A case report of an effective treatment for diabetic foot ulcers with integration of traditional Chinese medicine and Western medicine

The wound healing and hypoglycemic activates of date palm (Phoenix dactylifera) leaf extract and saponins in diabetic and normal rats

INTRODUCTION

Indigenous plants have historically been crucial in treating human diseases across various cultures worldwide. Research continues to uncover new therapeutic uses for indigenous plants, from treating infectious diseases to managing chronic conditions such as diabetes and wound care. This study aimed to examine the effect of palm tree leaves "Phoenix dactylifera L" extract and its topical film formulation on wound healing and blood glucose levels.

METHODS

Palm leaves were collected, authenticated, powdered, and extracted with ethanol by cold maceration. Saponins were isolated. The dried extract was analyzed using reverse-phase high-pressure liquid chromatography to identify the phytochemicals present. Diabetes mellitus was induced by a single intraperitoneal injection of Streptozotocin (40mg/kg). Rats with blood glucose levels ≥ 200 mg/dl were used to determine the reduction in blood glucose with or without the oral extract. Incision and excision wounds were induced in both diabetic and normal rats. Topical films containing extract or saponin and inert films were applied to the wounds every other day, and wound sizes were recorded until the wound was completely healed.

RESULTS

The presence of six flavonoids, Naringin, Rutin, Quercetin, Kaempferol, Apigenin, and Catechin, and five phenolic acids, Syringic acid, p Coumaric acid, Caffeic acid, Ferulic acid, Ellagic acid were detected in the dried extract. A significant reduction in blood sugar in diabetic rats and wound diameter in the treated group compared to the control group in both diabetic and normal rats was observed, confirming the promising role of palm leaf extract on diabetes and wound care. Macroscopic, morphometric, and histological data suggested that the cutaneous wound healing in rats treated with the leaf extract was better and faster than the control or inert groups.

CONCLUSIONS

Our research findings highlight the marked effect of Phoenix dactylifera extract as a supportive or alternative treatment for both hyperglycemia and incision or excision wounds. Further research and clinical trials are warranted to validate these findings and explore the underlying mechanisms of action.

Current scenario of traditional medicines in management of diabetic foot ulcers: A review

Diabetic foot infections and diabetic foot ulcers (DFU) cause significant suffering and are often recurring. DFU have three important pathogenic factors, namely, microangiopathy causing local tissue anoxia, neuropathy making the foot prone to injuries from trivial trauma, and local tissue hyperglycaemia favouring infection and delaying the wound healing. DFU have been the leading cause for non-traumatic amputations of part or whole of the limb. Western medicines focus mainly on euglycaemia, antimicrobials, debridement and wound cover with grafts, and off-loading techniques. Advances in euglycaemic control, foot care and footwear, systemic antimicrobial therapy, and overall health care access and delivery, have resulted in an overall decrease in amputations. However, the process of wound care after adequate debridement remains a major cost burden globally, especially in developing nations. This process revolves around two basic concerns regarding control/eradication of local infection and promotion of faster healing in a chronic DFU without recurrence. Wound modulation with various dressings and techniques are often a costly affair. Some aspects of the topical therapy with modern/Western medicines are frequently not addressed. Cost of and compliance to these therapies are important as both the wounds and their treatment are “chronic.” Naturally occurring agents/medications from traditional medicine systems have been used frequently in different cultures and nations, though without adequate clinical base/relevance. Traditional Chinese medicine involves restoring yin-yang balance, regulating the ‘chi’, and promoting local blood circulation. Traditional medicines from India have been emphasizing on ‘naturally’ available products to control wound infection and promote all the aspects of wound healing. There is one more group of chemicals which are not pharmaceutical agents but can create acidic milieu in the wound to satisfy the above-mentioned basic concerns. Various natural and plant derived products (e.g., honey, aloe vera, oils, and calendula) and maggots are also used for wound healing purposes. We believe that patients with a chronic wound are so tired physically, emotionally, and financially that they usually accept native traditional medicine which has the same cultural base, belief, and faith. Many of these products have never been tested in accordance to “evidence-based medicine.” There are usually case reports and experience-based reports about these products. Recently, there have been some trials (in vitro and in vivo) to verify the claims of usage of traditional medicines in management of DFU. Such studies show that these natural products enhance the healing process by controlling infection, stimulating granulation tissue, antimicrobial action, promoting fibroblastic activity and collagen deposition, etc. In this review, we attempt to study and analyse the available literature on results of topical traditional medicines, which are usually advocated in the management of DFU. An integrated and ‘holistic’ approach of both modern and traditional medicine may be more acceptable to the patient, cost effective, and easy to administer and monitor. This may also nevertheless lead to further improvement in quality of life and decrease in the rates of amputations for DFU.

Exploration of the Specific Pathology of HXMM Tablet Against Retinal Injury Based on Drug Attack Model to Network Robustness

Retinal degenerative diseases are related to retinal injury because of the activation of the complement cascade, oxidative stress-induced cell death mechanisms, dysfunctional mitochondria, chronic neuroinflammation, and production of the vascular endothelial growth factor. Anti-VEGF therapy demonstrates remarkable clinical effects and benefits in retinal degenerative disease patients. Hence, new drug development is necessary to treat patients with severe visual loss. He xue ming mu (HXMM) tablet is a CFDA-approved traditional Chinese medicine (TCM) for retinal degenerative diseases, which can alleviate the symptoms of age-related macular degeneration (AMD) and diabetic retinopathy (DR) alone or in combination with anti-VEGF agents. To elucidate the mechanisms of HXMM, a quantitative evaluation algorithm for the prediction of the effect of multi-target drugs on the disturbance of the disease network has been used for exploring the specific pathology of HXMM and TCM precision positioning. Compared with anti-VEGF agents, the drug disturbance of HXMM on the functional subnetwork shows that HXMM reduces the network robustness on the oxidative stress subnetwork and inflammatory subnetwork to exhibit the anti-oxidation and anti-inflammation activity. HXMM provides better protection to ARPE-19 cells against retinal injury after H₂O₂ treatment. HXMM can elevate GSH and reduce LDH levels to exhibit antioxidant activity and suppress the expression of IL-6 and TNF-α for anti-inflammatory activity, which is different from the anti-VEGF agent with strong anti-VEGF activity. The experimental result confirmed the accuracy of the computational prediction. The combination of bioinformatics prediction based on the drug attack on network robustness and experimental validation provides a new strategy for precision application of TCM.

Integration of traditional Chinese medicine and nibble debridement and dressing method reduces thrombosis and inflammatory response in the treatment of thromboangiitis obliterans

Background

Thromboangiitis obliterans (TAO), also known as Buerger's disease, is an occlusive arterial disease; however, the pathogenesis of TAO is still unclear. Research has shown that traditional Chinese medicine (TCM) has significant advantages in the treatment of TAO. Our purpose was to explore the underlying roles of TCM in combination with nibble debridement and dressing method (NDDM) in a TAO rat model.

Methods

We administered rats with 10 mg/mL sodium laurate to establish a TAO model, and then the TAO model rats were treated with notoginseng powder (NP), maifusheng (MFS), or the combination of NP or MFS and NDDM. Gangrene classification and blood rheology were evaluated; the pathological characteristics of rat limbs were examined by hematoxylin and eosin (H&E) staining and Masson staining; and cluster of differentiation 3+ (CD3+) and cluster of differentiation 20+ (CD20+) levels were measured by immunohistochemistry (IHC) and flow cytometry. In addition, inflammation-associated cytokines were analyzed by quantitative reverse transcription polymerase chain reaction (RT-qPCR), western blot, and enzyme-linked immunosorbent assay (ELISA).

Results

Integration of NP or MFS and NDDM dramatically reduced the gangrene classification and affected blood rheology parameters of TAO model rats compared with NP and MFS alone. Meanwhile, NP or MFS in combination with NDDM decreased CD3+CD20+ T cells, reduced thrombosis and inflammatory cell infiltration, and dramatically decreased the levels of inflammation-associated cytokines.

Conclusions

Our results suggested that integration of NP or MFS and NDDM could relieve the symptoms of TAO model rats induced by sodium laurate, which might provide a new management strategy for TAO.

Traditional Chinese Medicine in Emergency Treatment Mechanism and Application

Traditional Chinese medicine has usually been recognized to be efficacious to treat chronic diseases from the western point-of-view. However, there is a long history in China of applying traditional Chinese medicine in many acute and urgent medical conditions. In this review, selected methods documented in traditional Chinese medicine including blowing air to ear, nose insufflating therapy, acupuncture and moxibustion were presented as the common practices to promote consciousness recovery from coma. We aimed to explore the mechanism of these four methods with current scientific evidence, further discuss the potential of traditional Chinese medicine to be applied in emergency medicine and provide a path forward to more rigorously validate these procedures. The development of the integrated traditional Chinese medicine and western medicines provides a new therapeutic direction for the new first-aid treatment.

Caribbean “substitution culture” is a barrier to effective treatment of persons with diabetic foot infections

Diabetes-related amputation rates are high in the Caribbean. Many authorities have identified independent risk factors for diabetes-related amputations, but cultural factors remain underappreciated. We coined the term “Caribbean substitution culture” to describe the attitude of patients with diabetic foot infections in which they refuse to access medical care, instead voluntarily choosing to substitute “bush medicines” or other alternative therapies in the place of conventional treatment. Recognizing that the Caribbean substitution culture is a barrier to effective treatment of diabetic foot infections is the first step in curbing these practices. In this paper, we discuss the issues related to the Caribbean substitution culture, including the demographics of the population at risk, the alternative therapeutic practices and potential public health strategies to combat this practice.

Chemistry, pharmacology and analysis of Pseudostellaria heterophylla: a mini-review

Pseudostellaria heterophylla is one of the well-known traditional Chinese medicines and has been used in clinics for 100 years in China. The chemistry and pharmacology of P. heterophylla were reviewed to understand its active compounds. Then analysis of these compounds related to quality control of this herb was discussed. For the analysis of chemicals, three aspects have been discussed in this review. The first two aspects focused on the methodologies for analysis of cyclic peptides and carbohydrates in P. heterophylla, respectively. The last one dealt with the other methods used for identification of P. heterophylla. Some rich chemicals such as oligosaccharides in this plant were rarely evaluated. Many analyses were performed on this plant, however, few of them were accepted as quality control method.

Employing observational method for prospective data collection: A case study for analyzing diagnostic process and evaluating efficacy of TCM treatments for diabetes mellitus

ETHNOPHARMACOLOGICAL RELEVANCE

With the mounting pandemic of glucose metabolism dysregulation and type 2 Diabetes Mellitus (T2DM), traditional medicine such as traditional Chinese medicine (TCM) recipes has been widely adopted as a part of therapeutic approach, especially in Asian countries.

AIM OF THE STUDY

A novel approach, which is adopted from cohort studies from epidemiology has been applied to explore the clinical efficacy, as well as the herbal component selection of a variety of TCM formulations against T2DM.

MATERIALS AND METHODS

In the current study, 98 newly diagnosed T2DM patients were recruited in two hospitals. Over a span of 4 weeks, the patients were treated by prescriptions of their individual TCM physicians. General TCM symptoms, blood glucose parameters, as well as general metabolic health biomarkers were evaluated over the therapy period. The pattern of which herbs were used, together with association between blood glucose level change and the use of herbs, were analyzed.

RESULTS

TCM diabetic syndrome diagnosis was made by physicians based on symptoms, who prescribed herbal TCM medication afterwards for individual subjects. The results showed significant reduction in fasting and postmeal glucose levels, as well as insulin after the TCM treatment regimen as compared to baseline. As secondary endpoint, total triglyceride level decreased over the period of study as well. Kudzuvine root, Rhemannia root, Figwoot root, and Mulberry leaf were the top herbs associated with pronounced glucose reduction.

CONCLUSIONS

In conclusion, an observational study on a cohort of patients receiving TCM therapy has shown good clinical outcome for T2DM patients receiving TCM treatments. Association analysis on herbal usage and clinical outcome suggested opportunity in constructing optimized formulation for superior efficacy with future studies at a larger scale.

Ozone therapy for treating foot ulcers in people with diabetes

BACKGROUND

It has been reported that ozone therapy might be helpful in treating foot ulcers in people with diabetes mellitus (DM).

OBJECTIVES

To assess the effects of ozone therapy on the healing of foot ulcers in people with DM.

SEARCH METHODS

In March 2015 we searched: The Cochrane Wounds Group Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid EMBASE, EBSCO CINAHL, Science Citation Index, Chinese Biomedical Literature Database and The Chinese Clinical Registry. There were no restrictions based on language, date or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared ozone therapy with sham ozone therapy or any other interventions for foot ulcers in people with DM, irrespective of publication date or language.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened all retrieved citations, selected relevant citations and extracted data. Disagreements were resolved by discussion with a third reviewer. The methodological quality of included studies and the evidence level of outcomes were assessed using the Cochrane risk of bias tool and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach respectively. Data were expressed using risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with their 95% confidence interval (95% CI). Review Manager (RevMan) software was used to analyse the data.

MAIN RESULTS

Three studies (212 participants) were included in this review. The overall risk of bias was high for two trials and unclear for one.One trial (101 participants) compared ozone treatment with antibiotics for foot ulcers in people with DM. The study had a follow-up period of 20 days. This study showed that ozone treatment was associated with a greater reduction in ulcer area from baseline to the end of the study than treatment with antibiotics (MD -20.54 cm(2), 95% CI -20.61 to -20.47), and a shorter duration of hospitalisation (MD -8.00 days, 95% CI -14.17 to -1.83), but did not appear to affect the number of ulcers healed over 20 days (RR 1.10, 95% CI 0.87 to 1.40). No side effects were observed in either group.The other two trials (111 participants) compared ozone treatment plus usual care with usual care for foot ulcers in people with DM. The meta-analysis results did not show evidence of a difference between groups for the outcomes of reduction of ulcer area (MD -2.11 cm(2), 95% CI -5.29 to 1.07), the number of ulcers healed (RR 1.69, 95% CI 0.90 to 3.17), adverse events (RR 2.27, 95% CI 0.48 to 10.79), or amputation rate (RR 2.73, 95%CI 0.12, 64.42).

AUTHORS' CONCLUSIONS

The available evidence was three small RCTs with unclear methodology, so we are unable to draw any firm conclusions regarding the effectiveness of ozone therapy for foot ulcers in people with DM.

Adverse events in diabetic foot infections: a case control study comparing early versus delayed medical treatment after home remedies

Background

The aim of conventional medical therapy in diabetic foot infections is to control infection, thereby reducing amputation rates, infectious morbidity, and death. Any delay incurred during a trial of home remedies could allow an infection to progress unchecked, increasing the risk of these adverse outcomes. This study sought to determine the effects of delayed operative interventions and amputations in these patients.

Methods

A questionnaire study targeting all consecutive patients admitted with diabetic foot infection was carried out over 1 year. Two groups were defined, ie, a medical therapy group comprising patients who sought medical attention after detecting their infection and a home remedy group comprising those who voluntarily chose to delay medical therapy in favor of home remedies. The patients were followed throughout their hospital admissions. We recorded the duration of hospitalization and number of operative debridements and amputations performed.

Results

There were 695 patients with diabetic foot infections, comprising 382 in the medical therapy group and 313 in the home remedy group. Many were previously hospitalized for foot infections in the medical therapy (78%) and home remedy (74.8%) groups. The trial of home remedies lasted for a mean duration of 8.9 days. The home remedy group had a longer duration of hospitalization (16.3 versus 8.5 days; P<0.001), more operative debridements (99.7% versus 94.5%; P<0.001), and more debridements per patient (2.85 versus 2.45; P<0.001). Additionally, in the home remedy group, there was an estimated increase in expenditure of US $10,821.72 US per patient and a trend toward more major amputations (9.3% versus 5.2%; P=0.073).

Conclusion

There are negative outcomes when patients delay conventional medical therapy in favour of home remedies to treat diabetic foot infections. These treatments need not be mutually exclusive. We encourage persons with diabetes who wish to try home remedies to seek medical advice in addition as a part of holistic care.

Troxerutin improves hepatic lipid homeostasis by restoring NAD(+)-depletion-mediated dysfunction of lipin 1 signaling in high-fat diet-treated mice

Recent evidences suggest that NAD(+) depletion leads to abnormal hepatic lipid metabolism in high-fat diet (HFD)-induced nonalcoholic fatty liver disease (NAFLD); however, the contributing mechanism is not well understood. Our previous study showed that troxerutin, a trihydroxyethylated derivative of natural bioflavonoid rutin, effectively inhibited obesity, and normalized hyperglycemia and hyperlipidemia in high-cholesterol diet-induced diabetic mice. Here we investigated whether troxerutin improved hepatic lipid metabolism via preventing NAD(+) depletion in HFD-induced NAFLD mouse model and the mechanisms underlying these effects. Our results showed that troxerutin markedly prevented obesity, liver steatosis and injury in HFD-fed mice. Troxerutin largely suppressed oxidative stress-mediated NAD(+)-depletion by increasing nicotinamide phosphoribosyltransferase (NAMPT) protein expression and decreasing poly (ADP-ribose) polymerase-1 (PARP1) protein expression and activity in HFD-treated mouse livers. Consequently, troxerutin remarkably restored Silent mating type information regulation 2 homolog1 (SirT1) protein expression and activity in HFD-treated mouse livers. Therefore, troxerutin promoted SirT1-mediated AMP-activated protein kinase (AMPK) activation to inhibit mammalian target of rapamycin complex 1 (mTORC1) signaling, which enhanced nuclear lipin 1 localization, lowered cytoplasmic lipin 1 localization and the ratio of hepatic Lpin 1β/α. Ultimately, troxerutin improved lipid homeostasis by enhancing fatty acid oxidation and triglyceride secretion, and suppressing lipogenesis in HFD-fed mouse livers. In conclusion, troxerutin displayed beneficial effects on hepatic lipid homeostasis in HFD-induced NAFLD by blocking oxidative stress to restore NAD(+)-depletion-mediated dysfunction of lipin 1 signaling. This study provides novel mechanistic insights into NAFLD pathogenesis and indicates that troxerutin is a candidate for pharmacological intervention of NAFLD via restoring NAD(+) levels.

Inflammatory state of type II diabetic patients with chronic ulcers in response to herbal treatment

BACKGROUND

Type II diabetic patients easily develop ulcers over their feet which heal with great difficulties and not infrequently, end up in amputations. In the quest for innovative means to avoid amputation, herbal medicine has been used in China to heal ulcers.

METHOD

A randomized placebo controlled clinical trial involving 80 patients was conducted to test whether a herbal formula taken orally could help to preserve the ulcerated leg. Other parameters measured included granulation maturation time, skin temperature and circulation, and tumor necrosis factor alpha (TNF-α).

RESULTS

showed a 85% limb rescue with the herbal treatment group showing superiority over placebo group. TNF-α decline was observed with gradual ulcer healing and the herbal supplement group showed a more impressive decline (p=0.037).

Urine metabolomics combined with the personalized diagnosis guided by Chinese medicine reveals subtypes of pre-diabetes

The prevalence of type 2 diabetes continuously increases globally. A personalized strategy applied in the pre-diabetic stage is vital for diabetic prevention and management. The personalized diagnosis of Chinese Medicine (CM) may help to stratify the diabetics. Metabolomics is regarded as a potential platform to provide biomarkers for disease-subtypes. We designed an explorative study of 50 pre-diabetic males, combining GC-MS urine metabolomics with CM diagnosis in order to identify diagnostic biomarkers for pre-diabetic subtypes. Three CM physicians reached 85% diagnosis consistency resulting in the classification of 3 pre-diabetic groups. The urine metabolic patterns of groups 1 'Qi-Yin deficiency' and 2 'Qi-Yin deficiency with dampness' (subtype A) and group 3 'Qi-Yin deficiency with stagnation' (subtype B) were clearly discriminated. The majority of metabolites (51%), mainly sugars and amino acids, showed higher urine levels in subtype B compared with subtype A. This indicated more disturbances of carbohydrate metabolism and renal function in subtype B compared with subtype A. No differences were found for hematological and biochemical parameters except for levels of glucose and γ-glutamyltransferase that were significantly higher in subtype B compared with subtype A. This study proved that combining metabolomics with CM diagnosis can reveal metabolic signatures for pre-diabetic subtypes. The identified urinary metabolites may be of special clinical relevance for non-invasive screening for subtypes of pre-diabetes, which could lead to an improvement in personalized interventions for diabetics.

Is oral administration of Chinese herbal medicine effective and safe as an adjunctive therapy for managing diabetic foot ulcers? A systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to assess the effectiveness and safety of Chinese herbal medicine (CHM) as an adjunctive method to standard therapy for patients with diabetic foot ulcers (DFU).

METHODS

Randomized controlled trials (RCTs) of CHM to treat DFU were searched in the following electronic databases: MEDLINE; EMBASE; Chinese Biomedical Database (CBM); Cochrane Central Register of Controlled Trials (CENTRAL); Allied & Complementary Medicine Resources (AMED); and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Two (2) researchers independently assessed the quality and validity of included trials and extracted outcome data for synthesis.

RESULTS

Six (6) trials were included for analysis. Compared to using standard therapy alone, CHM combined with standard therapy significantly increased the number of patients whose ulcers healed (risk ratio [RR], 0.62, [95% confidence interval (CI), 0.39-0.97]) and number of patients with at least a 30% reduction in the ulcer area (RR, 0.81 [95%CI, 0.71-0.92]). In addition, the two therapies combined significantly decreased the number of patients without any improvement (RR, 0.34 [95%CI, 0.21-0.53]). However, with respect to blood flow volume in the dorsal artery of the foot, no significant difference between the two therapies was observed (standardized mean difference, 1.71 [95% CI -1.25-4.67]), but the result favored the CHM combined with standard therapy group. Only 2 of 6 trials reported adverse events, which included nausea, epigastric pain, and dry mouth.

CONCLUSIONS

CHM may be effective and safe as an adjunctive therapy for treating DFU. However, a firm conclusion could not be reached because of the poor quality of the included trials. Further trials with higher quality are justified.