDES/CINTESIS - Health Information and Decision Sciences Department, Oporto University Faculty of Medicine, Oporto, U753-FCT, Portugal
| | - M Dinis-Ribeiro
- CIDES/CINTESIS - Health Information and Decision Sciences Department, Oporto University Faculty of Medicine, Oporto, U753-FCT, Portugal
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Jung K, Covington S, Sen CK, Januszyk M, Kirsner RS, Gurtner GC, Shah NH. Rapid identification of slow healing wounds. Wound Repair Regen 2016; 24:181-8. [PMID: 26606167 DOI: 10.1111/wrr.12384] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/28/2015] [Accepted: 11/22/2015] [Indexed: 01/22/2023]
Abstract
Chronic nonhealing wounds have a prevalence of 2% in the United States, and cost an estimated $50 billion annually. Accurate stratification of wounds for risk of slow healing may help guide treatment and referral decisions. We have applied modern machine learning methods and feature engineering to develop a predictive model for delayed wound healing that uses information collected during routine care in outpatient wound care centers. Patient and wound data was collected at 68 outpatient wound care centers operated by Healogics Inc. in 26 states between 2009 and 2013. The dataset included basic demographic information on 59,953 patients, as well as both quantitative and categorical information on 180,696 wounds. Wounds were split into training and test sets by randomly assigning patients to training and test sets. Wounds were considered delayed with respect to healing time if they took more than 15 weeks to heal after presentation at a wound care center. Eleven percent of wounds in this dataset met this criterion. Prognostic models were developed on training data available in the first week of care to predict delayed healing wounds. A held out subset of the training set was used for model selection, and the final model was evaluated on the test set to evaluate discriminative power and calibration. The model achieved an area under the curve of 0.842 (95% confidence interval 0.834-0.847) for the delayed healing outcome and a Brier reliability score of 0.00018. Early, accurate prediction of delayed healing wounds can improve patient care by allowing clinicians to increase the aggressiveness of intervention in patients most at risk.
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Affiliation(s)
- Kenneth Jung
- Program in Biomedical Informatics, Stanford University, Stanford, California
| | | | - Chandan K Sen
- Departments of Surgery, Comprehensive Wound Center, Davis Heart and Lung Research Institute, Centers for Regenerative Medicine and Cell-based Therapies, The Ohio State University Medical Center, Columbus, Ohio
| | - Michael Januszyk
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
| | - Robert S Kirsner
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Geoffrey C Gurtner
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
| | - Nigam H Shah
- Center for Biomedical Informatics Research, Stanford University, Stanford, California
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Game F. Classification of diabetic foot ulcers. Diabetes Metab Res Rev 2016; 32 Suppl 1:186-94. [PMID: 26455509 DOI: 10.1002/dmrr.2746] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/02/2015] [Accepted: 08/02/2015] [Indexed: 12/15/2022]
Abstract
It is known that the relative importance of factors involved in the development of diabetic foot problems can vary in both their presence and severity between patients and lesions. This may be one of the reasons why outcomes seem to vary centre to centre and why some treatments may seem more effective in some people than others. There is a need therefore to classify and describe lesions of the foot in patients with diabetes in a manner that is agreed across all communities but is simple to use in clinical practice. No single system is currently in widespread use, although a number have been published. Not all are well validated outside the system from which they were derived, and it has not always been made clear the clinical purposes to which such classifications should be put to use, whether that be for research, clinical description in routine clinical care or audit. Here the currently published classification systems, their validation in clinical practice, whether they were designed for research, audit or clinical care, and the strengths and weaknesses of each are explored.
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Affiliation(s)
- Frances Game
- Department of Diabetes and Endocrinology, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
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Wang SC, Ye L, Sanders AJ, Ruge F, Harding KG, Jiang WG. Tumour endothelial marker-8 in wound healing and its impact on the proliferation and migration of keratinocytes. Int J Mol Med 2015; 37:293-8. [PMID: 26677171 PMCID: PMC4716791 DOI: 10.3892/ijmm.2015.2434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/13/2015] [Indexed: 11/06/2022] Open
Abstract
Chronic wound management represents a significant burden on healthcare systems and negatively impacts on the quality of patient life. New strategies to understand and identify wounds that will not heal in a normal manner are required. Tumour endothelial marker‑8 (TEM‑8) has been implicated in the wound healing and angiogenesis processes. TEM‑8 expression was examined at the transcript level in a cohort of acute (n=10) and chronic (n=14) wounds and in normal skin (n=10). Protein analysis of TEM‑8 was also undertaken for this cohort using immunohistochemistry (IHC). TEM‑8 impact on keratinocyte cell growth and migration was assessed following TEM‑8 ribozyme transgene transfection of human HaCaT keratinocytes using cell growth and electric cell‑substrate impedance sensing (ECIS)‑based assays. Expression of TEM‑8 was observed to be increased in acute wounds compared to chronic wounds and normal skin using quantitative polymerase chain reaction transcript analysis and IHC staining of wound tissues. Knockdown of TEM‑8 in HaCaT cells, using two independent ribozyme transgenes, resulted in significant decreases in cell growth as well as reductions in the rate of migration assessed using an ECIS‑based system. TEM‑8 may be differentially expressed between wound types and loss of this molecule impacts HaCaT growth and migration, potentially implicating this molecule as a factor involved in successful progression of wound healing.
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Affiliation(s)
- Sheila C Wang
- Cardiff China Medical Research Collaborative (CCMRC), Cardiff University School of Medicine, Cardiff CF14 4XN, UK
| | - Lin Ye
- Cardiff China Medical Research Collaborative (CCMRC), Cardiff University School of Medicine, Cardiff CF14 4XN, UK
| | - Andrew J Sanders
- Cardiff China Medical Research Collaborative (CCMRC), Cardiff University School of Medicine, Cardiff CF14 4XN, UK
| | - Fiona Ruge
- Cardiff China Medical Research Collaborative (CCMRC), Cardiff University School of Medicine, Cardiff CF14 4XN, UK
| | - Keith G Harding
- Department of Wound Healing, Cardiff University School of Medicine, Cardiff CF14 4XN, UK
| | - Wen G Jiang
- Cardiff China Medical Research Collaborative (CCMRC), Cardiff University School of Medicine, Cardiff CF14 4XN, UK
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Liu J, Zhang P, Tian J, Li L, Li J, Tian JH, Yang K. Ozone therapy for treating foot ulcers in people with diabetes. Cochrane Database Syst Rev 2015; 2015:CD008474. [PMID: 26505864 PMCID: PMC8246444 DOI: 10.1002/14651858.cd008474.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND It has been reported that ozone therapy might be helpful in treating foot ulcers in people with diabetes mellitus (DM). OBJECTIVES To assess the effects of ozone therapy on the healing of foot ulcers in people with DM. SEARCH METHODS In March 2015 we searched: The Cochrane Wounds Group Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid EMBASE, EBSCO CINAHL, Science Citation Index, Chinese Biomedical Literature Database and The Chinese Clinical Registry. There were no restrictions based on language, date or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared ozone therapy with sham ozone therapy or any other interventions for foot ulcers in people with DM, irrespective of publication date or language. DATA COLLECTION AND ANALYSIS Two reviewers independently screened all retrieved citations, selected relevant citations and extracted data. Disagreements were resolved by discussion with a third reviewer. The methodological quality of included studies and the evidence level of outcomes were assessed using the Cochrane risk of bias tool and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach respectively. Data were expressed using risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with their 95% confidence interval (95% CI). Review Manager (RevMan) software was used to analyse the data. MAIN RESULTS Three studies (212 participants) were included in this review. The overall risk of bias was high for two trials and unclear for one.One trial (101 participants) compared ozone treatment with antibiotics for foot ulcers in people with DM. The study had a follow-up period of 20 days. This study showed that ozone treatment was associated with a greater reduction in ulcer area from baseline to the end of the study than treatment with antibiotics (MD -20.54 cm(2), 95% CI -20.61 to -20.47), and a shorter duration of hospitalisation (MD -8.00 days, 95% CI -14.17 to -1.83), but did not appear to affect the number of ulcers healed over 20 days (RR 1.10, 95% CI 0.87 to 1.40). No side effects were observed in either group.The other two trials (111 participants) compared ozone treatment plus usual care with usual care for foot ulcers in people with DM. The meta-analysis results did not show evidence of a difference between groups for the outcomes of reduction of ulcer area (MD -2.11 cm(2), 95% CI -5.29 to 1.07), the number of ulcers healed (RR 1.69, 95% CI 0.90 to 3.17), adverse events (RR 2.27, 95% CI 0.48 to 10.79), or amputation rate (RR 2.73, 95%CI 0.12, 64.42). AUTHORS' CONCLUSIONS The available evidence was three small RCTs with unclear methodology, so we are unable to draw any firm conclusions regarding the effectiveness of ozone therapy for foot ulcers in people with DM.
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Affiliation(s)
- Jian Liu
- The First Hospital of Lanzhou UniversityCritical Care Medicine DepartmentNo 1 Donggang West RoadLanzhou CityGansuChina730000
| | - Peng Zhang
- Nanyang Central HospitalDepartment of Pediatric SurgeryNanyangHenanChina473000
| | - Jing Tian
- Nanyang Central HospitalNanyangHenanChina473000
| | - Lun Li
- The Second Xiangya Hospital of Central South UniversityDepartment of Breast‐Thyroid SurgeryChangshaChina
| | - Jun Li
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | - Jin Hui Tian
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | - KeHu Yang
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceNo. 199, Donggang West RoadLanzhou CityGansuChina730000
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Monteiro-Soares M, Martins-Mendes D, Vaz-Carneiro A, Dinis-Ribeiro M. Lower-limb amputation following foot ulcers in patients with diabetes: classification systems, external validation and comparative analysis. Diabetes Metab Res Rev 2015; 31:515-29. [PMID: 25529456 DOI: 10.1002/dmrr.2634] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 12/13/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study aimed to validate and compare the existing systems developed to stratify subjects with diabetic foot ulcers by risk of consequent lower extremity amputation. METHODS We conducted a prospective cohort study on a consecutive series of patients (mean age of 68 years; 64% male) with active ulcer who were attending our Hospital Diabetic Foot Clinic (n = 293) from January 2010 to March 2013. At baseline, we collected information on the participants' characteristics and the relevant variables. Afterwards, we assessed the predictive value of each variable and each system's prognostic accuracy for amputation occurrence. RESULTS During a median follow-up of 91 days (interquartile range of 98), ulcers healed in 62% of the subjects. Major amputation occurred in 7% and minor occurred in 17%. Previous ulcer or amputation, ulcer area, and gangrene were associated with amputation occurrence. Nephropathy, pulses number, ulcer aetiology, depth, and number were associated with risk of amputation. Systems typically presented sensitivity values ≥80% and negative likelihood ratios ≤0.5 for the highest risk group; area under the receiver operating characteristic curve ranged from 0.56 to 0.83 and positive likelihood ratios from 1.0 to 5.9. If one chose only major amputation as an outcome, positive predictive values were lower, and negative predictive values tended to be higher. CONCLUSIONS System stages, grades, scores, and/or prognostics were generally associated with amputation, presenting overall substantial accuracy values. Nevertheless, great improvement is possible. A multicentre study validating and refining the existing systems is needed to improve clinical decision-making in this area.
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Affiliation(s)
- Matilde Monteiro-Soares
- CIDES/CINTESIS, Health Information and Decision Sciences Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Daniela Martins-Mendes
- Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
- Diabetic Foot Clinic, Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
- Department of Biochemistry, Faculty of Medicine, University of Porto, Porto, Portugal
| | - António Vaz-Carneiro
- CIDES/CINTESIS, Health Information and Decision Sciences Department, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Evidence-Based Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Portuguese Collaborating Center of the Iberoamerican Cochrane Network, Lisbon, Portugal
| | - Mário Dinis-Ribeiro
- CIDES/CINTESIS, Health Information and Decision Sciences Department, Faculty of Medicine, University of Porto, Porto, Portugal
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White-Chu EF. Prognostication and Management of Non-Healable Wounds and Wounds at the End of Life. CURRENT GERIATRICS REPORTS 2015. [DOI: 10.1007/s13670-015-0129-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nordheim LV, Haavind MT, Iversen MM. Effect of telemedicine follow-up care of leg and foot ulcers: a systematic review. BMC Health Serv Res 2014; 14:565. [PMID: 25373875 PMCID: PMC4230629 DOI: 10.1186/s12913-014-0565-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/24/2014] [Indexed: 01/11/2023] Open
Abstract
Background Leg ulcers and diabetes-related foot ulcers are frequent and costly complications of their underlying diseases and thus represent a critical issue for public health. Since the population is aging, the prevalence of these conditions will probably increase considerably and require more resources. Treatment of leg and foot ulcers often demands frequent contact with the health care system, may pose great burden on the patient, and involves follow-up in both primary and specialist care. Telemedicine provides potential for more effective care management of leg and foot ulcers. The objective of this systematic review of the literature was to assess the effect of telemedicine follow-up care on clinical, behavioral or organizational outcomes among patients with leg and foot ulcers. Methods We searched Ovid MEDLINE (1980–), Ovid EMBASE (1980–), Clinical Trials in the Cochrane Library (via Wiley), Ebsco CINAHL with Fulltext (1981–) and SveMed + (1977–) up to May 2014 for relevant articles. We considered randomized controlled trials, non-randomized trials, controlled before-after studies and prospective cohort studies for inclusion and selected studies according to predefined criteria. Three reviewers independently assessed the included studies using the Cochrane Collaboration risk-of-bias tool. We performed a narrative synthesis of results and assessed the strength of evidence for each outcome using GRADE (grading of recommendations, assessment, development and evaluation). Results Only one non-randomized study was included. The study (n = 140) measured the effect of real-time interactive video consultation compared with face-to-face follow-up on healing time, adjusted healing ratio and the number of ulcers at 12 weeks among patients with neuropathic forefoot ulcerations. There were no statistically significant differences in results of the different outcomes between patients receiving telemedicine and traditional follow-up. We assessed the study to have a high risk of bias. Conclusions There is insufficient evidence available to unambiguously determine whether telemedicine consultation of leg and foot ulcers is as effective as traditional follow-up.
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