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Bonnet E, Maulin L, Senneville E, Castan B, Fourcade C, Loubet P, Poitrenaud D, Schuldiner S, Sotto A, Lavigne JP, Lesprit P. Clinical practice recommendations for infectious disease management of diabetic foot infection (DFI) - 2023 SPILF. Infect Dis Now 2024; 54:104832. [PMID: 37952582 DOI: 10.1016/j.idnow.2023.104832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Abstract
In march 2020, the International Working Group on the Diabetic Foot (IWGDF) published an update of the 2015 guidelines on the diagnosis and management of diabetic foot infection (DFI). While we (the French ID society, SPILF) endorsed some of these recommendations, we wanted to update our own 2006 guidelines and specifically provide informative elements on modalities of microbiological diagnosis and antibiotic treatment (especially first- and second-line regiments, oral switch and duration). The recommendations put forward in the present guidelines are addressed to healthcare professionals managing patients with DFI and more specifically focused on infectious disease management of this type of infection, which clearly needs a multidisciplinary approach. Staging of the severity of the infection is mandatory using the classification drawn up by the IWGDF. Microbiological samples should be taken only in the event of clinical signs suggesting infection in accordance with a strict preliminarily established protocol. Empirical antibiotic therapy should be chosen according to the IWGDF grade of infection and duration of the wound, but must always cover methicillin-sensitive Staphylococcus aureus. Early reevaluation of the patient is a fundamental step, and duration of antibiotic therapy can be shortened in many situations. When osteomyelitis is suspected, standard foot radiograph is the first-line imagery examination and a bone biopsy should be performed for microbiological documentation. Histological analysis of the bone sample is no longer recommended. High dosages of antibiotics are recommended in cases of confirmed osteomyelitis.
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Affiliation(s)
- E Bonnet
- Service des Maladies Infectieuses et Tropicales, CHU Toulouse-Purpan, 31059 Toulouse, France.
| | - L Maulin
- Maladies Infectieuses, CH du Pays d'Aix, 13100 Aix en Provence, France
| | - E Senneville
- Service Universitaire des Maladies Infectieuses, CH Dron, 59200 Tourcoing, France
| | - B Castan
- Service de Médecine Interne et Maladies Infectieuses, CH Périgueux, 24019 Périgueux, France
| | - C Fourcade
- Equipe Mobile d'Infectiologie, Clinique Pasteur, Clinavenir, 31300 Toulouse, France
| | - P Loubet
- Service des Maladies Infectieuses et Tropicales, CHU Caremeau, 30029 Nîmes, France
| | - D Poitrenaud
- Unité Fonctionnelle d'Infectiologie, CH Notre Dame de la Miséricorde, 20000 Ajaccio, France
| | - S Schuldiner
- Service des Maladies Métaboliques et Endocriniennes, CHU Caremeau, 30029 Nîmes, France
| | - A Sotto
- Service des Maladies Infectieuses et Tropicales, CHU Caremeau, 30029 Nîmes, France
| | - J P Lavigne
- Service de Microbiologie et Hygiène Hospitalière, CHU Caremeau, 30029 Nîmes, France
| | - P Lesprit
- Maladies Infectieuses, CHU Grenoble Alpes, 38043, Grenoble, France
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Kim KH, Ko IC, Kim H, Lim SY. Preserving finger length in a patient with symmetric digital gangrene under local anesthesia: A case report. World J Clin Cases 2023; 11:6640-6645. [PMID: 37900227 PMCID: PMC10601016 DOI: 10.12998/wjcc.v11.i27.6640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/09/2023] [Accepted: 08/31/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Case reports of symmetric digital gangrene resulting from high-dose vasopressors use in patients with alcoholic ketoacidosis, leading to cardiac arrest, are rare. To date, no specific treatment method for autolysis or surgical amputation or guidelines for determining the level of amputation have been established. CASE SUMMARY In this case report, we describe a treatment method that effectively preserved the function of fingers by surgical treatment under local anesthesia with a minimum operative time, while also preserving finger length to the maximum possible extent. CONCLUSION Our approach may contribute to improved postoperative quality of life by preserving finger length.
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Affiliation(s)
- Keun Hyung Kim
- Department of Plastic and Reconstructive Surgery, Konyang University Medical Center, Konyang University of College of Medicine, Daejeon 35365, South Korea
| | - In Chang Ko
- Department of Plastic and Reconstructive Surgery, Konyang University Medical Center, Konyang University of College of Medicine, Daejeon 35365, South Korea
| | - Hoon Kim
- Department of Plastic and Reconstructive Surgery, Konyang University Medical Center, Konyang University of College of Medicine, Daejeon 35365, South Korea
| | - Soo Yeon Lim
- Department of Plastic and Reconstructive Surgery, Konyang University Hospital, Konyang University of College of Medicine, Myunggok Medical Research Center, Daejeon 35365, South Korea
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Zhang J, Liu H, Che T, Zheng Y, Nan X, Wu Z. Nanomaterials for diabetic wound healing: Visualization and bibliometric analysis from 2011 to 2021. Front Endocrinol (Lausanne) 2023; 14:1124027. [PMID: 36761188 PMCID: PMC9905413 DOI: 10.3389/fendo.2023.1124027] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/11/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Nanomaterials have recently been shown to have a considerable advantage in promoting wound healing in diabetic patients or animal models. However, no bibliometric analysis has been conducted to evaluate global scientific production. Herein, this study aimed to summarize the current characteristics, explore research trends, and clarify the direction of nanomaterials and diabetic wound healing in the future. METHODS Relevant publications from 2011 to 2021 were collected from the Web of Science Core Collection on October 3, 2022. VOSviewer, CiteSpace, bibliometrix-R package, Origin 2021, and Microsoft Excel 2019 were used for bibliometric and visualization analyses. RESULTS We identified 409 publications relating to nanomaterials and diabetic wound healing. The number of annual productions remarkably increased from 2011 to 2021, with China and Shanghai Jiao Tong University being the most productive. The most prolific authors were Hasan Anwarul. The leading journal was the International Journal of Biological Macromolecules, with 22 publications. The most popular keywords were "nanoparticles," "delivery," "in vitro," "electrospinning," "angiogenesis," and "antibacterial." Keyword burst analysis showed "cerium oxide," "matrix metalloproteinase 9," "composite nanofiber," "hif 1 alpha," and "oxide nanoparticle" were emerging research hotspots. CONCLUSION We found there has been a great progress in the application of nanomaterials in diabetic wound healing from 2011 to 2021. Although many researchers and institutions from different countries or regions contributed contributed to publications, it will be helpful or the development of this field if the degree of international cooperation can be enhanced. In the future, nanomaterials with powerful antioxidant and antibacterial qualities and promoting angiogenesis are the research hotspots.
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Affiliation(s)
- Jun Zhang
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Hongyan Liu
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Tingting Che
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Yin Zheng
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xixi Nan
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zhongming Wu
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- *Correspondence: Zhongming Wu,
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Effect of Nursing Intervention on Promoting Healing of RW in Patients with Diabetic Foot: A Systematic Review and Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:8284870. [PMID: 36277014 PMCID: PMC9586770 DOI: 10.1155/2022/8284870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/11/2022] [Accepted: 09/06/2022] [Indexed: 11/18/2022]
Abstract
Objective. To systematically assess the effect of nursing intervention on promoting the healing of refractory wounds (RW) in patients with diabetic foot (DF). Methods. A computer search of PubMed, EMBASE, ScienceDirect, CochraneLibrary, China knowledge Network Database (CNKI), China VIP Database, Wanfang Database, and China Biomedical Literature Database (CBM) online database was conducted in a randomized controlled trial (RCT) of traditional Chinese and western medicine nursing intervention on patients with RW of DF. Retrieval time was limited to the period from the date the database was established to present. Separately, two researchers gathered the data. RevMan5.3 statistical software was used to analyze the collected data by meta-analysis according to Cochrane Handbook 5.3. Results. Finally, 8 articles were included with a total sample size of 772 cases. The meta-analysis of the wound healing time after intervention indicated that the wound healing time of the study group was notably shorter, and the difference was statistically significant (
). Qualitative, fixed-effect model analysis indicated that the nursing effective rate after treatment in the study group was notably higher, and the difference was statistically significant (
). Fasting blood glucose level in the study group after treatment was notably lower, and the difference was statistically significant (
). The life quality in the study group was notably higher, and the difference was statistically significant (
). Further subgroup analysis indicated that the score of physical function (PF), emotional function (RE), social function (SF), physical pain (BP), general health (GH), vitality (VT), and mental health (MH) in the study group were higher, and the difference was statistically significant (
). A publication bias analysis was conducted using the inverted funnel chart as the outcome indicator for this study. The results indicated that most of the funnel maps were symmetrical and a few were asymmetrical, suggesting that there exhibited a certain publication bias in the included literature. Conclusion. The application of traditional Chinese and western medicine nursing intervention when treating DF patients clinically can effectively promote the healing of foot ulcer wounds. Traditional Chinese and western medicine nursing can help patients heal wounds faster and enhance their life quality compared to simplistic western medicine nursing. According to the original literature, the conclusion deserves to be popularized in clinic.
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Ji JY, Ren DY, Weng YZ. Efficiency of Multifunctional Antibacterial Hydrogels for Chronic Wound Healing in Diabetes: A Comprehensive Review. Int J Nanomedicine 2022; 17:3163-3176. [PMID: 35909814 PMCID: PMC9326039 DOI: 10.2147/ijn.s363827] [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: 03/01/2022] [Accepted: 06/16/2022] [Indexed: 12/26/2022] Open
Abstract
Diabetic chronic wounds or amputation, which are complications of diabetes mellitus (DM), are a cause of great suffering for diabetics. In addition to the lack of oxygen, elevated reactive oxygen species (ROS) and reduced vascularization, microbial invasion is also a critical factor that induces non-healing chronic diabetic wounds, ie, wounds still remaining in the stage of inflammation, after which the wound tissue begins to age and becomes necrotic. To clear up the infection, alleviate the inflammation in the wound and prevent necrosis, many kinds of hydrogel have been fabricated to eliminate infections with pathogens. The unique properties of hydrogels make them ideally suited to wound dressings because they provide a moist environment for wound healing and act as a barrier against bacteria. This review article will mainly cover the recent developments and innovations of antibacterial hydrogels for diabetic chronic wound healing.
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Affiliation(s)
- Jia-Ying Ji
- Department of Plastic Surgery, The Affiliated People's Hospital of Ningbo University, Ningbo, 315100, People's Republic of China
| | - Dan-Yang Ren
- Zhejiang University School of Medicine, Hangzhou, 310016, People's Republic of China
| | - Ying-Zheng Weng
- Department of Cardiology, Zhejiang Hospital, Hangzhou, 310016, People's Republic of China
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Jarl G, Johannesson GA, Carlberg M, Jansson SPO, Hiyoshi A. Editor's Choice - Incidence of Lower Limb Amputations in Sweden from 2008 to 2017. Eur J Vasc Endovasc Surg 2022; 64:266-273. [PMID: 35644457 DOI: 10.1016/j.ejvs.2022.05.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 05/09/2022] [Accepted: 05/22/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE This study examined the recent national and regional incidence of lower limb amputations (LLAs) in Sweden and their annual changes. METHODS This was an observational study using Swedish national register data. All initial amputations were identified in Sweden from 2008 to 2017 in individuals 18 years or older using the national inpatient register. The amputations were categorised into three levels: high proximal (through or above the knee joint), low proximal (through the tibia to through the ankle joint), and partial foot amputations. To examine the national and regional incidence and annual changes, the age, sex, and region specific population count each year was used as the denominator and Poisson regression or negative binomial regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) adjusted for age and sex. RESULTS The national annual incidence of LLAs was 22.1 per 100 000 inhabitants, with a higher incidence in men (24.2) than in women (20.0). The incidence of LLAs (all levels combined) declined during the study period, with an IRR of 0.984 per year (95% CI 0.973 - 0.994). This was mainly due to a decrease in high proximal amputations (0.985, 95% CI 0.974 - 0.995) and low proximal amputations (0.973, 95% CI 0.962 - 0.984). No change in the incidence of partial foot amputations was observed (0.994, 95% CI 0.974 - 1.014). Such declines in LLA incidence (all levels combined) were observed in nine of the 21 regions. Compared with the national average and with adjustment for age, sex, diabetes, and artery disease, the regional IRR varied from 0.85 to 1.36 for all LLAs, from 0.67 to 1.61 for high proximal amputations, from 0.50 to 1.51 for low proximal amputations, and from 0.13 to 3.68 for partial foot amputations. CONCLUSION The incidence of LLAs has decreased in Sweden. However, regional variations in incidence, time trends, and amputation levels warrant further research.
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Affiliation(s)
- Gustav Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | | | - Michael Carlberg
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Stefan P O Jansson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Ayako Hiyoshi
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
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Boffeli TJ, Luer SA, Brett KM, Chang HC. A Review of Consecutive Cases to Identify the Rate of Underlying Osteomyelitis in Patients Undergoing Surgical Treatment of Gangrene of the Forefoot and Impact of Acute Infection on Outcome Following Amputation. J Foot Ankle Surg 2022; 61:286-292. [PMID: 34544643 DOI: 10.1053/j.jfas.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 07/26/2021] [Accepted: 08/04/2021] [Indexed: 02/03/2023]
Abstract
Medical literature offers no clear treatment guidelines when performing amputations for gangrene of the forefoot despite a high percentage that suffer poor outcome due to infection. Gas gangrene and wet gangrene are often preceded by dry stable gangrene. This is a retrospective review of consecutive patients who underwent forefoot amputation and bone biopsy as treatment of forefoot gangrene by a single surgeon. Procedures performed included digital, ray, or transmetatarsal amputation with bone biopsy sent for both culture and histopathologic evaluation. One hundred patients (35 females, 65 males) met inclusion criteria. Mean follow-up was 9.6 months. Mean age was 63.5 years old. Forty-six out of 100 (46%) had elective amputation while 54/100 (54%) were emergent for acute infection. Vascular intervention was performed in 52/100 (52%). Seventy-eight out of 100 (78%) had histopathologic diagnosis of acute osteomyelitis while 82/100 (82%) had positive bone culture. Patients with acute infection had worse outcomes, with higher rates of more proximal amputation and delayed wound healing. We found that 79.7% of patients who underwent forefoot amputation due to gangrene had underlying osteomyelitis. We also found that those with acute infection during the time of amputation had poorer postamputation outcomes such as delayed wound healing, revision surgery, and high rates of more proximal amputation. Therefore, it may imply that earlier amputation of stable gangrene prior to becoming acutely infected may decrease the occurrence of osteomyelitis and avoid some of the preventable postamputation complications. Further studies are warranted.
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Affiliation(s)
- Troy J Boffeli
- Director, Foot & Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education & Research, Saint Paul, MN
| | | | - Kristen M Brett
- Resident, Foot & Ankle Surgery, Regions Hospital/HealthPartners Institute for Education and Research, Saint Paul, MN.
| | - Howard C Chang
- Resident, Foot & Ankle Surgery, Regions Hospital/HealthPartners Institute for Education and Research, Saint Paul, MN
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Latz CA, Deluca E, Lella S, Waller HD, DeCarlo C, Dua A. Rates of Conversion from Dry to Wet Gangrene Conversion Following Lower Extremity Revascularization. Ann Vasc Surg 2022; 83:20-25. [DOI: 10.1016/j.avsg.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/15/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
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Blanchette V, Brousseau-Foley M. [Multidisciplinary management of diabetic foot ulcer infection]. Rev Med Interne 2021; 42:193-201. [PMID: 33451819 DOI: 10.1016/j.revmed.2020.09.004] [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] [Received: 03/22/2020] [Revised: 08/16/2020] [Accepted: 09/01/2020] [Indexed: 12/12/2022]
Abstract
Infection is one of the most common complications of diabetic foot ulceration resulting in lower extremity amputations and early mortality in this population. Several factors influence the course of diabetic foot ulceration infection and in that context, integrated multidisciplinary management is required as soon as possible. In fact, a holistic interdisciplinary approach should be the standard of care. Whether the infection is categorized as mild, moderate or severe, with or without bone infection, the overall individual's characteristics must be addressed, in addition to local wound care, offloading and antibiotic therapy. Some severe infections have potential indications for hospitalization and are considered as surgical emergencies. In some DFU cases, surgical revascularization of the limb is mandatory to treat the infection. However, surgical interventions and amputations, are sometimes inevitable, they are predictors of bad prognosis. Although some adjuvant therapies are effective to promote wound healing, their use is not recommended to treat diabetic foot ulcer infection. Infection management can be divided into three general interventions: proper clinical diagnosis, microbiological and imaging investigations, and treatment. This review is an update on the up-to-date evidences in scientific literature and includes the latest recommendations from the International Working Group on the Diabetic Foot (IWGDF).
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Affiliation(s)
- V Blanchette
- Université du Québec à Trois-Rivières, programme de médecine podiatrique, département des sciences de l'activité physique, 3351, boulevard des Forges, CP 500, G9A 5H7 Trois-Rivières, Québec, Canada.
| | - M Brousseau-Foley
- Université du Québec à Trois-Rivières, programme de médecine podiatrique, département des sciences de l'activité physique, 3351, boulevard des Forges, CP 500, G9A 5H7 Trois-Rivières, Québec, Canada; Centre intégré universitaire de santé et de services sociaux de la Mauricie et du Centre-du-Québec (CIUSSS-MCQ) affilié à l'Université de Montréal, Faculté de Médecine, Groupe de médecine familiale universitaire de Trois-Rivières, G9A 1X9 Trois-Rivières, Québec, Canada.
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Tian Y, Sun X, Zhu C, Sun H, Shi Y, Liu T, Zhang Z. Treatment of Diabetic Foot Ulcers With Necrotizing Fasciitis in the Lower Leg Using the STAGE Principles: A Report of 9 Cases With a Literature Review. INT J LOW EXTR WOUND 2020; 20:150-157. [PMID: 32734795 DOI: 10.1177/1534734620943021] [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] [Indexed: 11/17/2022]
Abstract
Diabetic foot ulcers (DFUs) combined with necrotizing fasciitis (NF) has rapid onset, involves a wide range of lesions, is difficult to treat, and has a high mortality rate. It has become a clinically critical disease. DFU patients are at high risk for NF. The STAGE principles guide surgical intervention in the treatment of DFU wounds and emphasizes that "based on anatomical layers, the management focuses on blood supply and includes layer-by-layer incision to the infected area, maintenance of effective wound drainage, and step-by-step treatment of the wound." This work reports the application of the STAGE principles for the treatment of 9 cases of DFUs combined with NF in the lower leg (Wagner grade 3-5). The mean ankle-brachial index was 0.55 (0-0.91, standard deviation [SD] = 0.33), the mean years of smoking were 19.56 years (0-50, SD = 17.83), and the mean cigarette consumption was 9.11 cigarettes/day (0-20, SD = 7.77). The mean duration of ulcers was 45.56 days (3-103, SD = 35.44). Among the 9 patients, only patient no. 9 died, and the mean follow-up time for the other 8 patients was 12 months (3-36, SD = 13.42). In short, the STAGE principles are also applicable to the treatment of DFUs combined with NF in the lower leg.
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Affiliation(s)
- Ying Tian
- Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xu Sun
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Chaojun Zhu
- Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Hanchi Sun
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yue Shi
- Fourth Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Tingting Liu
- Fourth Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhaohui Zhang
- Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
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