Health economics of diabetic foot ulcer and recent trends to accelerate treatment

Advances in the study of polysaccharide-based hydrogel wound dressings

Due to the complexity of wound healing, the rapid promotion of wound healing has been a major unresolved challenge for the medical community. If a suitable wound dressing is not found, it can easily induce wound infection and slow down the wound repair process. Hydrogels have been recognized as the best alternative to traditional wound dressings due to their unique water-retention properties as well as their drug-carrying properties. We first outlined the entire process of wound healing, while introducing the biological activities of ten different natural polysaccharides and their mechanisms for promoting wound healing. Subsequently, we summarized the advantages and limitations of various polysaccharides in use and proposed corresponding solutions. In addition, wound dressings for a wide range of wounds, including diabetes, burns, and radiation, have also been reviewed, providing a comprehensive understanding of the applications of these hydrogels in different wound types. This paper provides an important reference for the biomedical application and clinical research of natural polysaccharide-based hydrogel in wound dressings.

Using Three-Dimensional Bioprinting to Generate Realistic Models of Wound Healing

Significance: The skin serves as the primary defense against external stimuli, making it vulnerable to damage. Injuries can cause a dysregulated environment, resulting in chronic inflammation and inhibition of cell proliferation and migration, which delays recovery. Innovative approaches, such as three-dimensional (3D) bioprinting, can foster a controlled healing environment by promoting synergy between the skin microbiome and cells. Recent Advances: Traditional approaches to wound healing have focused on fostering an environment conducive to the interplay between cells, extracellular proteins, and growth factors. 3D bioprinting, a manufacturing technology with applications in tissue engineering, deposits biomaterial-based bioink containing living cells to fabricate custom-designed tissue scaffolds in a layer-by-layer fashion. This process controls the architecture and composition of a construct, producing multilayered and complex structures such as skin. Critical Issues: The selection of biomaterials for scaffolds has been a challenge when 3D skin tissue engineering. While prioritizing mechanical properties, current biomaterials often lack the ability to interact with environmental stimuli such as pH, temperature, or oxygen levels. Employing smart biomaterials that integrate bioactive molecules and adapt to external conditions could overcome these limitations. This innovation would enable scaffolds to create a sustainable wound-healing environment, fostering microbiome balance, reducing inflammation, and facilitating cellular recovery and tissue restoration, addressing critical gaps in existing wound care solutions. Future Directions: Novel bioink formulations for skin injury recovery are focused on improving long-term cell viability, proliferation, vascularization, and immune integration. Efficient recovery of the skin microbiome using bioactive molecules has the potential to create microenriched environments that support the recovery of the skin microbiome and restore immune regulation. This promising direction for future research aims to improve patient outcomes in wound care.

Uncovering Sex-Related Differences in Skin Macrophage Polarization During Wound Healing in Diabetic Mice

BACKGROUND

Chronic wounds, such as diabetes-related foot ulcers, arise from delayed wound healing and create significant health and economic burdens. Macrophages regulate healing by shifting between pro- and anti-inflammatory phenotypes, known as macrophage polarization. Sex and diabetes can impair wound healing, but their influence on macrophage phenotype in skin tissue during wound healing remains unclear, which was investigated in this study using a novel two-sex diabetic mouse model.

METHODS

Diabetes was induced in male and female C57BL/6J mice using low-dose streptozotocin injections and high-fat diet feeding, with chow-fed mice as controls. After 18 weeks, each mouse received four circular full-thickness dorsal skin wounds. The macrophage phenotypes in wounded skin tissues at Day 0 and Day 10 post-wounding were analyzed using mass cytometry with manual gating and automated computational clustering.

RESULTS

Male diabetic mice exhibited more severe hyperglycemia and insulin resistance compared to females. Although diabetic mice did not display delayed wound healing, male mice had a greater proportion of total macrophages than females, especially a higher proportion of pro-inflammatory matrix metalloproteinase-9 (MMP-9)+ macrophages and a lower proportion of anti-inflammatory adiponectin receptor 1 (AdipoR1)+ macrophages in male diabetic mice compared to females, indicating an imbalanced polarization towards a pro-inflammatory phenotype that could result in poorer wound healing. Interestingly, computational clustering identified a new pro-inflammatory, pro-healing phenotype (Ly6C+AdipoR1+CD163-CD206-) more abundant in females than males, suggesting this phenotype may play a role in the transition from the inflammatory to the proliferative stage of wound healing.

CONCLUSIONS

This study demonstrated a significant sex-based difference in macrophage populations, with male diabetic mice showing a pro-inflammatory bias that may impair wound healing, while a unique pro-inflammatory, pro-healing macrophage population more abundant in females could facilitate recovery. Further research is needed to investigate the role of these newly identified phenotypes in regulating impaired wound healing.

The Burden of Diabetic Foot Ulcers on Hospital Admissions and Costs in Romania

Background/Objectives: Diabetic foot ulcers represent an important economic burden for healthcare systems worldwide. We aimed to analyze the costs of care for diabetic foot ulcers (DFUs) associated with peripheral neuropathy (DPN) and peripheral arterial disease (PAD) and their trends in a tertiary-care hospital. Methods: We used data from the electronic system of the Emergency Clinical County Hospital Cluj-Napoca, Romania. We included all episodes of hospitalization with a discharge date between 1 January 2015 and the 31 December 2018 and a discharge diagnosis of type 1 or type 2 diabetes, DPN, PAD, and foot ulcers. Results: During the analyzed period, 1094 episodes of hospitalization with type 1 or type 2 diabetes and DFUs were recorded. Of these, 25.9% had neuropathic, 47.1% ischemic, and 16.6% neuroischemic DFUs. The median length of hospital stay was 8.0 days, and the median cost per episode of hospitalization was 810.8 EUR, with no significant variations during the analyzed years. The cost per episode of hospitalization was higher in cases with ischemic DFUs than for other etiologies of foot ulcers for 2015-2017 (p < 0.001). In 2018, the costs for ischemic and neuroischemic DFUs were similar and significantly higher compared to neuropathic ones. Predictors of higher costs per episode of hospitalization included the etiology of the DFUs (β = 0.032, p = 0.034) and the length of hospital stay (β = 0.860, p < 0.001). Conclusions: By analyzing data from a tertiary care hospital, we showed higher costs for the care of persons with ischemic DFU.

The Role of MicroRNA-206 in the Regulation of Diabetic Wound Healing via Hypoxia-Inducible Factor 1-Alpha

Successful wound healing in diabetic patients is hindered by dysregulated miRNA expression. This study aimed to investigate the abnormal expression of miRNAs in diabetic wound healing and the potential therapeutic role of modulating the miR-206/HIF-1α pathway. MicroRNA assays were used to identify differentially expressed miRNAs in diabetic wound sites and adjacent areas. In vitro models and a rat diabetic model were established to evaluate the effects of miR-206 on HIF-1α regulation and wound healing. The study revealed differential expression of miR-206 in diabetic wound tissues, its interaction with HIF-1α, and the inhibitory effect of miR-206 on cell growth under high glucose conditions. Modulating the miR-206/HIF-1α pathway using miR-206 antagomir promoted HIF-1α, CD34, and VEGF expression, ultimately enhancing diabetic wound healing.

In-hospital costs of diabetic foot infection at a national referral hospital in Jakarta, Indonesia

Aims

To determine the in-hospital costs of patients with diabetic foot problems who either require or do not require amputation.

Methods

We conducted a retrospective cross-sectional study of 213 subjects with low, moderate and high ulcer grades from January 2019 to December 2022 at a national referral hospital in Jakarta, Indonesia. Data were taken from the medical admissions record unit, electronic health records (EHR), hospital integrated system (HIS) and the foot registry system in the metabolic endocrine division, in relation to diabetic foot infection (DFI) as the primary or secondary diagnosis. We analysed data referring to patient characteristics, in-hospital costs and length of stay (LOS), with further comparison based on amputation status.

Results

The total DFI costs were estimated at IDR 13.833 billion (median IDR 51.225 [min - max; 10.309-507.281) million]). The total costs were estimated at IDR 64.95 ± 50.89 million per patient. All cost variables were driven by intervention costs estimated at IDR 5.176 billion (median IDR 19.676 [min - max; 1.245-136.348) million per patient). Daily costs were IDR 3.281 million per patient per day. The total treatment costs for amputation and non-amputation were IDR 6.99 billion (median IDR 61.398 (18.785-268.768) million) and IDR 6.842 billion (median IDR 45.016 (10.309-507.282) million, respectively. The average LOS was 19.79 ± 10.77 days per DFI episode, which did not differ significantly between the amputation and non-amputation groups (p > 0.176) but not for total costs (p < 0.003). DFI is associated with high costs and long-term hospital stays.

Conclusions

Our study provides evidence on in-patient hospital costs by capturing the real costs of DFI treatment, with the total treatment costs for amputation being higher than for non-amputation. This information might benefit for health practitioners in clinical practice improvements and policy adjustments, including INA-CBGs tariff for DFI patients.

Prevalence and Molecular Characterization of Carbapenemase-Producing Multidrug-Resistant Bacteria in Diabetic Foot Ulcer Infections

Background: Diabetic foot ulcers (DFUs) represent severe complications in diabetic patients, often leading to chronic infections and potentially resulting in nontraumatic lower-limb amputations. The increasing incidence of multidrug-resistant (MDR) bacteria in DFUs complicates treatment strategies and worsens patient prognosis. Among these pathogens, carbapenemase-producing pathogens have emerged as particularly concerning owing to their resistance to β-lactam antibiotics, including carbapenems. Methods: This study evaluated the prevalence of MDR bacteria, specifically carbapenemase-producing pathogens, in DFU infections. A total of 200 clinical isolates from DFU patients were analyzed via phenotypic assays, including the modified Hodge test (MHT) and the Carba NP test, alongside molecular techniques to detect carbapenemase-encoding genes (blaKPC, blaNDM, blaVIM, blaIMP, and blaOXA-48). Results: Among the isolates, 51.7% were confirmed to be carbapenemase producers. The key identified pathogens included Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, and Escherichia coli. The most commonly detected carbapenemase genes were blaKPC (27.6%) and blaNDM (24.1%). Carbapenemase-producing isolates presented high resistance to β-lactam antibiotics, whereas non-carbapenemase-producing isolates presented resistance through mechanisms such as porin loss and efflux pumps. Conclusions: The findings of this study highlight the significant burden of MDR infections, particularly carbapenemase-producing organisms, in DFUs. MDR infections were strongly associated with critical clinical parameters, including pyrexia (p = 0.017), recent antibiotic use (p = 0.003), and the severity of infections. Notably, the need for minor amputations was much higher in MDR cases (p < 0.001), as was the need for major amputations (p < 0.001). MDR infections were also strongly associated with polymicrobial infections (p < 0.001). Furthermore, Wagner ulcer grade ≥II was more common in MDR cases (p = 0.002). These results emphasize the urgent need for enhanced microbiological surveillance and the development of tailored antimicrobial strategies to combat MDR pathogens effectively. Given the high prevalence of carbapenem resistance, there is an immediate need to explore novel therapeutic options to improve clinical outcomes for diabetic patients with DFUs.

Potentilla fulgens root extract rich in polyphenols ameliorate diabetic foot ulcers in wistar rats via regulating oxidative stress and connective tissue markers

BACKGROUND

Potentilla fulgens (Wall.) ex Hook. (Rosaceae), commonly known as 'Bajradanti' is native to the lower Himalayan regions inclusive of the North-East India. Traditionally, the plant is used to treat chronic ailments like diabetes and diverse wounds, including gastric and mouth ulcers, and injuries from tiger bites.

OBJECTIVE

This study aims to assess the efficacy of P. fulgens root extract rich in polyphenolics in healing diabetic foot ulcer (DFU) in rats.

METHODS

DFU was induced in streptozotocin-nicotinamide diabetic rat feet by open excision wound model. Rats were divided into eight groups (n = 6/group): normal, negative control, plain gel (placebo) control, 1% silver sulfadiazine, and P. fulgens treated with topical ethyl acetate (EAPF, 5% and 10%) and methanol extract (MEPF, 5% and 10%). The morphological, histological and various biochemical parameters associated with the wound healing process such as connective tissue repair and oxidative stress biomarkers were evaluated.

RESULTS

Topical application of EAPF 10% and MEPF 10% over 21 days significantly (p < 0.05) reduced ulcer area in DFU rats compared to negative control. Furthermore, the extracts treated group notably (p < 0.05) increased levels of connective tissue biomarkers (total protein, hydroxyproline, hexosamine, and hexuronic acid) and antioxidant components (SOD and GSH), while significantly (p < 0.05) decreasing levels of lipid peroxidation (LPO) in foot tissue homogenate. Histological analysis of rats treated with the extracts revealed significant evidence of tissue repair, characterised by enhanced epithelial and collagen formation, along with decreased polymorphonuclear infiltration and edema.

CONCLUSION

In summary, treatment with EAPF 10% significantly improved foot ulcers by modulating oxidative stress and connective tissue biomarkers in DFU animals.

SwinDFU-Net: Deep learning transformer network for infection identification in diabetic foot ulcer

BACKGROUND

The identification of infection in diabetic foot ulcers (DFUs) is challenging due to variability within classes, visual similarity between classes, reduced contrast with healthy skin, and presence of artifacts. Existing studies focus on visual characteristics and tissue classification rather than infection detection, critical for assessing DFUs and predicting amputation risk.

OBJECTIVE

To address these challenges, this study proposes a deep learning model using a hybrid CNN and Swin Transformer architecture for infection classification in DFU images. The aim is to leverage end-to-end mapping without prior knowledge, integrating local and global feature extraction to improve detection accuracy.

METHODS

The proposed model utilizes a hybrid CNN and Swin Transformer architecture. It employs the Grad CAM technique to visualize the decision-making process of the CNN and Transformer blocks. The DFUC Challenge dataset is used for training and evaluation, emphasizing the model's ability to accurately classify DFU images into infected and non-infected categories.

RESULTS

The model achieves high performance metrics: sensitivity (95.98%), specificity (97.08%), accuracy (96.52%), and Matthews Correlation Coefficient (0.93). These results indicate the model's effectiveness in quickly diagnosing DFU infections, highlighting its potential as a valuable tool for medical professionals.

CONCLUSION

The hybrid CNN and Swin Transformer architecture effectively combines strengths from both models, enabling accurate classification of DFU images as infected or non-infected, even in complex scenarios. The use of Grad CAM provides insights into the model's decision process, aiding in identifying infected regions within DFU images. This approach shows promise for enhancing clinical assessment and management of DFU infections.

Harnessing Mesenchymal Stromal Cells for Advanced Wound Healing: A Comprehensive Review of Mechanisms and Applications

Chronic wounds and injuries remain a substantial healthcare challenge, with significant burdens on patient quality of life and healthcare resources. Mesenchymal stromal cells (MSCs) present an innovative approach to enhance tissue repair and regeneration in the context of wound healing. The intrinsic presence of MSCs in skin tissue, combined with their roles in wound repair, ease of isolation, broad secretory profile, and low immunogenicity, makes them especially promising for treating chronic wounds. This review explores the current landscape of MSC application, focusing on preclinical and clinical data across chronic wounds, diabetic ulcers, burns, non-union bone fractures, lower extremity venous ulcers, pressure ulcers, and genetic skin conditions like epidermolysis bullosa. Special emphasis is given to the mechanisms through which MSCs exert their regenerative effects, underscoring their potential in advancing wound healing therapies and supporting the broader field of regenerative medicine.

Matrix Metalloproteinase-9 as a Predictor of Healing in Diabetic Foot Ulcers

Background Wound healing in diabetic foot ulcers (DFUs) is hindered by several physiological and biochemical abnormalities, including prolonged inflammation, an imbalance in extracellular matrix (ECM) synthesis and degradation, insufficient neovascularization, and reduced macrophage activity. In DFUs, excessive and uncontrolled matrix metalloproteinases (MMPs) degrade the ECM and impede wound healing. Matrix metalloproteinase-9 (MMP-9) concentration plays a key role in inflammation and ECM degradation. This study explores the relationship between wound type in DFUs and MMP-9 levels, hypothesizing that a high MMP-9 environment may indicate inflammation and impaired wound healing. Materials and methods Forty individuals with type 2 diabetes and foot ulcers were recruited for the study. The participants were divided into two groups: nonhealing and healing, with 20 patients in each group. Biopsy samples were homogenized, and MMP-9 activity was measured using an ELISA. Results The MMP-9 concentration was significantly higher in nonhealing ulcers compared to healing ulcers. Receiver operating characteristic analysis revealed that MMP-9 measurement was the most accurate predictor of wound healing, with an area under the curve value of 0.945 and high sensitivity and specificity. Although there was a weak correlation between MMP-9 concentration and glycosylated hemoglobin, it was not statistically significant. Conclusions MMP-9 expression serves as a marker of poor wound healing. MMP-9 levels in the wound at the time of presentation may predict the healing trajectory and help tailor a specific treatment plan for each DFU patient.

The Potential of Mesenchymal Stem/Stromal Cells in Diabetic Wounds and Future Directions for Research and Therapy-Is It Time for Use in Everyday Practice?

The treatment of diabetic wounds is impaired by the intricate nature of diabetes and its associated complications, necessitating novel strategies. The utilization of mesenchymal stem/stromal cells (MSCs) as a therapeutic modality for chronic and recalcitrant wounds in diabetic patients is an active area of investigation aimed at enhancing its therapeutic potential covering tissue regeneration. The threat posed to the patient and their environment by the presence of a diabetic foot ulcer (DFU) is so significant that any additional therapeutic approach that opens new pathways to halt the progression of local changes, which subsequently lead to a generalized inflammatory process, offers a chance to reduce the risk of amputation or even death. This article explores the potential of MSCs in diabetic foot ulcer treatment, examining their mechanisms of action, clinical application challenges, and future directions for research and therapy.

Emerging technologies for the management of diabetic foot ulceration: a review

Diabetic foot ulcers (DFUs) and infections are common complications that frequently result in reduced quality of life and even morbidity for patients with diabetes. This paper highlights significant findings in DFU treatments and emerging advanced technologies for monitoring ulceration in patients with diabetes. The management of DFUs requires a multidisciplinary approach that involves patient education. It is well-established that poor glycemic control significantly contributes to diabetic foot ulcer complications, presenting global challenges in quality of life, economics, and resource allocation, affecting approximately half a billion people and potentially leading to lower limb amputation or mortality. Therefore, effective DFU management necessitates a multidisciplinary approach that includes patient education. However, current clinical guidelines for DFU treatment are not performing effectively, resulting in unnecessary increases in financial and emotional burden on patients. Researchers have experimented with advanced technologies and methods, including traditional approaches, to address complications related to DFU healing. This paper also presents the evolution of patents in the field of DFU medication and advanced diagnostic methods, showcasing relevant innovations that may benefit a wide range of researchers.

Endogenous/exogenous stimuli‐responsive smart hydrogels for diabetic wound healing

Diabetes significantly impairs the body's wound‐healing capabilities, leading to chronic, infection‐prone wounds. These wounds are characterized by hyperglycemia, inflammation, hypoxia, variable pH levels, increased matrix metalloproteinase activity, oxidative stress, and bacterial colonization. These complex conditions complicate effective wound management, prompting the development of advanced diabetic wound care strategies that exploit specific wound characteristics such as acidic pH, high glucose levels, and oxidative stress to trigger controlled drug release, thereby enhancing the therapeutic effects of the dressings. Among the solutions, hydrogels emerge as promising due to their stimuli‐responsive nature, making them highly effective for managing these wounds. The latest advancements in mono/multi‐stimuli‐responsive smart hydrogels showcase their superiority and potential as healthcare materials, as highlighted by relevant case studies. However, traditional wound dressings fall short of meeting the nuanced needs of these wounds, such as adjustable adhesion, easy removal, real‐time wound status monitoring, and dynamic drug release adjustment according to the wound's specific conditions. Responsive hydrogels represent a significant leap forward as advanced dressings proficient in sensing and responding to the wound environment, offering a more targeted approach to diabetic wound treatment. This review highlights recent advancements in smart hydrogels for wound dressing, monitoring, and drug delivery, emphasizing their role in improving diabetic wound healing. It addresses ongoing challenges and future directions, aiming to guide their clinical adoption.

Biofilms and microbiome profiles in chronic wounds: links to antibiotic use and wound severity in a Sri Lankan cohort

AIMS

We have characterized the microbiome of infected chronic diabetic wounds (CDWs), exploring associations with antibiotic use and wound severity in a Sri Lankan cohort.

METHODS AND RESULTS

Fifty CDW patients were enrolled, 38 of whom received antibiotics. Tissue biopsies were analysed by microbiome profiling, and wounds were graded using the University of Texas Wound Grading System. Biofilm presence was assessed in 20 wounds. The microbiome was largely dominated by Enterobacteriaceae, Pseudomonadaceae, Streptococcaceae, and Corynebacteriaceae. Proteobacteria levels were significantly higher in antibiotic-treated wounds (P = .019), with increased Pseudomonas abundance. Wounds were categorized as grade 1 (10), grade 2 (29), and grade 3 (11). Alpha diversity varied by wound grade (P = .015), with grade 2 wounds showing the highest diversity and grade 3 the lowest. All 20 tested wounds were biofilm-positive, and community composition varied more in antibiotic-treated wounds (P = .004).

CONCLUSIONS

CDW microbiomes were dominated by Enterobacteriaceae and Pseudomonadaceae, with elevated Proteobacteria in antibiotic-treated wounds. Alpha diversity correlated with wound severity, peaking in grade 2 wounds. The high prevalence of biofilms in wounds underscores the need for management of CDWs that address microbial complexity.

Temporal and regional trends in Canada for the epidemiology and management of diabetic foot ulcers

OBJECTIVE

Diabetic foot ulcers (DFUs) are a common downstream consequence of diabetes and pose significant concern to the health of affected individuals. There are currently limited data available that detail the epidemiology and inpatient burden of DFUs in Canada. This study aims to provide updated data on the epidemiological and economic burden of DFUs in Canada between 2015 and 2019.

METHOD

Using the Canadian Institute for Health Information Patient Cost Estimator the authors estimated, as the primary outcome, the number of DFU inpatient cases in Canada, the associated financial burden of these admissions on the Canadian healthcare system, physician compensation, and average patient length of hospitalisation. This analysis covered 12 Canadian jurisdictions and was stratified by age, sex, province and geographical region. The secondary outcome was to highlight temporal trends in the public health burden of DFUs by computing the average annual percentage change (AAPC; the weighted average of several annual percentage changes over multiple years) using Joinpoint (Surveillance Research Program National Cancer Institute, US) regression analysis.

RESULTS

The total number of cases, average length of hospitalisation and physician costs across Canada were highest for patients over ≥60 years of age. By region, the total number of cases and standardised physician costs were highest in Central Canada, followed by Western Canada, and subsequently Eastern and Northern Canada. In 2019, there were >1800 patients with DFUs admitted to Canadian acute care hospitals. Despite having the lowest number of inpatient admissions, Northern Canada had the highest associated inpatient costs, followed by Central, then Western and, lastly, Eastern Canada. Overall, mean inpatient costs remained stable over time across all age groups (AAPC 0.61; 95% confidence interval: -1.87-3.15), with an average cost of >$10,000 CAD per case. Average physician cost across all jurisdictions was approximately $1000 CAD per case, with the mean hospitalisation time being nine days.

CONCLUSION

The findings of this study emphasise the dynamic nature of the economic and epidemiological DFU burden in Canada, underscoring the need for targeted interventions, multidisciplinary care and evidence-based resource allocation for the optimal management of diabetes and DFUs.

Passive Movement Exercise of the Lower Limbs May Facilitate Wound Healing in Patients With Diabetic Foot Ulcers

BACKGROUND

Diabetic foot ulcers are a frequent and serious complication of diabetes with a high risk of amputation. Exercise has been shown to promote wound healing; however, patients with non-healing foot ulcers have limited ability to exercise due to the foot ulcer. Other strategies are therefore warranted.

METHODS

We evaluated the effect of eight weeks of two-leg passive movement exercise on wound healing in patients with non-healing diabetic foot ulcers. Twenty-one patients were included in the study and randomized into either a control or a passive movement exercise intervention group. The primary outcome measure was the wound area.

RESULTS

Sixteen participants completed the trial. Wound sizes for the passive movement intervention group were 274 mm2 and 58 mm2 at baseline and week 8, compared to 148 mm2 (p=0.31) and 136 mm2 (p=0.51) in the control group (week 16; 7 mm2 vs. 23 mm2, p=0.55). The mean wound area percentual reduction between baseline and week 8 was higher in the intervention group (76% vs. 36%, difference 40%, p=0.062).

CONCLUSION

The two-leg passive movement intervention showed a non-significant difference in wound healing and was well tolerated by patients with diabetic foot ulcers. Although the study shows potential, the results should be interpreted with its limitations of being underpowered and potentially confounded. We encourage larger randomized controlled trials to be conducted, to elucidate whether the two-leg passive movement intervention can be used to accelerate wound healing in non-healing ulcers.

An overview of current developments and methods for identifying diabetic foot ulcers: A survey

Diabetic foot ulcers (DFUs) present a substantial health risk across diverse age groups, creating challenges for healthcare professionals in the accurate classification and grading. DFU plays a crucial role in automated health monitoring and diagnosis systems, where the integration of medical imaging, computer vision, statistical analysis, and gait information is essential for comprehensive understanding and effective management. Diagnosing DFU is imperative, as it plays a major role in the processes of diagnosis, treatment planning, and neuropathy research within automated health monitoring and diagnosis systems. To address this, various machine learning and deep learning‐based methodologies have emerged in the literature to support healthcare practitioners in achieving improved diagnostic analyses for DFU. This survey paper investigates various diagnostic methodologies for DFU, spanning traditional statistical approaches to cutting‐edge deep learning techniques. It systematically reviews key stages involved in diabetic foot ulcer classification (DFUC) methods, including preprocessing, feature extraction, and classification, explaining their benefits and drawbacks. The investigation extends to exploring state‐of‐the‐art convolutional neural network models tailored for DFUC, involving extensive experiments with data augmentation and transfer learning methods. The overview also outlines datasets commonly employed for evaluating DFUC methodologies. Recognizing that neuropathy and reduced blood flow in the lower limbs might be caused by atherosclerotic blood vessels, this paper provides recommendations to researchers and practitioners involved in routine medical therapy to prevent substantial complications. Apart from reviewing prior literature, this survey aims to influence the future of DFU diagnostics by outlining prospective research directions, particularly in the domains of personalized and intelligent healthcare. Finally, this overview is to contribute to the continual evolution of DFU diagnosis in order to provide more effective and customized medical care.

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Exploring the potential of an Aloe vera and honey extract loaded bi-layered nanofibrous scaffold of PCL-Col and PCL-SBMA mimicking the skin architecture for the treatment of diabetic wounds

Diabetic wounds are often chronic in nature, and issues like elevated blood sugar, bacterial infections, oxidative stress and persistent inflammation impede the healing process. To ensure the appropriate healing of wounds, scaffolds should promote complete tissue regeneration in wounds, both functionally and structurally. However, the available scaffolds lack the explicit architecture and functionality that could match those of native skin, thus failing to carry out the scar-free skin regeneration in diabetic wounds. This study deals with the synthesis of a bi-layered nanofibrous scaffold mimicking the native skin architecture in terms of porosity and hydrophobic-hydrophilic gradients. In addition, herbal extracts of Aloe vera and litchi honey were added in consecutive layers to manage the high blood glucose level, inflammation, and increased ROS level associated with diabetic wounds. In vitro studies confirmed that the prepared scaffold with herbal extracts showed enhanced proliferation of skin cells with good mechanical strength, degradability, anti-bacterial and anti-diabetic properties. The scaffold also demonstrated superior wound healing in vivo with quicker scar-free wound recovery and appropriate skin regeneration, compared to conventional treatment. Altogether, the synthesized herbal extract loaded bi-layered nanofibrous scaffold can be used as a regenerative template for hard-to-heal diabetic wounds, offering a new strategy for the management of chronic wounds.

Sheffield One-Stop Service: A potential model to improve the screening uptake of diabetic peripheral neuropathy and other microvascular complications of diabetes

The world is experiencing an enormous rise in the prevalence of diabetes, which is associated with massive healthcare costs that threaten to overwhelm many healthcare systems. Most of the diabetes expenditure is attributed to the management of chronic diabetes complications, including diabetic peripheral neuropathy (DPN)/diabetic foot complications, chronic kidney disease, sight-threatening retinopathy and cardiovascular diseases. Of these complications, the most overlooked is DPN. Most consultations around the world do not even involve taking off shoes and socks to carry out a foot examination, and even when carried out, the peripheral neurological examination using the 10-g monofilament diagnoses DPN when it is already at an advanced stage. Thus, all too often diabetes complications are diagnosed late, resulting in devastating outcomes, particularly in low- to middle-income countries. There is, therefore, an urgent need to instigate new strategies to improve microvascular screening uptake using a holistic protocol for annual diabetes health checks outside the busy diabetes clinic. One such approach, the Sheffield One-Stop Microvascular Screening Service, which involves modern point of care devices to diagnose DPN, has been shown to be feasible and effective, resulting in high uptake and early management of diabetes complications. This article outlines the advantages of this One-Stop Microvascular Screening Service and a plan to trial an adapted version of this service to a resource-limited country, the Philippines. If successful, this model has the potential for implementation in other countries around the world.

Improved Diabetic Foot Ulcer Outcomes in Medicaid Beneficiaries with Podiatric Care Access

Objectives

This study aims to examine the association between state Medicaid coverage of podiatry services and the outcomes of beneficiaries with new diabetic foot ulcers (DFUs).

Methods

Medicaid beneficiaries who developed a DFU between 2010 and 2015 were identified using the PearlDiver claims database. The states were categorized into covered states (CS) and non-covered states (NCS) based on podiatric coverage during the study period. The outcomes included major amputation, minor amputation, and hospitalization due to foot infection within 12 months of index diagnosis. Logistic regression was used to assess the association of state coverage type and outcomes, controlling for age, sex, and the Charlson Comorbidity Index (CCI).

Results

Our study included 16,905 Medicaid beneficiaries who developed new DFUs: 14,748 in CS and 2157 in NCS. The overall major amputation rate was 2.6%. The risk of major amputation was 48% lower among Medicaid beneficiaries in CS (OR 0.52, 95% CI 0.31-0.90) than in NCS. The Medicaid beneficiaries in CS had a 24% lower risk of hospitalization for foot infection (OR 0.76, 95% CI 0.67-0.85) but had a 58% higher risk of minor amputation (OR 1.58, 95% CI 1.22-2.07) than in NCS.

Conclusions

Medicaid coverage of podiatry services might be associated with lower rates of major amputation and reduced risk of hospitalization for foot infection.

The prevalence of depression among patients with diabetic foot ulcers at King Khalid University Hospital, Riyadh, Saudi Arabia

Background and Aim

The prevalence rates of depression and anxiety among diabetic patients with diabetic foot ulcers (DFU) vary from one study to the other. We aimed to determine the prevalence of depression and the associated risk factors among patients with DFU.

Methods

We conducted a cross-sectional study using a self-reported questionnaire on adult patients aged 18 years old and above with DFU at our institution. We used the 9-item Patient Health Questionnaire to evaluate the presence of depressive symptoms.

Results

A total of 75 patients, 56 (74.7%) males and 19 (25.3%) females, participated in the study; 33 (44.0%) were more than 60 years old. The prevalence of moderate to severe depression among our patients was 35 (46.7%). Patients who had DFU for more than 1 year had a higher proportion of moderate to severe depression (P = 0.032). There were no significant differences in the proportion of patients who had depression according to age groups (P = 0.456), gender (P = 0.095), level of education (P = 0.145), employment (P = 0.514), type of diabetes (P = 0.561), duration of diabetes (P = 0.704), level of HbA1c (P = 0.525), smoking history (P = 0.163), and previous history of DFU (P = 0.713). Logistic regression analysis showed that patients who had DFU for more than 1 year were three times more at risk to have moderate to severe depression (P = 0.049).

Conclusion

Patients with DFU have a high frequency of moderate to severe depression regardless of age, gender, or other sociodemographic characteristics, with patients with long-standing DFU having triple the risk of depression as those with freshly diagnosed DFU. Diabetic persons should be thoroughly assessed to reduce the diabetes result, and preventative actions and patient education about DFU are crucial.

Clinical practice guidelines of foot care practice for patients with type 2 diabetes: A scoping review using self-care model

BACKGROUND

Type 2 diabetes can lead to severe foot complications, making self-care education, guided by clinical guidelines, crucial. However, fragmented and dispersed recommendations challenge effective implementation of these guidelines. Bringing together recommendations and presenting them according to a self-care model can provide a solid framework and facilitate the interpretation of results.

AIMS

to map the international guidelines that provide recommendations to nurses to enable people with type 2 diabetes for foot self-care and synthesize the recommendations according to the key concepts of the middle-range theory of self-care for chronic diseases.

DESIGN

A scoping review was undertaken, using the methodological guidance of the Joanna Briggs Institute.

DATA SOURCES

Databases were searched between September 2022 and June 2023, including PubMed, CINAHL, PsycINFO, Scopus, Web of Science Core Collection, ProQuest Dissertations and Theses Global, guideline websites and related professional association websites. The databases were chosen for their comprehensive coverage of the area.

METHODS

Eligible articles included guidance documents providing foot care recommendations for diabetes, published or updated between 2013 and 2023. Two reviewers summarized the recommendations presented in at least two guidelines according to the key concepts of the self-care model. The PRISMA-ScR checklist was used.

RESULTS

Seventeen guidelines were included. In total, we synthesized 175 recommendations. The recommendations were framed in three dimensions and their respective categories: Self-care maintenance (education for prevention, control of risk factors, daily foot care, footwear, and socks), Self-care monitoring (foot inspection, detection of signs of infection, and detection of other diabetes-related foot disease complications), and Self-care management (responses to signs and symptoms, foot wound care, follow-up with health professionals, and health services).

CONCLUSIONS

The main aspect of foot care revolves around daily care, including cleaning, moisturizing, nail care, selecting appropriate footwear, and regular inspection of both feet and footwear.

Effects of different treatment measures on the efficacy of diabetic foot ulcers: a network meta-analysis

Introduction

Through a network meta-analysis, we compared different treatment measures for patients with diabetic foot ulcers (DFU), assessing their impact on the healing of DFU and ranking them accordingly.

Methods

We searched the PubMed, the China National Knowledge Infrastructure (CNKI), Embase, the WanFang and the WeiPu database. The retrieval time was from database establishment to January 2024, and retrieval entailed subject and free words. Randomized controlled trials (RCTs) with different treatment measures for DFU were included. Data extraction and evaluation were based on the PRISMA guidelines. Meta-analyses using pairwise and network methods were employed to compare and rank the effectiveness of different treatments for DFU.

Results

Ultimately, we included 57 RCTs involving a total of 4,826 patients with DFU. When it comes to ulcer healing rates, compared to standard of care(SOC),platelet-rich plasma(PRP), hyperbaric oxygen therapy(HBOT), topical oxygen therapy(TOT), acellular dermal matrix(ADM), and stem cells(SCs) in both direct meta-analysis(DMA) and network meta-analysis(NMA) can effectively increase the complete healing rate. For Scs+PRP, a statistically significant improvement was only observed in the NMA. Moreover, when compared to the negative pressure wound therapy(NPWT) group, the PRP+NPWT group was more effective in promoting the complete healing of ulcers. In terms of promoting the reduction of ulcer area, no statistical differences were observed among various treatment measures. When it comes to ulcer healing time, both PRP and NPWT can effectively shorten the healing time compared to SOC. Furthermore, when compared to the NPWT group, the combined treatment of PRP and ultrasonic debridement(UD) with NPWT is more effective in reducing healing time. In terms of amputation rates and adverse reactions, the PRP group effectively reduced the amputation rate and adverse reactions for patients with DFU. Additionally, compared to the NPWT group, the combined treatment of PRP and UD with NPWT reduced the incidence of adverse reactions. However, no significant differences were observed among other treatment measures in terms of amputation rates and adverse reactions. The ranking results showed that the efficacy of PRP+NPWT and UD+NPWT in promoting ulcer healing, reducing ulcer area, shortening healing time, decreasing amputation rates and adverse reactions is superior to that of the alone PRP group, NPWT group, and UD group. Conversely, the SOC group demonstrates the least effective performance in all aspects.

Conclusion

Due to the particularity of the wound of DFU, the standard of care is not effective, but the new treatment scheme has a remarkable effect in many aspects. And the treatment of DFU is not a single choice, combined with a variety of methods often achieve better efficacy, and will not bring more adverse reactions.

The promising approach of 3D bioprinting for diabetic foot ulcer treatment: A concise review of recent developments

Diabetic foot ulcer (DFU), one of the most significant complications of diabetes, is a condition that causes anatomical and functional alterations of the foot resulting in an important social and economic impact, related to disability and health care costs. Recently, three-dimensional bioprinting - which allows the fabrication of complex and biocompatible structures - has been identified as a promising approach in the field of regenerative medicine to promote the healing of chronic wounds, such as DFU. In this concise review we highlight the most relevant and recent attempts of using 3D bioprinted constructs in vivo - both on animals and people - in order to treat non-healing diabetic ulcers and prevent their worsening. Finally, we briefly focus on the future implications of bioprinting, suggesting its forthcoming importance not only for DFU treatment but also for other areas of clinical care.

Identification of phase angle and Triglyceride-Glucose index as biomarkers for prediction and management of diabetic foot disease

Introduction

Approximately 25 % of diabetic patients develop diabetic foot ulcers (DFUs), significantly increasing morbidity, mortality, and healthcare costs. Effective control and prevention are crucial.

Objective

This study aims to identify easily measurable parameters for predicting DFU risk by assessing the correlation between Phase Angle (PA) and the Triglyceride-Glucose (TyG) index with DFU risk.

Materials and methods

A comparative case-control study was conducted at the General Hospital of Elche from March to June 2023 with 70 participants (33 with diabetes, 37 without). Cases had diabetes for over five years and a diabetic foot risk grade of 0, 1, or 2 (IWGDF 2019). Exclusion criteria included inability to walk, prior use of orthoses, and severe complications like edema or wounds. Predictive variables were PA, TyG index, body composition, and biochemical markers. Statistical analyses included Pearson/Spearman tests for correlations, Student's t-test/Mann-Whitney test for group comparisons, and ANOVA/Kruskal-Wallis tests for normally and non-normally distributed variables.

Results

PAand TyG index were strongly linked to diabetic foot risk, supporting their potential as biomarkers. Significant relationships with other relevant biomarkers were also confirmed.

Conclusion

PA and TyG index are valuable, easily measurable biomarkers for assessing diabetic foot risk, and can be monitored in primary care settings. Implementing these biomarkers in routine practice could enhance the management of diabetic complications, particularly in resource-limited settings, by enabling early detection and intervention, thus improving patient outcomes and reducing the burden of advanced complications.

Early screening for foot problems in people with diabetes is the need of the hour: 'Save the Feet and Keep Walking Campaign' in India

INTRODUCTION

Evidence on the prevalence of foot problems among people with diabetes in India at a national level is lacking. Hence, this study was aimed to assess the burden of high-risk (HR) feet in people with diabetes across India.

RESEARCH DESIGN AND METHODS

A cross-sectional national-level project 'Save the Feet and Keep Walking' campaign was conducted by the Research Society for the Study of Diabetes in India (RSSDI) from July 10, 2022 to August 10, 2022. A modified version of 3 min foot examination was used to assess the foot problems. Around 10 000 doctors with RSSDI membership were trained online to conduct foot screening and provided a standardised monofilament for detection of loss of protective sensation. People with diabetes aged >18 years who visited the clinics during the study period were examined for foot problems. Data were collected online using the semi-structured questionnaire. A total of 33 259 participants with complete information were included for the final analysis. The foot at risk was categorised based on International Working Group on the Diabetic Foot guidelines 2023.

RESULTS

Nearly 75% of the participants were aged above 45 years. Around 49% had diabetes duration >5 years and uncontrolled diabetes (hemoglobin A1c >8%). Presence of history of foot ulcer (20%), lower limb amputation (15.3%), foot deformities (24.5%) and absence of diminished dorsal pedis and posterior tibial pulses (26.4%) was noted in the study participants. Around 25.2% of them had HR feet and highly prevalent among males. Diabetic kidney and retinal complications were present in 70% and 75.5% of people with HR feet. Presence of heel fissures (OR (95% CI) 4.6 (4.2 to 5.1)) and callus or corns (OR (95% CI) 3.6 (3.3 to 4.0)) were significantly associated with HR feet.

CONCLUSIONS

One-fourth of people with diabetes were found to have HR feet in India. The findings are suggestive of regular screening of people with diabetes for foot problems and strengthening of primary healthcare.

Effects of diabetes-related foot ulcer depth on healing days, cost, and quality of life: A prospective observational study

The relationship between the depth of the diabetes-related foot ulcers, and the healing days, cost, and QOL was examined.Depth 4 and 5 ulcers, namely beyond the tendons, exhibited significantly longer healing days and higher costs than Depth 2 and 3 ulcers. As for QOL, there were no significant differences in utility values between the depth categories.Results on healing time and cost reiterate the importance of early consultation, especially before the depth becomes deeper than the tendon.

Leveraging smart image processing techniques for early detection of foot ulcers using a deep learning network

Purpose

To detect foot ulcers in diabetic patients by analysing thermal images of the foot using a deep learning model and estimate the effectiveness of the proposed model by comparing it with some existing studies.

Material and methods

Open-source thermal images were used for the study. The dataset consists of two types of images of the feet of diabetic patients: normal and abnormal foot images. The dataset contains 1055 total images; among these, 543 are normal foot images, and the others are images of abnormal feet of the patient. The study's dataset was converted into a new and pre-processed dataset by applying canny edge detection and watershed segmentation. This pre-processed dataset was then balanced and enlarged using data augmentation, and after that, for prediction, a deep learning model was applied for the diagnosis of an ulcer in the foot. After applying canny edge detection and segmentation, the pre-processed dataset can enhance the model's performance for correct predictions and reduce the computational cost.

Results

Our proposed model, utilizing ResNet50 and EfficientNetB0, was tested on both the original dataset and the pre-processed dataset after applying edge detection and segmentation. The results were highly promising, with ResNet50 achieving 89% and 89.1% accuracy for the two datasets, respectively, and EfficientNetB0 surpassing this with 96.1% and 99.4% accuracy for the two datasets, respectively.

Conclusions

Our study offers a practical solution for foot ulcer detection, particularly in situations where expert analysis is not readily available. The efficacy of our models was tested using real images, and they outperformed other available models, demonstrating their potential for real-world application.

Advancements in diabetic foot insoles: a comprehensive review of design, manufacturing, and performance evaluation

The escalating prevalence of diabetes has accentuated the significance of addressing the associated diabetic foot problem as a major public health concern. Effectively offloading plantar pressure stands out as a crucial factor in preventing diabetic foot complications. This review comprehensively examines the design, manufacturing, and evaluation strategies employed in the development of diabetic foot insoles. Furthermore, it offers innovative insights and guidance for enhancing their performance and facilitating clinical applications. Insoles designed with total contact customization, utilizing softer and highly absorbent materials, as well as incorporating elliptical porous structures or triply periodic minimal surface structures, prove to be more adept at preventing diabetic foot complications. Fused Deposition Modeling is commonly employed for manufacturing; however, due to limitations in printing complex structures, Selective Laser Sintering is recommended for intricate insole designs. Preceding clinical implementation, in silico and in vitro testing methodologies play a crucial role in thoroughly evaluating the pressure-offloading efficacy of these insoles. Future research directions include advancing inverse design through machine learning, exploring topology optimization for lightweight solutions, integrating flexible sensor configurations, and innovating new skin-like materials tailored for diabetic foot insoles. These endeavors aim to further propel the development and effectiveness of diabetic foot management strategies. Future research avenues should explore inverse design methodologies based on machine learning, topology optimization for lightweight structures, the integration of flexible sensors, and the development of novel skin-like materials specifically tailored for diabetic foot insoles. Advancements in these areas hold promise for further enhancing the effectiveness and applicability of diabetic foot prevention measures.

The use of fetal bovine acellular dermal matrix in severe diabetic foot ulceration and threatened limbs with tissue loss the use of FBADM as an adjunct for complex wounds

OBJECTIVES

Foot ulceration associated with diabetic foot disease (DFD) and chronic limb-threatening ischaemia (CLTI) presents a complex clinical challenge and failure to heal the wound imposes a significant risk of major limb amputation (MLA). In attempt to accelerate wound healing rates and decrease MLA, tissue engineering research into bio-engineered scaffolds and skin substitutes has become a growing area of interest. Advanced wound therapies such as fetal bovine acellular dermal matrix (FBADM) may have success in the treatment of difficult to heal chronic foot ulcers. The FBADM traps and binds the patients' own epithelial cells to rebuild the dermis layer of the skin. Previous studies have suggested that wounds treated with FBADM had a faster healing rate than wounds managed with conventional dressings. However, these studies excluded foot wounds with chronic exposed bone or tendon, active infection, gangrene, or osteomyelitis and patients with uncontrolled blood glucose levels were excluded. The aim of this study was to assess the efficacy of FBADM for patients admitted to hospital acutely with severe foot ulceration secondary to DFD and CLTI.

METHODS

Between February 2020 and December 2021, inpatients admitted acutely at a single tertiary centre with a severe non-healing foot ulcer and had a wound suitable for application of a FBADM after primary debridement were included in the study. A severe non-healing foot wound was defined as a Society for Vascular Surgery Wound, Ischaemia, and foot Infection (WIfI) stage of 3 or 4. Participants were prospectively followed up at regular intervals at a multidisciplinary high-risk diabetic foot clinic until June 2022. The primary endpoint was time to wound closure. The secondary endpoints were number of applications of FBADM, readmission rate and amputation-free survival.

RESULTS

There were 22 patients included in the study with a median age of 71 (50-87) years and 15 were male. Five patients had a WIfI stage of 3 and 17 had a WIfI score of 4. Overall, 14 patients required revascularisation procedures (6 open surgery,8 endovascular intervention). A total of 18 patients achieved complete wound healing with a median time to wound healing of 178 (28-397) days. Two patients underwent a MLA and two patients died prior to complete wound healing. The median length of stay was 16.5 (5-115) days, and 4 patients were readmitted to hospital within 12 months.

CONCLUSION

FBADM may be a useful adjunct in the acute setting of complex DFD and CLTI ulceration to assist with wound healing. Future comparative prospective studies are required to further validate these preliminary findings.

Effectiveness of Ya-Samarn-Phlae in diabetic wound healing: Evidence from in vitro studies and a multicenter randomized controlled clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Ya-Samarn-Phlae (YaSP) has traditionally been widely used in southern Thailand for treating chronic and infected wounds, including diabetic foot ulcers. However, there are only a limited number of clinical studies supporting the use of this polyherbal formulation. Therefore, the present work aims to provide clinical evidence to support the application of YaSP, prepared according to a standardized traditional procedure (T-YaSP). Additionally, its potential chemical markers and wound healing-related biological activities were examined.

MATERIALS AND METHODS

The in vitro wound healing-related biological activities of YaSP ethanol extract and T-YaSP, including antibacterial activity against Staphylococcus epidermidis, inhibition and eradication of staphylococcal biofilm, anti-inflammatory effects, and enhancement of human dermal fibroblast migration in scratch wounds, were examined using well-established protocols. The chemical profiles of the ethanol extract of YaSP and T-YaSP were compared, and with promising chemical markers, arecoline, alpha-mangostin, and curcumin were selected and quantified using the HPLC method. A prospective, multicenter, randomized, controlled, parallel-group study was conducted over 12 weeks to evaluate the efficacy of the YaSP solution as an adjunct therapy, combined with standard wound care, for diabetic ulcers compared to standard treatment.

RESULTS

The YaSP extract reduces NO production and can scavenge NO radicals in LPS-induced RAW 264.7 macrophage cells. Additionally, in a scratch assay, this extract and one of its herbal components, Curcuma longa, enhance the migration of human dermal fibroblasts. T-YaSP, containing 2.412 ± 0.002 mg/g of arecoline, 2.399 ± 0.005 mg/g of curcumin, and 0.017 ± 0.000 mg/g of α-mangostin, has shown the ability to inhibit the development and eradicate the mature biofilm of S. epidermidis. The use of T-YaSP as an adjunct therapy led to a significantly higher proportion of patients achieving healing within six weeks compared to the standard treatment group (36%/9 patients vs. 4%/1 patient; p = 0.013). After 12 weeks, 19 out of 25 patients in the T-YaSP group experienced complete healing, whereas only four patients in the standard treatment group achieved complete wound healing (76% in the T-YaSP group vs. 16% in the control group; p < 0.001).

CONCLUSION

The results presented here represent the first randomized controlled trial to demonstrate the effectiveness of the traditional polyherbal solution, T-YaSP, which exhibits a wide range of wound healing-related activities. Utilizing T-YaSP as an adjunctive treatment resulted in a significant improvement in the number of type 2 diabetic patients achieving complete healing. However, to explore and utilize YaSP further, conducting a double-blind, randomized controlled trial with a larger population is necessary.

Bacteriological analysis and antibiotic resistance in patients with diabetic foot ulcers in Dhaka

The primary objective of this study was to isolate bacteria from diabetic foot ulcers and subsequently assess their antibiotic resistance capabilities. Seventy-five patients diagnosed with diabetic foot ulcers were investigated. A number of these patients (97.33%) had type 2 diabetes, with a significant proportion of them having been diagnosed for 1-5 years (29.33%). Notably, a substantial number of these individuals were on insulin usage (78.66%). Among the patients under examination, 49.33% reported having no use of tobacco products, alcohol, or betel leaf. The ulcers analyzed in this study were classified into grades 1-5 according to the Wagner scale. Wagner grade 2 diabetic foot ulcers had the highest number of culture-positive patients, at 33.33%. Pus samples collected from patients were cultured on selective media, and bacterial identity was confirmed by biochemical tests and polymerase chain reaction. A total of 141 isolates were isolated. Among the isolates, 82.97% gram-negative bacteria and 17.02% gram-positive bacteria were detected. Klebsiella pneumoniae was the most common isolate. Proteus spp., Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus were also detected. Approximately 61.33% of the ulcers exhibited were polybacterial. In this study, it was observed that all bacterial isolates, except for Proteus spp., were primarily detected in patients classified under Wagner's grade 2. Moreover, antibiotic susceptibility was also tested on these 141 isolates. Among them, Escherichia coli showed the highest multidrug resistance, 81.81%. Most of the gram-negative bacteria were resistant to ampicillin. All of the gram-negative isolates exhibited high levels of susceptibility to piperacillin-tazobactam, and these levels were Klebsiella pneumoniae (97.56%), Pseudomonas aeruginosa (95.24%), Escherichia coli (81.82%), and Proteus spp. (80%). On the other hand, gram-positive Staphylococcus aureus mostly showed sensitivity towards vancomycin and norfloxacin (79.17%).

Modulation of diabetic wound healing using carbon monoxide gas-entrapping materials

Diabetic wound healing is uniquely challenging to manage due to chronic inflammation and heightened microbial growth from elevated interstitial glucose. Carbon monoxide (CO), widely acknowledged as a toxic gas, is also known to provide unique therapeutic immune modulating effects. To facilitate delivery of CO, we have designed hyaluronic acid-based CO-gas-entrapping materials (CO-GEMs) for topical and prolonged gas delivery to the wound bed. We demonstrate that CO-GEMs promote the healing response in murine diabetic wound models (full-thickness wounds and pressure ulcers) compared to N2-GEMs and untreated controls.

Infrared Thermography Shows That a Temperature Difference of 2.2°C (4°F) or Greater Between Corresponding Sites of Neuropathic Feet Does Not Always Lead to a Diabetic Foot Ulcer

BACKGROUND

There is emerging interest in the application of foot temperature monitoring as means of diabetic foot ulcer (DFU) prevention. However, the variability in temperature readings of neuropathic feet remains unknown. The aim of this study was to analyze the long-term consistency of foot thermograms of diabetic feet at the risk of DFU.

METHODS

A post-hoc analysis of thermal images of 15 participants who remained ulcer-free during a 12-month follow-up were unblinded at the end of the trial. Skin foot temperatures of 12 plantar, 15 dorsal, 3 lateral, and 3 medial regions of interests (ROIs) were derived on monthly thermograms. The temperature differences (∆Ts) of corresponding ROIs of both feet were calculated.

RESULTS

Over the 12-month study period, out of the total 2026 plantar data points, 20.3% ROIs were rated as abnormal (absolute ∆T ≥ 2.2°C). There was a significant between-visit variability in the proportion of plantar ROIs with ∆T ≥ 2.2°C (range 7.6%-30.8%, chi-square test, P = .001). The proportion of patients presenting with hotspots (ROIs with ∆T ≥ 2.2°C), abnormal plantar foot temperature (mean ∆T of 12 plantar ROIs ≥ 2.2°C), and abnormal whole foot temperature (mean ∆T of 33 ROIs ≥ 2.2°C) varied between visits and showed no pattern (P > .05 for all comparisons). This variability was not related to the season of assessment.

CONCLUSIONS

Despite the high rate of hotspots on monthly thermograms, all feet remained intact. This study underscores a significant between-visit inconsistency in thermal images of neuropathic feet which should be considered when planning DFU-prevention programs for self-testing and behavior modification.

Evidence-based interventions for identifying candidate quality indicators to assess quality of care in diabetic foot clinics: a scoping review

BACKGROUND

Foot ulcers in people with diabetes are a serious complication requiring a complex management and have a high societal impact. Quality monitoring systems to optimize diabetic foot care exist, but a formal and more evidence-based approach to develop quality indicators (QIs) is lacking. We aimed to identify a set of candidate indicators for diabetic foot care by adopting an evidence-based methodology.

METHODS

A systematic search was conducted across four academic databases: PubMed, Embase CINAHL and Cochrane Library. Studies that reported evidence-based interventions related to organization or delivery of diabetic foot care were searched. Data from the eligible studies were summarized and used to formulate process and structure indicators. The evidence for each candidate QI was described in a methodical and transparent manner. The review process was reported according to the "Preferred Reported Items for Systematic reviews and Meta-Analysis" (PRISMA) statements and its extension for scoping reviews.

RESULTS

In total, 981 full-text articles were screened, and 322 clinical studies were used to formulate 42 candidate QIs.

CONCLUSIONS

An evidence-based approach could be used to select candidate indicators for diabetic foot ulcer care, relating to the following domains: wound healing interventions, peripheral artery disease, offloading, secondary prevention, and interventions related to organization of care. In a further step, the feasibility of the identified set of indicators will be assessed by a multidisciplinary panel of diabetic foot care stakeholders.

Effect of Buerger-Allen exercise on wound healing in patients with diabetic foot ulcers: a randomised controlled trial

OBJECTIVE

A diabetic foot ulcer (DFU) is a complication of type 2 diabetes that is difficult to treat. Buerger-Allen exercise has shown effectiveness in improving foot circulation and neuropathy in several studies; however, to the best of our knowledge, no randomised controlled study has investigated its effectiveness for DFU healing. Therefore, this study aimed to assess the effects of Buerger-Allen exercise on the healing of DFUs in patients with type 2 diabetes.

METHOD

This is a parallel-group randomised controlled trial (RCT). Of 50 patients with neuropathic DFUs, 41 completed the study. They were assigned randomly to a study group (n=21) and a control group (n=20). Patients in the study group received the standard medical treatment and semi-supervised Buerger-Allen exercise for three sessions per week for four weeks, while patients in the control group only received the standard medical treatment. The outcome measures were: ankle-brachial pressure index (ABPI); ulcer size; ulcer depth; SINBAD score; and ulcer risk for poor outcomes (based on the SINBAD score).

RESULTS

The study group's mean age was 49.48±6.45 years and the control group's mean age was 49.15±5.85. The study group's ABPI increased significantly compared to the baseline (1.17±0.04 versus 1.11±0.05, respectively; p<0.001) and the control group (1.17±0.04 versus 1.14±0.05, respectively; p=0.04) post-intervention. Ulcer size also reduced significantly in the study group compared to the baseline (2.63±2.0 versus 7.48±5.55cm2, respectively; p<0.001) and the control group (2.63±2.0 versus 6.43±4.45cm2, respectively; p<0.001) post-intervention. Ulcer depth decreased significantly in the study group compared to the baseline (1.71±1.05 versus 4.19±1.74mm, respectively; p<0.001) and the control group (1.71±1.05 versus 2.80±1.57mm, respectively; p=0.01) post-intervention. Furthermore, the SINBAD score in the study group decreased significantly compared to the baseline (1.38±0.86 versus 2.14±1.06, respectively; p<0.001) and the control group (1.38±0.86 versus 2.0±0.79, respectively; p=0.02) post-intervention. Moreover, the ulcer risk for poor outcomes, based on the SINBAD score, reduced significantly only in the study group, compared to the baseline (p=0.041). The control group showed non-significant changes compared to the baseline in all outcome measures (p>0.05).

CONCLUSION

From the findings of this RCT, Buerger-Allen exercise, in combination with standard wound care, may help accelerate the healing of neuropathic DFUs in patients with type 2 diabetes, and could be suggested as part of the management plan for such conditions as an easy-to-perform offloading exercise intervention.

Highly Absorbent Egg White/Carbomer-940 Hydrofilm as a Potential Diabetic Wound Dressing

Diabetic foot ulcer (DFU) is the most critical problem in diabetic patients. Managing exudate in this kind of wound presents significant challenges in clinics. Advanced wound dressings serve as the most effective approach to managing DFU. Herein, a highly absorbent hydrofilm is presented through a combination of egg white (EW) and Carbomer-940, benefiting from the bioactivity of the EW component and superabsorption capacity of Carbomer-940. The crystallinity of samples rises due to the presence of Carbomer-940. Regarding the high water absorption capacity of Carbomer-940, the swelling ratio and water-holding capacity of samples are also improved via its incorporation of up to 1005%. In contrast, the transmission of water vapor and in vitro degradation rate decreases as Carbomer-940 powers the crystallinity of hydrofilms. Carbomer-940 incorporation in the EW structure accelerates protein release during the time, while this acceleration is partially compensated by the crystallization effect. The cell viability assay demonstrates no toxicity as well as high human foreskin fibroblast cell proliferation for the hybrid hydrofilm sample, where the cell migration is positively affected in the presence of the bioactive components extracted from the dressing. Taken together, the optimized hybrid hydrofilm could be suggested as a promising wound dressing for managing DFUs.

Strategies in surface engineering for the regulation of microclimates in skin-medical product interactions

There is a growing number of personal healthcare devices that are in prolonged contact with the skin. The functionality of these products is linked to the interface formed by the contact between the medical apparatus and the skin. The interface can be characterised by its topology, compliance, and moisture and thermal regulating capabilities. Many devices are, however, described to have suboptimal and occlusive contacts, resulting in physiological unfavourable microclimates at the interface. The resulting poor management of moisture and temperature can impact the functionality and utility of the device and, in severe cases, lead to physical harm to the user. Being able to control the microclimate is therefore expected to limit medical-device related injuries and prevent associated skin complications. Surface engineering can modify and potentially enhance the regulation of the microclimate factors surrounding the interface between a product's surface and the skin. This review provides an overview of potential engineering solutions considering the needs for, and influences on, regulation of temperature and moisture by considering the skin-medical device interface as a system. These findings serve as a platform for the anticipated progress in the role of surface engineering for skin-device microclimate regulation.

Enhancement of bactericidal effects of bacteriophage and gentamicin combination regimen against Staphylococcus aureus and Pseudomonas aeruginosa strains in a mice diabetic wound model

Diabetic patients are more susceptible to developing wound infections resulting in poor and delayed wound healing. Bacteriophages, the viruses that target-specific bacteria, can be used as an alternative to antibiotics to eliminate drug-resistant bacterial infections. Pseudomonas aeruginosa (P. aeruginosa) and Staphylococcus aureus (S. aureus) are among the most frequently identified pathogens in diabetic foot ulcers (DFUs). The aim of this study was assessment of bacteriophage and gentamicin combination effects on bacterial isolates from DFU infections. Specific bacteriophages were collected from sewage and animal feces samples and the phages were enriched using S. aureus and P. aeruginosa cultures. The lytic potential of phage isolates was assessed by the clarity of plaques. We isolated and characterized four lytic phages: Stp2, Psp1, Stp1, and Psp2. The phage cocktail was optimized and investigated in vitro. We also assessed the effects of topical bacteriophage cocktail gel on animal models of DFU. Results revealed that the phage cocktail significantly reduced the mortality rate in diabetic infected mice. We determined that treatment with bacteriophage cocktail effectively decreased bacterial colony counts and improved wound healing in S. aureus and P. aeruginosa infections, especially when administrated concomitantly with gentamicin. The application of complementary therapy using a phage cocktail and gentamicin, could offer an attractive approach for the treatment of wound diabetic bacterial infections.

Current knowledge of morbidities and direct costs related to diabetic foot disorders: a literature review

Diabetes is a chronic disease associated with numerous complications including diabetic foot disorders, which are associated with significant morbidity and mortality as well as high costs. The costs associated with diabetic foot disorders comprise those linked to care (direct) and loss of productivity and poor quality of life (indirect). Due to the constant increase in diabetes prevalence, it is expected that diabetic foot disorder will require more resources, both in terms of caregivers and economically. We reviewed findings on management, morbidity, mortality, and costs related to diabetic foot disorder.

Diabetes knowledge and foot care practices among type 2 diabetes patients attending the chronic ambulatory care unit of a public health hospital in eastern Ethiopia: a cross-sectional study

OBJECTIVE

To assess diabetes knowledge and foot care practices among type 2 diabetes patients.

DESIGN

An institution-based cross-sectional study was undertaken from 1 January to 31 January 2021.

SETTING

Eastern Ethiopia.

PARTICIPANTS

Randomly selected type 2 diabetes patients who were available during the data collection period were included.

OUTCOMES

Patients' diabetes knowledge was assessed with the revised diabetes knowledge test questionnaire. Five items were used to evaluate foot self-care practices.

RESULTS

The study population comprised of 549 patients. About 52.5% of the patients had adequate diabetes knowledge (95% CI: 48.2% to 56.7%). Patients with an educational level of secondary school and above (adjusted OR (AOR): 2.04, 95% CI: 1.13 to 3.71), (AOR: 5.28, 95% CI: 2.28 to 12.22), and those with medium and above wealth status (AOR: 3.81, 95% CI: 2.24 to 6.47), (AOR: 3.46, 95% CI: 1.98 to 6.04), were found to have better odds of having adequate diabetes knowledge. However, those aged >55 years (AOR: 0.47, 95% CI: 0.22 to 0.99) were found to have lower odds of adequate diabetes knowledge.Of the total included patients, 20.2% (95% CI: 16.9% to 23.8%) had good foot care practices. Knowledge of the target fasting plasma glucose (AOR: 3.18, 95% CI: 1.94 to 5.22) and adequate diabetes knowledge (AOR: 3.40, 95% CI: 1.95 to 5.91) were significantly associated with good foot care practices.

CONCLUSION

According to this study, about half of individuals with type 2 diabetes have adequate levels of knowledge about the disease. In addition, only one out of every five patients has good foot care habits. Diabetes education should emphasise the significance of rigorous adherence to daily foot care practices.

Platelet-rich plasma for the treatment of diabetic foot ulcer: a systematic review

Background

With the increasing incidence of diabetes, diabetic foot ulcer(DFU) has become one of the most common and serious complications in people with diabetes. DFU is associated with significant morbidity and mortality, and can also result in significant economic, social and public health burdens. Due to peripheral neuropathy, peripheral vascular disease, hyperglycemic environment, inflammatory disorders and other factors, the healing of DFU is impaired or delayed, resulting in the formation of diabetic chronic refractory ulcer. Because of these pathological abnormalities in DFU, it may be difficult to promote wound healing with conventional therapies or antibiotics, whereas platelet-rich plasma(PRP) can promote wound healing by releasing various bioactive molecules stored in platelets, making it more promising than traditional antibiotics. Therefore, the purpose of this systematic review is to summarize and analyze the efficacy of PRP in the treatment of DFU.

Methods

A literature search was undertaken in PubMed, CNKI, EMB-ASE, the Cochrane Library, the WanFang Database and the WeiPu Database by computer. Included controlled studies evaluating the efficacy of PRP in the treatment of diabetic foot ulcers. The data extraction and assessment are on the basis of PRISMA.

Results

Twenty studies were evaluated, and nineteen measures for the evaluation of the efficacy of PRP in DFU treatment were introduced by eliminating relevant duplicate measures. The efficacy measures that were repeated in various studies mainly included the rate of complete ulcer healing, the percentage of ulcer area reduction, the time required for ulcer healing, wound complications (including infection rate, amputation rate, and degree of amputation), the rate of ulcer recurrence, and the cost and duration of hospitalization for DFU, as well as subsequent survival and quality of life scores. One of the most important indicators were healing rate, ulcer area reduction and healing time. The meta-analysis found that PRP was significantly improve the healing rate(OR = 4.37, 95% CI 3.02-6.33, P < 0.001) and shorten the healing time(MD = -3.21, 95% CI -3.83 to -2.59,P < 0.001)of patients with DFU when compared to the conventional treatment, but there was no significant difference in reducing the of ulcer area(MD = 5.67, 95% CI -0.77 to 12.11,P =0.08>0.05 ).

Conclusion

The application of PRP to DFU can improve ulcer healing rate and shorten ulcer healing time, but more clinical data are needed to clarify some efficacy measures. At the same time, a standardized preparation process for PRP is essential.

A Miniaturized, Battery-Free, Wireless Wound Monitor That Predicts Wound Closure Rate Early

Diabetic foot ulcers are chronic wounds that affect millions and increase the risk of amputation and mortality, highlighting the critical need for their early detection. Recent demonstrations of wearable sensors enable real-time wound assessment, but they rely on bulky electronics, making them difficult to interface with wounds. Herein, a miniaturized, wireless, battery-free wound monitor that measures lactate in real-time and seamlessly integrates with bandages for conformal attachment to the wound bed is introduced. Lactate is selected due to its multifaceted role in initiating healing. Studies in healthy and diabetic mice reveal distinct lactate profiles for normal and impaired healing wounds. A mathematical model based on the sensor data predicts wound closure rate within the first 3 days post-injury with ≈76% accuracy, which increases to ≈83% when pH is included. These studies underscore the significance of monitoring biomarkers during the inflammation phase, which can offer several benefits, including short-term use of wound monitors and their easy removal, resulting in lower risks of injury and infection at the wound site. Improvements in prediction accuracy can be achieved by designing mathematical models that build on multiple wound parameters such as pro-inflammatory and metabolic markers. Achieving this goal will require designing multi-analyte wound monitors.

Artificial intelligence for automated detection of diabetic foot ulcers: A real-world proof-of-concept clinical evaluation

OBJECTIVE

Conduct a multicenter proof-of-concept clinical evaluation to assess the accuracy of an artificial intelligence system on a smartphone for automated detection of diabetic foot ulcers.

METHODS

The evaluation was undertaken with patients with diabetes (n = 81) from September 2020 to January 2021. A total of 203 foot photographs were collected using a smartphone, analysed using the artificial intelligence system, and compared against expert clinician judgement, with 162 images showing at least one ulcer, and 41 showing no ulcer. Sensitivity and specificity of the system against clinician decisions was determined and inter- and intra-rater reliability analysed.

RESULTS

Predictions/decisions made by the system showed excellent sensitivity (0.9157) and high specificity (0.8857). Merging of intersecting predictions improved specificity to 0.9243. High levels of inter- and intra-rater reliability for clinician agreement on the ability of the artificial intelligence system to detect diabetic foot ulcers was also demonstrated (Kα > 0.8000 for all studies, between and within raters).

CONCLUSIONS

We demonstrate highly accurate automated diabetic foot ulcer detection using an artificial intelligence system with a low-end smartphone. This is the first key stage in the creation of a fully automated diabetic foot ulcer detection and monitoring system, with these findings underpinning medical device development.

Fear of Missing Organisms (FOMO): the discordance among broad-spectrum empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy for diabetic foot infections and lower extremity osteomyelitis

Objective

Empiric broad-spectrum antibiotic therapy is commonly prescribed for patients hospitalized with diabetic foot infections (DFI) and lower extremity osteomyelitis (OM). The primary objective was to evaluate the concordance between empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy with a focus on methicillin-resistant Staphylococcus aureus (MRSA) and resistant gram-negative organisms. The secondary objective was to evaluate the negative predictive values (NPV) of select risk factors for MRSA and resistant gram-negative organisms for microbiologic results with these organisms.

Design

Retrospective cohort study.

Setting

Safety-net health system in Ohio.

Patients

Adults hospitalized and receiving antibiotic therapy for DFI or lower extremity OM in 2021.

Results

For 259 unique patients, empiric therapies with activity against MRSA and resistant gram-negative organisms were administered to 224 (86.5%) and 217 (83.8%) patients, respectively. Definitive therapies with activity against MRSA and resistant gram-negative organisms were administered to 91 (35%) and 74 (28.6%) patients, respectively. Of 234 patients with microbiologic testing, 29 (12.4%) had positive cultures with MRSA and 41 (17.5%) with resistant gram-negative organisms. The NPVs of risk factors for MRSA and resistant gram-negative organisms for the absence of these organisms in culture were 91% and 85%, respectively.

Conclusions

For patients hospitalized with DFI and lower extremity OM, our data suggest opportunities for substantial reductions in empiric therapies with activity against MRSA and resistant gram-negative organisms. The absence of risk factors for these organisms was reasonably good at predicting negative cultures with these organisms.

Use of bioelectric dressings for patients with hard-to-heal wounds: a case report

There are many types of dressings available for the management of hard-to-heal (chronic) wounds. This case report illustrates the efficacy of bioelectric dressings in healing hard-to-heal wounds in five patients. Of the patients, four had diabetic foot ulcers (DFUs) and one had a surgical site infection. Wounds were examined using the TIMES concept and debridement was carried out if needed. Amorphous hydrogel was used as conduction fluid before the application of the bioelectric wound dressings. The wound was covered with foam dressing and crepe bandage. In this case report, among all five wounds, one wound healed completely while the other four reduced in size, with the presence of more granulation and re-epithelialisation. In this case report, bioelectric wound dressings were effective in managing infection and promoting wound healing.

Bacterial profile and antimicrobial resistance patterns of infected diabetic foot ulcers in sub-Saharan Africa: a systematic review and meta-analysis

The number of diabetic foot ulcer patients is substantially increasing, with the rapidly rising burden of diabetic mellitus in sub-Saharan Africa. The data on the regional prevalence of diabetic foot ulcer infecting bacteria and their antimicrobial resistance patterns is crucial for its proper management. This systematic review and meta-analysis determined the pooled prevalence of bacterial profiles and antimicrobial resistance patterns of infected diabetic foot ulcers in sub-Saharan Africa. A comprehensive search of the literature was performed on CINAHL, EMBASE, Google Scholar, PubMed, Scopus, and Web of Science databases. Critical appraisal was done using the Joanna Briggs Institute's tool for prevalence studies. A pooled statistical meta-analysis was conducted using STATA Version 17.0. The I2 statistics and Egger's test were used to assess the heterogeneity and publication bias. The pooled prevalence and the corresponding 95% confidence interval of bacterial profiles and their antimicrobial resistance patterns were estimated using a random effect model. Eleven studies with a total of 1174 study participants and 1701 bacteria isolates were included. The pooled prevalence of the most common bacterial isolates obtained from DFU were S. aureus (34.34%), E. coli (21.16%), and P. aeruginosa (20.98%). The highest pooled resistance pattern of S. aureus was towards Gentamicin (57.96%) and Ciprofloxacin (52.45%). E.coli and K. Pneumoniae showed more than a 50% resistance rate for the most common antibiotics tested. Both gram-positive and gram-negative bacteria were associated with diabetic foot ulcers in sub-Saharan Africa. Our findings are important for planning treatment with the appropriate antibiotics in the region. The high antimicrobial resistance prevalence rate indicates the need for context-specific effective strategies aimed at infection prevention and evidence-based alternative therapies.

Electrostatically assembled wound dressings deliver pro-angiogenic anti-miRs preferentially to endothelial cells

Chronic non-healing wounds occur frequently in individuals affected by diabetes, yet standard-of-care treatment leaves many patients inadequately treated or with recurring wounds. MicroRNA (miR) expression is dysregulated in diabetic wounds and drives an anti-angiogenic phenotype, but miRs can be inhibited with short, chemically-modified RNA oligonucleotides (anti-miRs). Clinical translation of anti-miRs is hindered by delivery challenges such as rapid clearance and uptake by off-target cells, requiring repeated injections, excessively large doses, and bolus dosing mismatched to the dynamics of the wound healing process. To address these limitations, we engineered electrostatically assembled wound dressings that locally release anti-miR-92a, as miR-92a is implicated in angiogenesis and wound repair. In vitro, anti-miR-92a released from these dressings was taken up by cells and inhibited its target. An in vivo cellular biodistribution study in murine diabetic wounds revealed that endothelial cells, which play a critical role in angiogenesis, exhibit higher uptake of anti-miR eluted from coated dressings than other cell types involved in the wound healing process. In a proof-of-concept efficacy study in the same wound model, anti-miR targeting anti-angiogenic miR-92a de-repressed target genes, increased gross wound closure, and induced a sex-dependent increase in vascularization. Overall, this proof-of-concept study demonstrates a facile, translational materials approach for modulating gene expression in ulcer endothelial cells to promote angiogenesis and wound healing. Furthermore, we highlight the importance of probing cellular interactions between the drug delivery system and the target cells to drive therapeutic efficacy.