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Ciaramella M, LoGerfo F, Liang P. Lower Extremity Bypass for Occlusive Disease: A Brief History. Ann Vasc Surg 2024; 107:17-30. [PMID: 38582212 DOI: 10.1016/j.avsg.2023.11.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 04/08/2024]
Abstract
BACKGROUND This is a narrative review that aims to highlight key advancements that led to the current state of lower extremity bypass surgery. It focuses on key contributors during the last century who have driven the standardization of surgical treatment of peripheral arterial occlusive disease. METHODS A narrative review was conducted utilizing available resources in the scientific and historical literature to track landmark achievements in the development of modern lower extremity bypass surgery for occlusive disease, focusing primarily on the last century of advancement. RESULTS Several critical conceptual, technological, and technical landmarks were identified as critical components of modern lower extremity bypass surgery. This includes fundamental developments in the techniques of vascular anastomosis led by Carrel and others, a developing understanding of vascular occlusive disease as a localized and segmental process with broad implementation of the techniques of arteriography, and the development of safe thromboendarterectomy aided by the development and utilization of heparin for anticoagulation. These factors led to the first femoral-to-popliteal artery bypass by Jean Kunlin in 1948. From here, advances in vascular prosthetic material pioneered by Voorhees and others, alternative vascular conduits, increasing acceptance of tibial revascularization, and dispelling the myth of diabetic "small vessel" disease broadened revascularization options for patients with complex patterns of occlusive disease and those who have limited conduit availability. CONCLUSIONS Modern lower extremity bypass surgery for occlusive disease arose steadily over a course of a century, driven by complex problem-solving in the pathophysiological understanding of atherosclerosis, technical developments in vascular anastomosis and arteriography, and evolution of conduit materials and pharmacologic therapy. Future advancements in bypass surgery are targeted at solving the complex problems of anastomotic intimal hyperplasia, expanding technology for alternative vascular conduits, ongoing optimization of risk factors, and scrutinizing of outcomes to make patient-centered, evidence-based decisions regarding revascularization strategy.
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Affiliation(s)
- Michael Ciaramella
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Frank LoGerfo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Chauhan S, Jhawat V, Singh RP, Yadav A. Topical delivery of insulin using novel organogel formulations: An approach for the management of diabetic wounds. Burns 2024; 50:1068-1082. [PMID: 38350788 DOI: 10.1016/j.burns.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/06/2023] [Accepted: 01/10/2024] [Indexed: 02/15/2024]
Abstract
Diabetes mellitus is a growing chronic form of diabetes, with lengthy health implications. It is predicted as poor diabetic wound recovery affects roughly 25% of all diabetes mellitus patients, frequently resulting in lower traumatic injury and severe external factors and emotional expenses. The insulin-resistant condition increases biofilm development, making diabetic wounds harder to treat. Nowadays, medical treatment and management of diabetic wounds, which have a significant amputation rate, a high-frequency rate, and a high death rate, have become a global concern. Topical formulations have played a significant part in diabetic wound management and have been developed to achieve a number of features. Because of its significant biocompatibility, moisture retention, and therapeutic qualities, topical insulin has emerged as an appealing and feasible wound healing process effector. With a greater comprehension of the etiology of diabetic wounds, numerous functionalized topical insulins have been described and shown good outcomes in recent years, which has improved some diabetic injuries. The healing of wounds is a physiological phenomenon that restores skin integrity and heals damaged tissues. Insulin, a powerful wound-healing factor, is also used in several experimental and clinical studies accelerate healing of diverse injuries.
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Affiliation(s)
- Sunita Chauhan
- Department of Pharmaceutical Science, School of Medical and Allied Science, GD Goenka University, Gurugram, Haryana, India
| | - Vikas Jhawat
- Department of Pharmaceutical Science, School of Medical and Allied Science, GD Goenka University, Gurugram, Haryana, India.
| | - Rahul Pratap Singh
- Department of Pharmaceutical Science, School of Medical and Allied Science, GD Goenka University, Gurugram, Haryana, India
| | - Abhishek Yadav
- Department of Pharmaceutical Science, School of Medical and Allied Science, GD Goenka University, Gurugram, Haryana, India
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Hofmann AG, Deinsberger J, Oszwald A, Weber B. The Histopathology of Leg Ulcers. Dermatopathology (Basel) 2024; 11:62-78. [PMID: 38390849 PMCID: PMC10885126 DOI: 10.3390/dermatopathology11010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Ulcerations of the lower extremities are a frequently encountered problem in clinical practice and are of significant interest in public health due to the high prevalence of underlying pathologies, including chronic venous disease, diabetes and peripheral arterial occlusive disease. However, leg ulcers can also present as signs and symptoms of various rare diseases and even as an adverse reaction to drugs. In such cases, correct diagnosis ultimately relies on histopathological examination. Apart from the macroscopic presentation, patient history and anatomic location, which are sometimes indicative, most ulcers have very distinct histopathological features. These features are found in different layers of the skin or even associated vessels. In this narrative review, we discuss and highlight the histopathological differences of several types of leg ulcers that can contribute to efficient and accurate diagnosis.
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Affiliation(s)
- Amun Georg Hofmann
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Julia Deinsberger
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - André Oszwald
- Department of Pathology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Benedikt Weber
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Du H, Li S, Lu J, Tang L, Jiang X, He X, Liang J, Liao X, Cui T, Huang Y, Liu H. Single-cell RNA-seq and bulk-seq identify RAB17 as a potential regulator of angiogenesis by human dermal microvascular endothelial cells in diabetic foot ulcers. BURNS & TRAUMA 2023; 11:tkad020. [PMID: 37605780 PMCID: PMC10440157 DOI: 10.1093/burnst/tkad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 01/10/2023] [Accepted: 03/22/2023] [Indexed: 08/23/2023]
Abstract
Background Angiogenesis is crucial in diabetic wound healing and is often impaired in diabetic foot ulcers (DFUs). Human dermal microvascular endothelial cells (HDMECs) are vital components in dermal angiogenesis; however, their functional and transcriptomic characteristics in DFU patients are not well understood. This study aimed to comprehensively analyse HDMECs from DFU patients and healthy controls and find the potential regulator of angiogenesis in DFUs. Methods HDMECs were isolated from skin specimens of DFU patients and healthy controls via magnetic-activated cell sorting. The proliferation, migration and tube-formation abilities of the cells were then compared between the experimental groups. Both bulk RNA sequencing (bulk-seq) and single-cell RNA-seq (scRNA-seq) were used to identify RAB17 as a potential marker of angiogenesis, which was further confirmed via weighted gene co-expression network analysis (WGCNA) and least absolute shrink and selection operator (LASSO) regression. The role of RAB17 in angiogenesis was examined through in vitro and in vivo experiments. Results The isolated HDMECs displayed typical markers of endothelial cells. HDMECs isolated from DFU patients showed considerably impaired tube formation, rather than proliferation or migration, compared to those from healthy controls. Gene set enrichment analysis (GSEA), fGSEA, and gene set variation analysis (GSVA) of bulk-seq and scRNA-seq indicated that angiogenesis was downregulated in DFU-HDMECs. LASSO regression identified two genes, RAB17 and CD200, as characteristic of DFU-HDMECs; additionally, the expression of RAB17 was found to be significantly reduced in DFU-HDMECs compared to that in the HDMECs of healthy controls. Overexpression of RAB17 was found to enhance angiogenesis, the expression of hypoxia inducible factor-1α and vascular endothelial growth factor A, and diabetic wound healing, partially through the mitogen-activated protein kinase/extracellular signal-regulated kinase signalling pathway. Conclusions Our findings suggest that the impaired angiogenic capacity in DFUs may be related to the dysregulated expression of RAB17 in HDMECs. The identification of RAB17 as a potential molecular target provides a potential avenue for the treatment of impaired angiogenesis in DFUs.
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Affiliation(s)
- Hengyu Du
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou 510630, P.R. China
| | - Shenghong Li
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou 510630, P.R. China
| | - Jinqiang Lu
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou 510630, P.R. China
| | - Lingzhi Tang
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou 510630, P.R. China
| | - Xiao Jiang
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou 510630, P.R. China
| | - Xi He
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou 510630, P.R. China
| | - Jiaji Liang
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou 510630, P.R. China
| | - Xuan Liao
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou 510630, P.R. China
| | - Taixing Cui
- Dalton Cardiovascular Research Center, Department of Medical Pharmacology and Physiology, University of Missouri, School of Medicine, 134 Research Park Dr, Columbia, MO 65211, USA
| | - Yuesheng Huang
- Institute of Wound Repair and Regeneration Medicine, Southern University of Science and Technology School of Medicine, and Department of Wound Repair, Southern University of Science and Technology Hospital, Shenzhen, Guangdong, 518055, China
| | - Hongwei Liu
- Department of Plastic Surgery of the First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine of Ministry of Education, Guangzhou 510630, P.R. China
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Matijević T, Talapko J, Meštrović T, Matijević M, Erić S, Erić I, Škrlec I. Understanding the multifaceted etiopathogenesis of foot complications in individuals with diabetes. World J Clin Cases 2023; 11:1669-1683. [PMID: 36970006 PMCID: PMC10037285 DOI: 10.12998/wjcc.v11.i8.1669] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
Diabetes mellitus, a chronic disease of metabolism, is characterized by a disordered production or cellular utilization of insulin. Diabetic foot disease, which comprises the spectrum of infection, ulceration, and gangrene, is one of the most severe complications of diabetes and is the most common cause of hospitalization in diabetic patients. The aim of this study is to provide an evidence-based overview of diabetic foot complications. Due to neuropathy, diabetic foot infections can occur in the form of ulcers and minor skin lesions. In patients with diabetic foot ulcers, ischemia and infection are the main causes of non-healing ulcers and amputations. Hyperglycemia compromises the immune system of individuals with diabetes, leading to persistent inflammation and delayed wound healing. In addition, the treatment of diabetic foot infections is challenging due to difficulty in accurate identification of pathogenic microorganisms and the widespread issue of antimicrobial resistance. As a further complicating factor, the warning signs and symptoms of diabetic foot problems can easily be overlooked. Issues associated with diabetic foot complications include peripheral arterial disease and osteomyelitis; accordingly, the risk of these complications in people with diabetes should be assessed annually. Although antimicrobial agents represent the mainstay of treatment for diabetic foot infections, if peripheral arterial disease is present, revascularization should be considered to prevent limb amputation. A multidisciplinary approach to the prevention, diagnosis, and treatment of diabetic patients, including those with foot ulcers, is of the utmost importance to reduce the cost of treatment and avoid major adverse consequences such as amputation.
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Affiliation(s)
- Tatjana Matijević
- Department of Dermatology and Venereology, University Hospital Center Osijek, Osijek 31000, Croatia
| | - Jasminka Talapko
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
| | - Tomislav Meštrović
- University Centre Varaždin, University North, Varaždin 42000, Croatia
- Institute for Health Metrics and Evaluation and the Department for Health Metrics Sciences, University of Washington School of Medicine, Seattle, WA 98195, United States
| | - Marijan Matijević
- Department of Surgery, National Memorial Hospital Vukovar, Vukovar 32000, Croatia
| | - Suzana Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Radiotherapy and Oncology, Clinical Hospital Center Osijek, Osijek 31000, Croatia
| | - Ivan Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Surgery, Osijek University Hospital Centre, Osijek 31000, Croatia
| | - Ivana Škrlec
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
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Zhou PB, Bao M. Clinical Effect Analysis of Spinal Cord Electrical Stimulator Implantation for Diabetic Foot. Neuromodulation 2023; 26:246-251. [PMID: 34270842 DOI: 10.1111/ner.13502] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/28/2021] [Accepted: 06/29/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To investigate the clinical effect of spinal cord electrical stimulator implantation in the treatment of a diabetic foot (DF). MATERIALS AND METHODS We recruited 19 patients with DF who were admitted to Shengjing Hospital of China Medical University between January 2018 and May 2020. All the patients were treated with spinal cord electrical stimulator implantation. Skin temperature, degree of pain, quality of life (QOL) score, limb (toe) preservation, and nerve conduction velocity of the patients were compared pre- and postoperatively. RESULTS The diameter and peak velocity of multisegment arteries in the lower limbs had significantly increased post surgery. Foot skin temperature significantly increased in patients with good effect. The postoperative visual analog scale score of the patients was significantly lower than that noted preoperatively (p < 0.05). The conduction velocities of the lower limb sensory nerves (eg, superficial peroneal nerve and sural nerve) and motor nerves (eg, common peroneal nerve and tibial nerve) had improved post surgery. Moreover, patients' QOL score had significantly improved postoperatively (p < 0.05). The limb (toe) salvage rate was 94.74%. CONCLUSION The implantation of a spinal cord electrical stimulator for treating DF can effectively relieve pain and other associated symptoms. Additionally, this device can promote nerve function recovery and lower limb blood supply and reduce the risk of toe amputation; therefore, it is clinically effective and should be considered in the treatment of DF.
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Affiliation(s)
- Peng-Bo Zhou
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Min Bao
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China.
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Wu H, Ni R, Shi Y, Hu Y, Shen Z, Pang Q, Zhu Y. The Promising Hydrogel Candidates for Preclinically Treating Diabetic Foot Ulcer: A Systematic Review and Meta-Analysis. Adv Wound Care (New Rochelle) 2023; 12:28-37. [PMID: 35229628 DOI: 10.1089/wound.2021.0162] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Significance: Diabetic foot ulcer (DFU) causes high amputation rates owing to its aberrant wound healing. Traditional dressings cannot effectively contribute to DFU healing. Functional hydrogels have been proposed as a promising novel dressing to treat DFU in future, but the evidence for various hydrogels to heal DFU is still ambiguous. Recent Advances: In accordance with PRISMA and CONSORT guidelines, a meta-analysis was performed to evaluate the efficacy of functional hydrogels. Four electronic databases and one website were used for data searching. Twenty-four animal studies and six clinical trials met the inclusion criteria with a total of 399 diabetic murine models and 278 patients with DFU. Critical Issues: Functional hydrogels accelerated the healing progress for DFU and relieved symptoms in patients. According to their characteristics, the functional hydrogels were divided into antioxidant hydrogel (AOH), antibacterial hydrogel (ABH), multifunctional hydrogel (MFH), proangiogenic hydrogel, and hydrogel promoting proliferation (PPH). By network meta-analysis, AOH and MFH were considered the premium options for treating wounds of diabetic patients at whole stage. Future Direction: Functional hydrogels effectively accelerate healing rates in wounds of diabetic animals. Hydrogels of AOH and MFH might become the ideal candidates for clinical trials on DFU treatment, based on the meta-analyses from the reported work. Early treatment with AOH followed a week later with ABH, which might become an advanced strategy for DFU in future. This information is very important for researchers or/and physicians in taking consideration for alternate application of hydrogel dressings. Scope and Significance: The treatment of DFU imposes a huge burden on medical workers. If DFU is not treated properly, patients will have to suffer from amputation and from spiritual agony. Although various topical dressings have been designated for DFU, the healing ability of those dressings is still unknown well. In this review and meta-analysis, we quantitatively evaluated the reported outcomes of functional hydrogels, pure scaffolds, and controls in 2-week interval. Healing ability of various kinds of functional hydrogels was also assessed in different stages of wound, aiming to screen promising candidates for DFU treatment. This information is valuable in designing smart dressings for researchers or/and physicians in future. Translational Relevance: Considering many external factors like formation of bacterial film and internal factors like hyperglycemia, the progress during DFU healing could involve many biochemical aspects. Persistent inflammation, oxidation stress, and impaired angiogenesis lead to prolonged wound healing and even lethal outcomes. Thus, improvement of topical conditions and inhibition of adverse factors will lead to the alleviated morbidity and even mortality. Clinical Relevance: DFU brings about great burden on patients and medical staffs because of high morbidity and poor prognosis. Improper and powerless treatment might induce high rates of amputation and mortality. Functional hydrogels, mimicking extracellular matrices, would provide the tissue with suitable media and functions to promote DFU healing. The application of various types of hydrogels could be a promising solution to heal DFU and reduce adverse events and costs.
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Affiliation(s)
- HaiJian Wu
- School of Medicine, Ningbo University, Ningbo, China
| | - Renhao Ni
- School of Medicine, Ningbo University, Ningbo, China
| | - Ying Shi
- Department of Hepatobiliary and Pancreatic Surgery, Ningbo First Hospital, Ningbo, China
| | - Yiwei Hu
- School of Medicine, Ningbo University, Ningbo, China
| | - Zhisen Shen
- Department of Otorhinolaryngology and Head and Neck Surgery, Ningbo Medical Center Lihuili Hospital Affiliated to Ningbo University, Ningbo, China
| | - Qian Pang
- School of Medicine, Ningbo University, Ningbo, China
| | - Yabin Zhu
- School of Medicine, Ningbo University, Ningbo, China
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Chakraborty R, Borah P, Dutta PP, Sen S. Evolving spectrum of diabetic wound: Mechanistic insights and therapeutic targets. World J Diabetes 2022; 13:696-716. [PMID: 36188143 PMCID: PMC9521443 DOI: 10.4239/wjd.v13.i9.696] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/12/2022] [Accepted: 08/18/2022] [Indexed: 02/05/2023] Open
Abstract
Diabetes mellitus is a chronic metabolic disorder resulting in an increased blood glucose level and prolonged hyperglycemia, causes long term health conse-quences. Chronic wound is frequently occurring in diabetes patients due to compromised wound healing capability. Management of wounds in diabetic patients remains a clinical challenge despite many advancements in the field of science and technology. Increasing evidence indicates that alteration of the biochemical milieu resulting from alteration in inflammatory cytokines and matrix metalloproteinase, decrease in fibroblast and keratinocyte functioning, neuropathy, altered leukocyte functioning, infection, etc., plays a significant role in impaired wound healing in diabetic people. Apart from the current pharmacotherapy, different other approaches like the use of conventional drugs, antidiabetic medication, antibiotics, debridement, offloading, platelet-rich plasma, growth factor, oxygen therapy, negative pressure wound therapy, low-level laser, extracorporeal shock wave bioengineered substitute can be considered in the management of diabetic wounds. Drugs/therapeutic strategy that induce angiogenesis and collagen synthesis, inhibition of MMPs, reduction of oxidative stress, controlling hyperglycemia, increase growth factors, regulate inflammatory cytokines, cause NO induction, induce fibroblast and keratinocyte proliferation, control microbial infections are considered important in controlling diabetic wound. Further, medicinal plants and/or phytoconstituents also offer a viable alternative in the treatment of diabetic wound. The focus of the present review is to highlight the molecular and cellular mechanisms, and discuss the drug targets and treatment strategies involved in the diabetic wound.
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Affiliation(s)
- Raja Chakraborty
- Institute of Pharmacy, Assam Don Bosco University, Kamrup 782402, Assam, India
| | - Pobitra Borah
- School of Pharmacy, Graphic Era Hill University, Dehradun 248002, Uttarakhand, India
| | - Partha Pratim Dutta
- Faculty of Pharmaceutical Science, Assam down town University, Guwahati 781026, Assam, India
| | - Saikat Sen
- Faculty of Pharmaceutical Science, Assam down town University, Guwahati 781026, Assam, India
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9
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Dando C, Lane G, Bowen C, Henshaw F. The evaluation of podiatrists, with knowledge and training in diagnostic musculoskeletal ultrasound, to describe sonographic images of diabetic foot wounds in the United Kingdom and Australia. J Foot Ankle Res 2022; 15:5. [PMID: 35078511 PMCID: PMC8787913 DOI: 10.1186/s13047-022-00511-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 01/11/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Currently, wound management decisions are based largely on visual observations such as photographs, descriptors or measurements which can lack detail and do not always capture the sub-wound area. A previous case series suggests that there is benefit in using ultrasound imaging (USI) to evaluate diabetic foot ulcers (DFU) at point-of-care, however no guidance exists to inform its use. This scoping exercise explores the capacity of podiatrists with experience in interpreting musculoskeletal structures using USI to interpret sonographic images of DFU. METHODS Following a short briefing session, podiatrists with previous musculoskeletal (MSK) USI training were asked to review and report on previously recorded static sonographic images (n = 8) of active DFU. Content analysis was utilised to identify recurring keywords within the podiatrists' reports which were coded and assigned to categories to gain context to the data. RESULTS Seven podiatrists participated in the study. Four categories were constructed for the purposes of analysis: 1) Frequency of reporting, 2) Language used in reporting, 3) Observations, 4) Clinical impression Frequently, the reported findings between podiatrists were found to be similar, especially those related to bone morphology. However greater variability was seen in the reporting of wound specific soft-tissue observations. CONCLUSION This scoping exercise has shown that podiatrists can translate their existing USI skills to make rudimentary reports on clinical findings in DFU. All participants were consistently able to identify and describe characteristics associated with DFU from a single b mode static wound ultrasound image. Findings from this investigation can be used as a foundation for further work to establish accuracy and reliability to validate DFU sonography. In conjunction the development of protocols and training materials will enable the adoption of USI to assess DFU in clinical practice. This will in turn, contribute to improved patient care and establish a new paradigm for wound surveillance which is translatable to other wound types.
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Affiliation(s)
- Charlotte Dando
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Georgia Lane
- Podiatry Department, Solent NHS Trust, Southampton, UK
| | - Catherine Bowen
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Centre for Sport, Exercise and Osteoarthritis Versus Arthritis, University of Southampton, Southampton, UK
| | - Frances Henshaw
- School of Medicine, Western Sydney University, Penrith, Australia
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10
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Jankauskas SS, Kansakar U, Varzideh F, Wilson S, Mone P, Lombardi A, Gambardella J, Santulli G. Heart failure in diabetes. Metabolism 2021; 125:154910. [PMID: 34627874 PMCID: PMC8941799 DOI: 10.1016/j.metabol.2021.154910] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 10/02/2021] [Accepted: 10/04/2021] [Indexed: 12/16/2022]
Abstract
Heart failure and cardiovascular disorders represent the leading cause of death in diabetic patients. Here we present a systematic review of the main mechanisms underlying the development of diabetic cardiomyopathy. We also provide an excursus on the relative contribution of cardiomyocytes, fibroblasts, endothelial and smooth muscle cells to the pathophysiology of heart failure in diabetes. After having described the preclinical tools currently available to dissect the mechanisms of this complex disease, we conclude with a section on the most recent updates of the literature on clinical management.
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Affiliation(s)
- Stanislovas S Jankauskas
- Department of Medicine, Fleischer Institute for Diabetes and Metabolism (FIDAM), Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Albert Einstein College of Medicine, New York, NY 10461, USA; Department of Molecular Pharmacology, Einstein Institute for Neuroimmunology and Inflammation, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Urna Kansakar
- Department of Medicine, Fleischer Institute for Diabetes and Metabolism (FIDAM), Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Albert Einstein College of Medicine, New York, NY 10461, USA; Department of Molecular Pharmacology, Einstein Institute for Neuroimmunology and Inflammation, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Fahimeh Varzideh
- Department of Medicine, Fleischer Institute for Diabetes and Metabolism (FIDAM), Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Albert Einstein College of Medicine, New York, NY 10461, USA; Department of Molecular Pharmacology, Einstein Institute for Neuroimmunology and Inflammation, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Scott Wilson
- Department of Medicine, Fleischer Institute for Diabetes and Metabolism (FIDAM), Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Pasquale Mone
- Department of Medicine, Fleischer Institute for Diabetes and Metabolism (FIDAM), Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Angela Lombardi
- Department of Medicine, Fleischer Institute for Diabetes and Metabolism (FIDAM), Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Jessica Gambardella
- Department of Medicine, Fleischer Institute for Diabetes and Metabolism (FIDAM), Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Albert Einstein College of Medicine, New York, NY 10461, USA; Department of Molecular Pharmacology, Einstein Institute for Neuroimmunology and Inflammation, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA; International Translational Research and Medical Education (ITME), Department of Advanced Biomedical Science, "Federico II" University, 80131 Naples, Italy
| | - Gaetano Santulli
- Department of Medicine, Fleischer Institute for Diabetes and Metabolism (FIDAM), Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Albert Einstein College of Medicine, New York, NY 10461, USA; Department of Molecular Pharmacology, Einstein Institute for Neuroimmunology and Inflammation, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA; International Translational Research and Medical Education (ITME), Department of Advanced Biomedical Science, "Federico II" University, 80131 Naples, Italy.
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11
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Al Amri AM, Shahrani IM, Almaker YA, Alshehri DM, Argabi MA, Alghamidi FA, Alqahtani YZ. Knowledge, Attitude and Practice Regarding Risk of Diabetic Foot Among Diabetic Patients in Aseer Region, Saudi Arabia. Cureus 2021; 13:e18791. [PMID: 34804657 PMCID: PMC8592378 DOI: 10.7759/cureus.18791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2021] [Indexed: 11/15/2022] Open
Abstract
Background Diabetic foot care is vital as it is preventable complication but dangerous even a small trauma can end with serious consequences. Diabetes may cause nerve damage that affects feet sensation. Diabetes may also reduce blood flow to the feet, making it harder to heal an injury or resist infection. Because of these problems, patients may lose notice of early foot abnormalities. Diabetic patients’ awareness regarding how to care for their feet plays a significant role in preventing these complications. Methods A correlation cross-sectional study was conducted targeting all diabetic patients aging 20 years or more. Online questionnaire was used for data collection. Questionnaire was uploaded online using social media platforms by the researchers and their relatives and friends. The questionnaire included patient personal data, patients’ knowledge regarding diabetic foot, attitude and practice regarding the risk of diabetic foot among diabetic patients. Results A total of 1,000 diabetic patients fulfilling the inclusion criteria completed the study questionnaire. Exact of 77.5% of the patients know that Diabetics can get gangrene in the foot, 74.9% know diabetics can develop ulcers in the foot, 66.7% reported that Diabetes can reduce blood flow to the feet of diabetic patients, 66.6% agreed that diabetic patients can suffer from a lack of sensation in the feet. Exact of 84.5% of the study participants agreed that Diabetics should check for any wounds on their feet daily, 78.7% agreed that Diabetics should visit a doctor when there is any infection or wound in the feet, 76.6% think that diabetic patients should wear specialized shoes to avoid diabetic foot according to the doctor's instructions. A total of 822 (82.2%) of the study patients wash their feet daily, and 295 (29.5%) usually wear cotton socks regularly and 39.6% sometimes wear the stock. Only 192 (19.2%) regularly walk barefoot and 41.7% sometimes do. Conclusion In conclusion, the current study results showed that nearly two out of each three diabetic patients were knowledgeable for diabetic foot and its care. High knowledge was associated with young age, high education and having family member with diabetes mellitus (DM). Also, patients had a good attitude towards diabetic foot care and the effect of diabetes on foot health with to some level accepted practice except for some issues.
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Affiliation(s)
- Ali M Al Amri
- Family Medicine & Diabetes, Asir Central Hospital, Abha, SAU
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12
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Durante W, Behnammanesh G, Peyton KJ. Effects of Sodium-Glucose Co-Transporter 2 Inhibitors on Vascular Cell Function and Arterial Remodeling. Int J Mol Sci 2021; 22:ijms22168786. [PMID: 34445519 PMCID: PMC8396183 DOI: 10.3390/ijms22168786] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 12/20/2022] Open
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality in diabetes. Recent clinical studies indicate that sodium-glucose co-transporter 2 (SGLT2) inhibitors improve cardiovascular outcomes in patients with diabetes. The mechanism underlying the beneficial effect of SGLT2 inhibitors is not completely clear but may involve direct actions on vascular cells. SGLT2 inhibitors increase the bioavailability of endothelium-derived nitric oxide and thereby restore endothelium-dependent vasodilation in diabetes. In addition, SGLT2 inhibitors favorably regulate the proliferation, migration, differentiation, survival, and senescence of endothelial cells (ECs). Moreover, they exert potent antioxidant and anti-inflammatory effects in ECs. SGLT2 inhibitors also inhibit the contraction of vascular smooth muscle cells and block the proliferation and migration of these cells. Furthermore, studies demonstrate that SGLT2 inhibitors prevent postangioplasty restenosis, maladaptive remodeling of the vasculature in pulmonary arterial hypertension, the formation of abdominal aortic aneurysms, and the acceleration of arterial stiffness in diabetes. However, the role of SGLT2 in mediating the vascular actions of these drugs remains to be established as important off-target effects of SGLT2 inhibitors have been identified. Future studies distinguishing drug- versus class-specific effects may optimize the selection of specific SGLT2 inhibitors in patients with distinct cardiovascular pathologies.
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13
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Won JH. [General Treatment Strategy for Intervention in Lower Extremity Arterial Disease]. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:500-511. [PMID: 36238791 PMCID: PMC9432442 DOI: 10.3348/jksr.2021.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/09/2021] [Accepted: 04/17/2021] [Indexed: 11/19/2022]
Abstract
The prevalence of lower extremity disease is increasing with age. With recent technological advancements, endovascular treatment is being performed more frequently. The treatment goal of intermittent claudication is to improve walking and reduce claudication. To achieve these goals, anatomical durability and patency are important. In patients with critical limb ischemia, the lesions are diffuse and particularly severe in below-the-knee arteries. The treatment goal of critical limb ischemia is to promote wound healing and to prevent major amputation, which is evaluated by the limb salvage rate. Primary stenting using covered or bare metal stents is a widely accepted endovascular treatment. While drug-eluting technologies with or without atherectomy are widely used in the treatment of femoropopliteal disease, balloon angioplasty is the mainstay treatment for below-the-knee intervention. CT angiography provides a road map for planning endovascular treatment in patients without absolute contraindications.
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14
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Lee CY, Wu TC, Lin SJ. Effects of Postoperative Percutaneous Coronary Intervention, Pharmacologic Treatment, and Predisposing Factors on Clinical Outcomes in Patients With and Without Type 2 Diabetes Along With Critical Limb Ischemia. Clin Ther 2020; 43:195-210.e2. [PMID: 33358255 DOI: 10.1016/j.clinthera.2020.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/29/2020] [Accepted: 11/22/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Critical limb ischemia (CLI) has been identified as being connected to rates of cardiovascular mortality and lower extremity amputation (LEA). This prospective study investigated the effects of percutaneous coronary intervention (PCI), pharmacologic treatment, and predisposing factors on clinical outcomes in patients with and without type 2 diabetes mellitus (DM) along with CLI after endovascular intervention. METHODS 249 consecutive patients with CLI (Fontaine stages III-IV) received pharmacologic treatment after successful endovascular intervention. Their primary patency rates of infrapopliteal lesions and cardiovascular and amputation events during a 36-month follow-up period were assessed. FINDINGS Patients with DM were more likely to be younger (P = 0.026); 50% (n = 63), 42.9% (n = 54), 52.4% (n = 66), and 77% (n = 97) of DM patients had arterial calcification, end-stage renal disease, diabetic neuropathy, and Fontaine stage IV (P < 0.001, P < 0.001, P < 0.001, and P = 0.019, respectively). The primary patency rates were 61%, 48.8%, and 42.3% at 12, 24, and 36 months, in the patients without DM (P = 0.034, P = 0.013, and P = 0.005). Patients with DM had higher risks of 36-month coronary artery disease, cerebrovascular accident, mortality, and LEA (P = 0.005, P = 0.042, P = 0.042, and P < 0.001). Patients with CLI receiving long-term cilostazol treatment had a better primary patency and amputation-free survival, and a lower risk of mortality at 36 months (P < 0.001, P < 0.001, and P = 0.001). Statin use was associated with 36-month amputation-free survival but not with primary patency (P = 0.032 and P = 0.088). Subgroup multivariate Cox analyses showed that primary patency was independently associated with long-term cilostazol treatment, PCI in the first postoperative year, and direct revascularization in the DM group, whereas in the control group, long-term cilostazol treatment was the main independent factor. The risk of amputation was independently associated with a high high-sensitivity chronic reactive protein level, diabetic neuropathy, sole use of an oral hypoglycemic agent, and lack of supervised exercise. IMPLICATIONS Long-term cilostazol treatment, aggressive management of dyslipidemia, and meticulous assessment and prevention of postoperative unstable coronary artery disease should be considered in CLI patients with and without DM to maximize clinical outcomes. PCI in the first postoperative year may be a predisposing factor for patency failure in patients with CLI, especially those with DM. A large-scale prospective randomized trial should be conducted to confirm these findings (TVGH IRB No. 2013-08-020B).
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Affiliation(s)
- Chiu-Yang Lee
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei City, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan.
| | - Tao-Cheng Wu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shing-Jong Lin
- Institute of Clinical Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan; Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan; Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.
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15
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Argarini R, McLaughlin RA, Joseph SZ, Naylor LH, Carter HH, Haynes A, Marsh CE, Yeap BB, Jansen SJ, Green DJ. Visualizing and quantifying cutaneous microvascular reactivity in humans by use of optical coherence tomography: impaired dilator function in diabetes. Am J Physiol Endocrinol Metab 2020; 319:E923-E931. [PMID: 32954827 DOI: 10.1152/ajpendo.00233.2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The pathophysiology and time course of impairment in cutaneous microcirculatory function and structure remain poorly understood in people with diabetes, partly due to the lack of investigational tools capable of directly imaging and quantifying the microvasculature in vivo. We applied a new optical coherence tomography (OCT) technique, at rest and during reactive hyperemia (RH), to assess the skin microvasculature in people with diabetes with foot ulcers (DFU, n = 13), those with diabetes without ulcers (DNU, n = 9), and matched healthy controls (CON, n = 13). OCT images were obtained from the dorsal part of the foot at rest and following 5 min of local ischemia induced by inflating a cuff around the thigh at suprasystolic level (220 mmHg). One-way ANOVA was used to compare the OCT-derived parameters (diameter, speed, flow rate, and density) at rest and in response to RH, with repeated-measures two-way ANOVA performed to analyze main and interaction effects between groups. Data are means ± SD. At rest, microvascular diameter in the DFU (84.89 ± 14.84 µm) group was higher than CON (71.25 ± 7.6 µm, P = 0.012) and DNU (71.33 ± 12.04 µm, P = 0.019) group. Speed in DFU (65.56 ± 4.80 µm/s, P = 0.002) and DNU (63.22 ± 4.35 µm/s, P = 0.050) were higher than CON (59.58 ± 3.02 µm/s). Microvascular density in DFU (22.23 ± 13.8%) was higher than in CON (9.83 ± 2.94%, P = 0.008), but not than in the DNU group (14.8 ± 10.98%, P = 0.119). All OCT-derived parameters were significantly increased in response to RH in the CON group (all P < 0.01) and DNU group (all P < 0.05). Significant increase in the DFU group was observed in speed (P = 0.031) and density (P = 0.018). The change in density was lowest in the DFU group (44 ± 34.1%) compared with CON (199.2 ± 117.5%, P = 0.005) and DNU (148.1 ± 98.4, P = 0.054). This study proves that noninvasive OCT microvascular imaging is feasible in people with diabetes, provides powerful new physiological insights, and can distinguish between healthy individuals and patients with diabetes with distinct disease severity.
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Affiliation(s)
- Raden Argarini
- Physiology Department, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
- Cardiovascular Research Group, School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Australia
| | - Robert A McLaughlin
- Faculty of Health and Medical Sciences, Australian Research Council Centre of Excellence for Nanoscale Biophotonics, Adelaide Medical School, University of Adelaide, Australia
- Institute for Photonics and Advanced Sensing, University of Adelaide, Adelaide, Australia
- Department of Electrical, Electronic and Computer Engineering, University of Western Australia, Perth, Australia
| | - Simon Z Joseph
- Faculty of Health and Medical Sciences, School of Surgery, The University of Western Australia, Perth, Australia
| | - Louise H Naylor
- Cardiovascular Research Group, School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Australia
| | - Howard H Carter
- Cardiovascular Research Group, School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Australia
| | - Andrew Haynes
- Cardiovascular Research Group, School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Australia
| | - Channa E Marsh
- Cardiovascular Research Group, School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Australia
| | - Bu B Yeap
- Medical School, The University of Western Australia, Perth, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Australia
| | - Shirley J Jansen
- Faculty of Health and Medical Sciences, School of Surgery, The University of Western Australia, Perth, Australia
- Department of Vascular and Endovascular Surgery Sir Charles Gardner Hospital, Perth, Australia
- Heart and Vascular Research Institute, Harry Perkins Institute of Medical Research, Perth, Australia
- Medical School, Curtin University, Perth, Australia
| | - Daniel J Green
- Cardiovascular Research Group, School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Australia
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Behroozian A, Beckman JA. Microvascular Disease Increases Amputation in Patients With Peripheral Artery Disease. Arterioscler Thromb Vasc Biol 2020; 40:534-540. [DOI: 10.1161/atvbaha.119.312859] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
It is estimated that >2 million patients are living with an amputation in the United States. Peripheral artery disease (PAD) and diabetes mellitus account for the majority of nontraumatic amputations. The standard measurement to diagnose PAD is the ankle-brachial index, which integrates all occlusive disease in the limb to create a summary value of limb artery occlusive disease. Despite its accuracy, ankle-brachial index fails to well predict limb outcomes. There is an emerging body of literature that implicates microvascular disease (MVD; ie, retinopathy, nephropathy, neuropathy) as a systemic phenomenon where diagnosis of MVD in one capillary bed implicates microvascular dysfunction systemically. MVD independently associates with lower limb outcomes, regardless of diabetic or PAD status. The presence of PAD and concomitant MVD phenotype reveal a synergistic, rather than simply additive, effect. The higher risk of amputation in patients with MVD, PAD, and concomitant MVD and PAD should prompt aggressive foot surveillance and diagnosis of both conditions to maintain ambulation and prevent amputation in older patients.
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Affiliation(s)
- Adam Behroozian
- From the Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN
| | - Joshua A. Beckman
- From the Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN
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Anichini R, Brocco E, Caravaggi CM, Da Ros R, Giurato L, Izzo V, Meloni M, Uccioli L. Physician experts in diabetes are natural team leaders for managing diabetic patients with foot complications. A position statement from the Italian diabetic foot study group. Nutr Metab Cardiovasc Dis 2020; 30:167-178. [PMID: 31848052 DOI: 10.1016/j.numecd.2019.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/16/2019] [Accepted: 11/18/2019] [Indexed: 12/16/2022]
Abstract
Diabetic foot syndrome (DFS) is a complex disease. The best outcomes are reported with the multi-disciplinary team (MDT) approach, where each member works collaboratively according to his/her expertise. However, which health provider should act as the team leader (TL) has not been determined. The TL should be familiar with the management of diabetes, related complications and comorbidities. He/she should be able to diagnose and manage foot infections, including prompt surgical treatment of local lesions, such as abscesses or phlegmons, in an emergent way in the first meeting with the patient. According to the Organization for Economic Co-operation and Development (OECD) reports, Italy is one of countries with a low amputation rate in diabetic patients. Many factors might have contributed to this result, including 1)the special attention directed to diabetes by the public health system, which has defined diabetes as a "protected disease", and accordingly, offers diabetic patients, at no charge, the best specialist care, including specific devices, and 2)the presence of a network of diabetic foot (DF) clinics managed by diabetologists with medical and surgical expertise. The health care providers all share a "patient centred model" of care, for which they use their internal medicine background and skills in podiatric surgery to manage acute or chronic needs in a timely manner. Therefore, according to Italian experiences, which are fully reported in this document, we believe that only a skilled diabetologist/endocrinologist should act as a TL. Courses and university master's degree programmes focused on DF should guarantee specific training for physicians to become a TL.
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Affiliation(s)
- R Anichini
- Diabetes Unit and Diabetic Foot Unit, Area Pistoiese, AUSL Centro Toscana, Italy
| | - E Brocco
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Italy
| | - C M Caravaggi
- Diabetic Foot Department, IRCCS Multimedica Milan, Italy
| | - R Da Ros
- Diabetes Center AAS2 Monfalcone-Gorizia, Italy
| | - L Giurato
- Diabetic Foot Unit, Department of Medicine Systems, University of Tor Vergata, Rome, Italy
| | - V Izzo
- Diabetic Foot Unit, Department of Medicine Systems, University of Tor Vergata, Rome, Italy
| | - M Meloni
- Diabetic Foot Unit, Department of Medicine Systems, University of Tor Vergata, Rome, Italy
| | - L Uccioli
- Diabetic Foot Unit, Department of Medicine Systems, University of Tor Vergata, Rome, Italy.
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Nikulainen V, Helmiö P, Hurme S, Hakovirta H. Vein Harvest Wound Healing after Bypass Surgery for Critical Limb Ischemia. Ann Vasc Surg 2019; 62:375-381. [PMID: 31445090 DOI: 10.1016/j.avsg.2019.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Lower-limb revascularization surgery, especially when performed using the great saphenous vein, predisposes patients to major surgical trauma on initially ischemic tissue. Vein harvest wounds (VHWs) after infrainguinal revascularization heal slowly. This study's aim was to assess the factors associated with VHW healing after infrainquinal bypass surgery for critical limb ischemia (CLI). METHODS A retrospective patient record study was conducted. All patients with CLI who underwent infrainguinal bypass surgery with autologous vein graft between January 1, 2015, and December 31, 2017, in the Turku University Hospital, were included. Follow-up data were collected until February 28, 2018. The following data was collected from the patient files; risk factors, ankle-brachial indices (ABIs), systolic toe pressures (STPs), the presence of an ischemic ulcer, VHW dehiscence, and the time when the VHW was completely healed. Procedures with outflow vessels at either popliteal or tibial artery were analyzed separately. Descriptive and univariate statistical analyses were performed. RESULTS Altogether, 195 patients were operated on for CLI, of whom 133 (68.2%) patients had ischemic ulcers. The mean follow-up time was 535.0 days (range 3.0-1143.0 days). The mean ABI improvement was 0.49 (P = 0.00), and STP improvement, 39.9 mm Hg (P = 0.00). The median time taken when VHW was healed was 48.0 days (95% confidence interval [CI], 39.4-56.6) in patients without ischemic ulcers and 82.0 days (95% CI, 59.7-104.3) in patients with ischemic ulcers, P = 0.03. VHW in patients who underwent popliteal artery bypass (62 days, 95% CI, 12.9-93.0) healed faster than VHW in those who underwent tibial artery bypass (132 days, 95% CI, 48.0-93.0), P = 0.02. Risk factors and the preoperative or postoperative ABIs or STPs had no effect on VHW healing time. CONCLUSIONS VHW healing was remarkably slower after revascularization surgery in patients with an ischemic foot ulcer than in those without ischemic ulcers.
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Affiliation(s)
- Veikko Nikulainen
- Department of Vascular Surgery, Turku University Hospital, Turku, Finland; University of Turku, Turku, Finland.
| | - Päivi Helmiö
- Department of Vascular Surgery, Turku University Hospital, Turku, Finland; University of Turku, Turku, Finland
| | | | - Harri Hakovirta
- Department of Vascular Surgery, Turku University Hospital, Turku, Finland; University of Turku, Turku, Finland
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Al-Rawaf HA, Gabr SA, Alghadir AH. Molecular Changes in Diabetic Wound Healing following Administration of Vitamin D and Ginger Supplements: Biochemical and Molecular Experimental Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2019; 2019:4352470. [PMID: 31428171 PMCID: PMC6679851 DOI: 10.1155/2019/4352470] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 07/06/2019] [Accepted: 07/11/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Circulating micro-RNAs are differentially expressed in various tissues and could be considered as potential regulatory biomarkers for T2DM and related complications, such as chronic wounds. AIM In the current study, we investigated whether ginger extract enriched with [6]-gingerol-fractions either alone or in combination with vitamin D accelerates diabetic wound healing and explores underlying molecular changes in the expression of miRNA and their predicted role in diabetic wound healing. METHODS Diabetic wounded mice were treated with [6]-gingerol-fractions (GF) (25 mg/kg of body weight) either alone or in combination with vitamin D (100 ng/kg per day) for two weeks. Circulating miRNA profile, fibrogenesis markers, hydroxyproline (HPX), fibronectin (FN), and collagen deposition, diabetic control variables, FBS, HbA1c, C-peptide, and insulin, and wound closure rate and histomorphometric analyses were, respectively, measured at days 3, 6, 9, and 15 by RT-PCR and immunoassay analysis. RESULTS Treatment of diabetic wounds with GF and vitamin D showed significant improvement in wound healing as measured by higher expression levels of HPX, FN, collagen, accelerated wound closure, complete epithelialization, and scar formation in short periods (11-13 days, (P < 0.01). On a molecular level, three circulating miRNAs, miR-155, miR-146a, and miR-15a, were identified in diabetic and nondiabetic skin wounds by PCR analysis. Lower expression in miR-155 levels and higher expression of miR-146a and miR-15a levels were observed in diabetic skin wounds following treatment with gingerols fractions and vitamin D for 15 days. The data showed that miRNAs, miR-146a, miR-155, and miR-15a, correlated positively with the expression levels of HPX, FN, and collagen and negatively with FBS, HbA1c, C-peptide, and insulin in diabetic wounds following treatment with GF and /or vitamin D, respectively. CONCLUSION Treatment with gingerols fractions (GF) and vitamin D for two weeks significantly improves delayed diabetic wound healing. The data showed that vitamin D and gingerol activate vascularization, fibrin deposition (HPX, FN, and collagen), and myofibroblasts in such manner to synthesize new tissues and help in the scar formation. Accordingly, three miRNAs, miR-155, miR-146a, and miR-15, as molecular targets, were identified and significantly evaluated in wound healing process. It showed significant association with fibrin deposition, vascularization, and reepithelialization process following treatment with GF and vitamin D. It proposed having anti-inflammatory action and promoting new tissue formation via vascularization process during the wound healing. Therefore, it is very interesting to consider miRNAs as molecular targets for evaluating the efficiency of nondrug therapy in the regulation of wound healing process.
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Affiliation(s)
- Hadeel A. Al-Rawaf
- Rehabilitation Research Chair, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Sami A. Gabr
- Rehabilitation Research Chair, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad H. Alghadir
- Rehabilitation Research Chair, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
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Edmonds M. Vascular disease in the lower limb in type 1 diabetes. Cardiovasc Endocrinol Metab 2019; 8:39-46. [PMID: 31646297 PMCID: PMC6739894 DOI: 10.1097/xce.0000000000000168] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/18/2019] [Indexed: 01/13/2023]
Abstract
This review considers peripheral arterial disease (PAD) in the diabetic ischaemic lower limb including both macrovascular and microvascular aspects. The presentation of PAD is probably not significantly different in type 1 compared with type 2 diabetes. PAD in diabetic patients is diffuse and located distally being most severe in the crural and also the foot arteries. It is associated with arterial calcification and occlusion of the arteries rather than stenosis. Compared with the nondiabetic patient, PAD develops at a younger age, and women are equally affected as men. It is not known whether the presentation of ischaemic lower limb disease in diabetes can be explained by one disease, namely, atherosclerosis, which has particular features peculiar to diabetes such as distal arterial involvement, or by the occurrence of two separate diseases: first, classical atherosclerosis and, second, a diabetic macroangiopathy, a term for nonatherosclerotic arterial disease in diabetes that is characterized by medial arterial calcification. Furthermore, there is controversy with regard to the significance of structural changes in the microcirculation of the diabetic foot.
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21
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Xia N, Morteza A, Yang F, Cao H, Wang A. Review of the role of cigarette smoking in diabetic foot. J Diabetes Investig 2019; 10:202-215. [PMID: 30300476 PMCID: PMC6400172 DOI: 10.1111/jdi.12952] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/11/2018] [Accepted: 09/30/2018] [Indexed: 12/13/2022] Open
Abstract
Diabetic foot ulceration has been a serious issue over the past decades in Asia, causing economic and social problems. Therefore, it is important to identify and reduce the risk factors of diabetic foot. Cigarette smoking has been reported to be associated with diabetes and its macrovascular complications, but the relationship between smoking and diabetic foot ulcers is still unclear. In the present review, we summarize the effects of cigarette smoking on diabetic foot ulcers with respect to peripheral neuropathy, vascular alterations and wound healing. One underlying mechanism of these impacts might be the smoking-induced oxidative stress inside the cells. At the end of this review, the current mainstream therapies for smoking cessation are also outlined. We believe that it is urgent for all diabetic patients to quit smoking so as to reduce their chances of developing foot ulcers and to improve the prognosis of diabetic foot ulcers.
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Affiliation(s)
- Nan Xia
- Diabetes & Wound Care CenterMingci Cardiovascular HospitalWuxiChina
| | - Afsaneh Morteza
- Endocrinology and Metabolism Research Center – EMRCVali‐Asr. HospitalTehran University of Medical SciencesTehranIran
| | - Fengyu Yang
- Diabetes & Wound Care CenterMingci Cardiovascular HospitalWuxiChina
| | - Hong Cao
- Department of EndocrinologyWuxi No. 3 People's HospitalWuxiChina
| | - Aiping Wang
- Diabetes & Wound Care CenterMingci Cardiovascular HospitalWuxiChina
- Department of EndocrinologyNanjing 454th HospitalNanjingChina
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Mavrogenis AF, Megaloikonomos PD, Antoniadou T, Igoumenou VG, Panagopoulos GN, Dimopoulos L, Moulakakis KG, Sfyroeras GS, Lazaris A. Current concepts for the evaluation and management of diabetic foot ulcers. EFORT Open Rev 2018; 3:513-525. [PMID: 30305936 PMCID: PMC6174858 DOI: 10.1302/2058-5241.3.180010] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The lifetime risk for diabetic patients to develop a diabetic foot ulcer (DFU) is 25%. In these patients, the risk of amputation is increased and the outcome deteriorates.More than 50% of non-traumatic lower-extremity amputations are related to DFU infections and 85% of all lower-extremity amputations in patients with diabetes are preceded by an ulcer; up to 70% of diabetic patients with a DFU-related amputation die within five years of their amputation.Optimal management of patients with DFUs must include clinical awareness, adequate blood glucose control, periodic foot inspection, custom therapeutic footwear, off-loading in high-risk patients, local wound care, diagnosis and control of osteomyelitis and ischaemia. Cite this article: EFORT Open Rev 2018;3:513-525. DOI: 10.1302/2058-5241.3.180010.
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Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Panayiotis D Megaloikonomos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Thekla Antoniadou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Vasilios G Igoumenou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Georgios N Panagopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Leonidas Dimopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Konstantinos G Moulakakis
- Department of Vascular Surgery, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - George S Sfyroeras
- Department of Vascular Surgery, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Andreas Lazaris
- Department of Vascular Surgery, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
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Brocco E, Ninkovic S, Marin M, Whisstock C, Bruseghin M, Boschetti G, Viti R, Forlini W, Volpe A. Diabetic foot management: multidisciplinary approach for advanced lesion rescue. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:670-684. [PMID: 29808982 DOI: 10.23736/s0021-9509.18.10606-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The diabetic foot is a complication of diabetes affecting 15% of diabetics in their lives. It is associated to diabetic neuropathy and peripheral vascular disease and its incidence has increased. The ulceration is the initial cause of a dramatic process leading, if not correctly treated, to amputations. Both neuropathy, neuro-ischemia and infections have a role in determining healing or worsening of the lesions and 85% of all amputations in diabetic patients are preceded by a foot ulceration deteriorating to a severe gangrene or infection. The different causative agents and the different clinical presentations of diabetic foot ask a multidisciplinary approach in order to address treatments to the final goals, the prevention of the amputations and the maintenance of a functional foot able with weight-bearing ability. Many professional figures, diabetologists, surgeons (both general and vascular and orthopedics), interventional radiologists, infectious diseases specialists, specialized nurses, podiatrists, orthotic technicians, are called to apply their knowledges to the diabetic patients affected by diabetic foot in a virtuous circle leading to reach the goals, with the imperative action of the multidisciplinary team. The so organized center will allow both a correct and rapid diagnosis, the use in ambulatorial environments of modern tools, or the hospitalization in multitasking wards, in which all the complications and the necessary treatments are possible, both in emergencies or in elective way, considering both revascularizations and surgery.
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Affiliation(s)
- Enrico Brocco
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy -
| | - Sasa Ninkovic
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Mariagrazia Marin
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Christine Whisstock
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Marino Bruseghin
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Giovanni Boschetti
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Raffaella Viti
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | | | - Antonio Volpe
- Department of Orthopedic Surgery, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
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Liang P, Soden PA, Zettervall SL, Shean KE, Deery SE, Guzman RJ, Hamdan AD, Schermerhorn ML. Treatment outcomes in diabetic patients with chronic limb-threatening ischemia. J Vasc Surg 2018; 68:487-494. [PMID: 29576404 DOI: 10.1016/j.jvs.2017.11.081] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 11/09/2017] [Indexed: 01/13/2023]
Abstract
OBJECTIVE There are conflicting reports about outcomes after infrainguinal bypass for chronic limb-threatening ischemia (CLTI) in patients with diabetes. We compared perioperative outcomes between patients with and patients without diabetes in the current era. METHODS The National Surgical Quality Improvement Program vascular module, 2011 to 2014, was used to identify patients undergoing infrainguinal revascularization for CLTI. Patients with and without diabetes were compared in terms of presentation, comorbidities, operative approach, and 30-day outcomes. Major adverse limb events (MALEs) included 30-day major reintervention or amputation, and major adverse cardiovascular events (MACEs) included 30-day myocardial infarction, cardiac arrest, stroke, or death. Multivariable logistic regression was used to adjust for baseline differences. RESULTS We identified 8887 patients undergoing open (5744; 50% diabetic) or endovascular (3143; 62% diabetic) treatment for CLTI. Patients with diabetes were younger and more often nonwhite, nonsmokers, and obese. Patients with diabetes presented more often with tissue loss (71% vs 47%; P < .001) and were more likely to be treated with endovascular intervention (41% vs 29%; P < .001). The 30-day mortality was similar before (open, 3.1% vs 2.8% [P = .53]; endovascular, 2.6% vs 2.1% [P = .37]) and after adjustment for baseline differences (open: odds ratio [OR], 1.1 [95% confidence interval (CI), 0.7-1.5]; endovascular: OR, 1.2 [95% CI, 0.7-2.0]). Patients with diabetes had longer lengths of stay (open, 8 vs 6 days [P < .001]; endovascular, 3 vs 2 days [P < .001]) and higher 30-day readmission rates (open, 21% vs 18% [P < .01]; endovascular, 20% vs 15% [P < .01]); however, these differences were no longer significant after adjustment for baseline differences. Patients with diabetes had a higher rate of MACEs (7.0% vs 5.1%; P < .01) and lower rate of MALEs (8.1% vs 10%; P < .01) after bypass. After adjustment, patients with diabetes still had a lower rate of MALEs (OR, 0.7; 95% CI, 0.6-0.9) but no longer had a higher rate of MACEs (OR, 1.2; 95% CI, 0.9-1.6). CONCLUSIONS CLTI patients with diabetes undergoing revascularization have similar 30-day outcomes compared with those without diabetes, although they appear to be at lower risk for MALEs after bypass. Prolonged length of stay and readmission in patients with diabetes is not due to underlying diabetic disease but likely secondary to other baseline comorbidities, such as higher rates of tissue loss. Concern for worse perioperative outcomes in patients with diabetes after lower extremity bypass is unsubstantiated and should not discourage a physician from performing an open bypass.
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Affiliation(s)
- Patric Liang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Raul J Guzman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
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Dam DHM, Paller AS. Gangliosides in Diabetic Wound Healing. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2018; 156:229-239. [PMID: 29747815 DOI: 10.1016/bs.pmbts.2017.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
An organized series of complicated biological and molecular phenomena is required for normal skin wound healing. These processes depend on normal cellular responses to cytokines, growth factors, and other mediators, such as clotting factors, prostaglandins, free radicals, and nitric oxide. In diabetic ulcers, impaired responses to these molecules lead to abnormalities in vascularization, innervation, matrix reconstruction, and reepithelialization of wounds. keratinocyte migration and proliferation on an extracellular matrix is critical in reepithelialization, but the response to growth factors is blunted in diabetes, including the insulin/IGF-1signaling axis. Ganglioside GM3, a sialylated epidermal glycosphingolipid, has been identified as a key mediator of the inhibition of insulin/IGF-1 signaling in response to factors, such as tumor necrosis factor-alpha (TNF-α) and hyperglycemia. Decreased expression of GM3 and the enzyme required for its synthesis, GM3 synthase (GM3S), leads to increased insulin/IGF-1 receptor signaling and accelerated keratinocyte migration, even in the presence of high glucose levels. GM3 depletion in GM3S knockout diabetic mice and diet-induced diabetic mice treated topically with nanoconstruct-mediated GM3S-targeting gene regulation also accelerates wound healing. These recent observations, coupled with evidence that GM3 depletion reverses distal innervation abnormalities in diabetic mice, suggest that GM3-depleting strategies are a promising new approach for human diabetic wounds.
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Affiliation(s)
| | - Amy S Paller
- Northwestern University, Chicago, IL, United States.
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26
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Rollins DL, Kalakuntla V, Wilson A. Arterial Revascularization in Patients with Diabetes: An Overview. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/154431670603000407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Arterial revascularization in patients with diabetes is challenging. The diabetic state predisposes patients to develop foot lesions, which often require distal arterial revascularization for limb salvage. New interventional techniques have allowed improved early limb salvage with decreased morbidity through the use of minimally invasive procedures. Standard arterial bypass techniques result in more durable limb salvage for most patients. Although long-term results and survival are reduced compared with nondiabetic patients, arterial revascularization is efficacious in healing foot lesions and improving the quality of life.
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Abstract
PURPOSE OF REVIEW Diabetic foot ulcerations (DFU) affect 25% of patients with diabetes mellitus during their lifetime and constitute a major health problem as they are often recalcitrant to healing due to a constellation of both intrinsic and extrinsic factors. The purpose of this review is to (1) detail the current mechanistic understanding of DFU formation and (2) highlight future therapeutic targets. RECENT FINDINGS From a molecular perspective, DFUs exhibit a chronic inflammatory predisposition. In addition, increased local hypoxic conditions and impaired cellular responses to hypoxia are pathogenic factors that contribute to delayed wound healing. Finally, recent evidence suggests a role for epigenetic alterations, including microRNAs, in delayed DFU healing due to the complex interplay between genes and the environment. In this regard, notable progress has been made in the molecular and genetic understanding of DFU formation. However, further studies are needed to translate preclinical investigations into clinical therapies.
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Affiliation(s)
- Frank M Davis
- Department of Surgery, Section of Vascular Surgery, University of Michigan, 5364 Cardiovascular Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5867, USA
| | - Andrew Kimball
- Department of Surgery, Section of Vascular Surgery, University of Michigan, 5364 Cardiovascular Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5867, USA
| | - Anna Boniakowski
- Department of Surgery, Section of Vascular Surgery, University of Michigan, 5364 Cardiovascular Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5867, USA
| | - Katherine Gallagher
- Department of Surgery, Section of Vascular Surgery, University of Michigan, 5364 Cardiovascular Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5867, USA.
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Adipose-derived stem cells for treatment of chronic cutaneous ulcers in patients with critical limb ischemia: a pilot study. EUROPEAN JOURNAL OF PLASTIC SURGERY 2017. [DOI: 10.1007/s00238-017-1383-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Lowry D, Saeed M, Narendran P, Tiwari A. The Difference Between the Healing and the Nonhealing Diabetic Foot Ulcer: A Review of the Role of the Microcirculation. J Diabetes Sci Technol 2017; 11:914-923. [PMID: 27390224 PMCID: PMC5950979 DOI: 10.1177/1932296816658054] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Diabetic foot disease carries a high morbidity and is a leading cause of lower limb amputation. This may in part be due to the effect diabetes mellitus (DM) has on the microcirculation including in the skin. METHOD We conducted a review of studies that have examined the relationship between microcirculatory function and wound healing in patients with DM. A search of the Medline, Embase, and Web of Science databases was performed coupled with a review of references for the period 1946 to March 2015. RESULTS Nineteen studies of diverse methodology and cohort selection were identified. Poor function of the microcirculation was related to poor outcome. Transcutaneous oxygen pressure (TcPO2) was the most commonly used method to measure the microcirculation and thresholds for poor outcome proposed ranged from 10 mmHg to <34 mmHg. Two studies reexamined microcirculatory function following revascularization. Both found an increase in TcPO2, however only 1 reached statistical significance. No significant difference in the results of microcirculation tests was found between diabetic and nondiabetic patients. CONCLUSIONS While it is not possible to draw firm conclusions from the evidence currently available there are clear areas that warrant research. Good microcirculation unsurprisingly appears to associate with better wound healing. The influence of DM is not clear, and neither is the degree of improvement required to achieve healing. Studies that examine a clearly defined cohort both with and without DM are urgently required. Accurate quantitative assessment of microcirculation will aid prediction of wound healing identifying those at greatest risk of amputation.
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Affiliation(s)
- Danielle Lowry
- Vascular Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Danielle Lowry, MBChB, MRCS, Vascular Department 6th Floor Nuffield House, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK.
| | - Mujahid Saeed
- Diabetes Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Parth Narendran
- Diabetes Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Alok Tiwari
- Vascular Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Barritault D, Gilbert-Sirieix M, Rice KL, Siñeriz F, Papy-Garcia D, Baudouin C, Desgranges P, Zakine G, Saffar JL, van Neck J. RGTA ® or ReGeneraTing Agents mimic heparan sulfate in regenerative medicine: from concept to curing patients. Glycoconj J 2016; 34:325-338. [PMID: 27924424 PMCID: PMC5487810 DOI: 10.1007/s10719-016-9744-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/18/2016] [Accepted: 10/20/2016] [Indexed: 01/12/2023]
Abstract
The importance of extracellular matrix (ECM) integrity in maintaining normal tissue function is highlighted by numerous pathologies and situations of acute and chronic injury associated with dysregulation or destruction of ECM components. Heparan sulfate (HS) is a key component of the ECM, where it fulfils important functions associated with tissue homeostasis. Its degradation following tissue injury disrupts this delicate equilibrium and may impair the wound healing process. ReGeneraTing Agents (RGTA®s) are polysaccharides specifically designed to replace degraded HS in injured tissues. The unique properties of RGTA® (resistance to degradation, binding and protection of ECM structural and signaling proteins, like HS) permit the reconstruction of the ECM, restoring both structural and biochemical functions to this essential substrate, and facilitating the processes of tissue repair and regeneration. Here, we review 25 years of research surrounding this HS mimic, supporting the mode of action, pre-clinical studies and therapeutic efficacy of RGTA® in the clinic, and discuss the potential of RGTA® in new branches of regenerative medicine.
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Affiliation(s)
- Denis Barritault
- OTR3, 4 rue Française, 75001 Paris, France
- Laboratory Cell Growth and Tissue Repair (CRRET), UPEC 4397/ERL CNRS 9215, Université Paris Est Cretéil, Université Paris Est, F-94000 Créteil, France
| | | | | | | | - Dulce Papy-Garcia
- Laboratory Cell Growth and Tissue Repair (CRRET), UPEC 4397/ERL CNRS 9215, Université Paris Est Cretéil, Université Paris Est, F-94000 Créteil, France
| | - Christophe Baudouin
- Institut de la Vision, 17 rue Moreau, 75012 Paris, France
- Universite Paris-Saclay, Université de Versailles Saint-Quentin-en-Yvelines (UVSQ), 55 Avenue de Paris, 78000 Versailles, France
- Centre Hospitalier National d’Opthalmologie des Quinze Vingts, 28 rue de Charenton, 75012 Paris, France
| | - Pascal Desgranges
- Department of Vascular Surgery, Hopital Henri Mondor, Université Paris-Est Créteil, 51 avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Gilbert Zakine
- Service de Chirurgie Plastique et Reconstructrice, 33 rue de la Tour, Paris, 75016 France
| | - Jean-Louis Saffar
- EA2496 Laboratoire Pathologies, Imagerie et Biothérapies Oro-Faciales, Faculté de Chirurgie Dentaire, Université Paris Descartes, Sorbonne Paris Cité, 1 rue Maurice Arnoux, 92120 Montrouge, France
| | - Johan van Neck
- Department of Plastic and Reconstructive Surgery, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
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The accuracy and cost-effectiveness of strategies used to identify peripheral artery disease among patients with diabetic foot ulcers. J Vasc Surg 2016; 64:1682-1690.e3. [DOI: 10.1016/j.jvs.2016.04.056] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 04/28/2016] [Indexed: 11/17/2022]
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Neville RF, Kayssi A, Buescher T, Stempel MS. The diabetic foot. Curr Probl Surg 2016; 53:408-37. [PMID: 27687301 DOI: 10.1067/j.cpsurg.2016.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 07/25/2016] [Indexed: 01/22/2023]
Affiliation(s)
- Richard F Neville
- Vascular Services, INOVA Healthcare System, INOVA Heart and Vascular Institute, Falls Church, VA.
| | - Ahmed Kayssi
- Vascular Services, INOVA Healthcare System, INOVA Heart and Vascular Institute, Falls Church, VA
| | - Teresa Buescher
- Division of Plastic Surgery, George Washington University, Washington, DC
| | - Michael S Stempel
- Department of Medicine, George Washington University, Washington, DC; Department of Surgery, George Washington University, Washington, DC
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Fiordaliso F, Clerici G, Maggioni S, Caminiti M, Bisighini C, Novelli D, Minnella D, Corbelli A, Morisi R, De Iaco A, Faglia E. Prospective study on microangiopathy in type 2 diabetic foot ulcer. Diabetologia 2016; 59:1542-1548. [PMID: 27121168 DOI: 10.1007/s00125-016-3961-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/24/2016] [Indexed: 01/07/2023]
Abstract
AIMS/HYPOTHESIS We investigated the significance of microangiopathy in the development of foot ulcer, which is still disputed. METHODS We assessed microangiopathy by histological analysis of the capillary ultrastructure using transmission electron microscopy and capillary density and arteriolar morphology in paraffin-embedded sections from the skin of type 2 diabetic patients: 30 neuroischaemic patients (Isc) revascularised with peripheral angioplasty and 30 neuropathic patients (Neu) with foot ulcer, compared with ten non-diabetic volunteers. RESULTS In the diabetic patients, capillaries in the dermal papillary layer were fewer (-22.2%, 159 ± 43 vs 205 ± 52 mm(2) in non-diabetic volunteers, p < 0.01). They also showed detrimental remodelling, with a 2.2-fold increase in capillary basement membrane thickness (3.44 ± 1.19 vs 1.53 ± 0.34 μm in non-diabetic volunteers, p < 0.001) and a 57.7% decrease in lumen area (14.6 ± 11.1 vs 34.7 ± 27.5 μm(2), p < 0.001). No differences were observed between the diabetic Isc or Neu patients. Isc were more prone to develop arteriolar occlusion than Neu (16.8 ± 6.9% vs 6.7 ± 3.7%, respectively, p < 0.001). No patient had been amputated at 30 days and healing time was significantly longer in Isc (180 ± 120 vs 64 ± 50 days in Neu, p < 0.001). CONCLUSIONS/INTERPRETATION Capillary microangiopathy is present in equal measure in neuroischaemic and neuropathic diabetic foot skin. The predominance of arteriolar occlusions with neuroischaemia indicated the existence of an additional 'small vessel disease' that did not affect an effective revascularisation and did not worsen the prognosis of major amputations but slowed the healing process of the neuroischaemic foot ulcer. TRIAL REGISTRATION ClinicalTrials.gov NCT02610036.
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Affiliation(s)
- Fabio Fiordaliso
- Unit of Bio-Imaging, Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche 'Mario Negri', Via La Masa 19, 20156, Milan, Italy.
| | - Giacomo Clerici
- Diabetic Foot Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Serena Maggioni
- Unit of Bio-Imaging, Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche 'Mario Negri', Via La Masa 19, 20156, Milan, Italy
| | - Maurizio Caminiti
- Diabetic Foot Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Cinzia Bisighini
- Unit of Bio-Imaging, Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche 'Mario Negri', Via La Masa 19, 20156, Milan, Italy
| | - Deborah Novelli
- Unit of Bio-Imaging, Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche 'Mario Negri', Via La Masa 19, 20156, Milan, Italy
| | - Daniela Minnella
- Diabetic Foot Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Alessandro Corbelli
- Unit of Bio-Imaging, Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche 'Mario Negri', Via La Masa 19, 20156, Milan, Italy
| | - Riccardo Morisi
- Department of Orthopedics, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Alberto De Iaco
- Department of Ophthalmology, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Ezio Faglia
- Diabetic Foot Center, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
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Lioupis C. The Role of Distal Arterial Reconstruction in Patients With Diabetic Foot Ischemia. INT J LOW EXTR WOUND 2016; 4:45-9. [PMID: 15860451 DOI: 10.1177/1534734605274915] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The diabetic foot, a common complication that affects patients with diabetes mellitus, is a therapeutic challenge. It places an increasing burden on society; the patient and caregivers as well as health care systems and clinicians are touched by this problem. The management of the diabetic foot with ischemia consequent to peripheral arterial disease is vexing, often leading to successive amputations. Surgical reconstruction of the peripheral arteries has always been a consideration, although the concept of coexistent small vessel disease has prejudiced the notion of offering reconstructive surgery to these patients. This article examines some of the literature relating to bypass surgery with a view to addressing the aforementioned notion. An appraisal of the literature suggests that vascular reconstructive surgery offers benefits to the diabetic patient, albeit these papers have weaknesses related to study design and methodology. Improved studies are indicated to address the role of bypass surgery to help the diabetic patient with foot complications; it is reasonable to hope that our understanding of the fundamental concepts of the pathogenesis of diabetic foot disease will also improve.
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Affiliation(s)
- Christos Lioupis
- Department of Vascular Surgery, The Red Cross General Hospital of Athens, Athens, Greece.
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Abstract
Impairment of the microcirculation of diabetic patients may contribute to secondary complications in the lower extremity, such as foot infections and ulcerations. These microcirculatory changes, which are mainly functional rather than structural, are responsible for the impaired ability of the microvasculature to vasodilate in response to injury. Dysfunction of vascular endothelial cells and vascular smooth muscle cells both contribute to the reduction in vasodilation that is observed in diabetic patients. Nerve-axon reflex related microvascular vasodilation is also impaired in the diabetic population, and there is a growing belief that both the failure of the vessels to dilate and the impairment of the nerve axon reflex are major causes for impaired wound healing in diabetic patients. Further studies are necessary to clarify the precise etiology of endothelial and smooth muscle dysfunction in diabetic patients so that potential therapeutic interventions may be identified.
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Affiliation(s)
- Jordan C Schramm
- Microcirculation, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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George RK, Verma AK, Agarwal A, Agarwal G, Mishra SK. An Audit of Foot Infections in Patients with Diabetes Mellitus Following Renal Transplantation. INT J LOW EXTR WOUND 2016; 3:157-60. [PMID: 15866807 DOI: 10.1177/1534734604267768] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Foot lesions in postrenal transplant diabetics are often overlooked and hence underestimated. An audit of patients attending the authors’ department was done. They reviewed the case notes to assess the presentation, clinical profiles, and outcomes of foot infections in patients with diabetes mellitus who received renal transplants at their center. Medical records of 192 diabetic foot patients were assessed, of which 8.8% (n = 17) had a history of previous renal transplantation for diabetic nephropathy. All 17 patients had noninsulin-dependent diabetes of mean duration of 16.2 years (range 7-27 years). Common complications and risk factors were studied. Mean duration to development of foot lesions in renal allograft recipients was 19.7 months (range 6-84 months). The big toe was the most commonsite of infection. Neuropathy and poor foot care appear to be important factors in the development of these foot lesions. Escherichia coli was the predominant organism on pus culture. Thirty-eight percent of patients needed major amputations; absence of an intact distal vascular tree was associated with a high major amputation rate. Two patients expired due to foot-related septicemia, and healing occurred in the remainder. Mean hospitalization time was 32.7 days. Most patients required more than one admission. The study emphasizes the need for greater attention to lower extremity complications in this patient group.
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Affiliation(s)
- Robbie K George
- Department of Endocrine Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
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39
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Abstract
Foot complications in patients with diabetes mellitus are a challenge to the health care industry. A great deal of expenditure is due to the management of diabetic foot complications. This places a great burden on the health care industry. It also places a great burden on those diabetic patients with foot complications and their families. Therefore, their effective management in an efficient manner is crucial to our patients. To deal with these problems, a dedicated, knowledgeable, and experienced multidisciplinary team is key. Intervention at the earliest possible time yields the best outcome. Prevention is the focus for those with no ulcerations. For those with ulcerations, prompt recognition and treatment is key. The importance of classifying ulcerations according to size, depth, presence or absence of infection, and vascular status can not be overstated. Proper offloading is vital for those with neuropathic lesions. Recognition of patients with a component of ischemia and vascular intervention to increase perfusion will aid in wound healing. Of course deep infection requires immediate drainage. All efforts of those in the multidisciplinary team are directed at the restoration and maintenance of an ulcer-free foot which is important in enabling our patients to maintain their ambulatory status.
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Affiliation(s)
- John M Giurini
- Division of Podiatry, Beth Israel Deaconess Medical Center, Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA
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40
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Abstract
The concept of microcirculation being implicated in the pathogenesis of diabetic foot disease is being challenged by evidence that fails to confirm it. However, there is evidence of structural changes with capillary and in the basement membrane that do not permit the concept to be denied either. The lack of evidence should not be a reason to argue against surgery in the diabetic foot.
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Affiliation(s)
| | - Mark A Creager
- Brigham and Women's Hospital, Harvard Medical School, USA
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Abstract
Managing nonhealing foot wounds in diabetic patients requires an understanding of the wounds' multiple contributing causes, including neuropathy, vascular occlusive disease, infection, and impaired wound healing. Proper attention to each cause may require consultations with vascular or orthopedic surgeons, diabetic education nurses, podiatrists, orthotists, and pedorthists. Wounds that fail to heal may respond to topical application of growth factors as part of a comprehensive clinical approach to the diabetic foot wound. An aggressive approach to diagnosis and treatment can result in improved wound healing and limb salvage.
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Affiliation(s)
- J E Keyser
- Baptist Wound Care Center, Nashville, TN 37203
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Naves CC. The Diabetic Foot: A Historical Overview and Gaps in Current Treatment. Adv Wound Care (New Rochelle) 2016; 5:191-197. [PMID: 27134763 PMCID: PMC4827295 DOI: 10.1089/wound.2013.0518] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 02/20/2014] [Indexed: 01/13/2023] Open
Abstract
Significance: The number of patients with diabetes is rapidly increasing around the world. A large percentage of this population can be expected to develop diabetic ulcers. The economic, social, and public health burden of these ulcers is enormous. It is a common problem that is tackled every day by many healthcare workers throughout the world. Recent Advances: Many pioneers contributed to the good standard of care we have today when treating diabetes and its complications. Current treatment of diabetic foot ulcers involves a multidisciplinary team approach, controls the underlying disease, and treats the wounds using debridement, different wound dressings, and redistributes pressure off the wound. Critical Issues: Since the discovery of the association between diabetes and gangrene of the foot 160 years ago, there have been developments and milestones that are the base of our treatment today. However, with all the modern wound treatment available today, there is a group of patients with hard-to-heal ulcers who do not seem to respond to the regular treatment. Future Directions: It is clear that more research has to be done to improve techniques that will enhance wound healing in chronic wounds. Innovative techniques will be discussed and outlined in this article.
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Massee M, Chinn K, Lim JJ, Godwin L, Young CS, Koob TJ. Type I and II Diabetic Adipose-Derived Stem Cells Respond In Vitro to Dehydrated Human Amnion/Chorion Membrane Allograft Treatment by Increasing Proliferation, Migration, and Altering Cytokine Secretion. Adv Wound Care (New Rochelle) 2016; 5:43-54. [PMID: 26862462 PMCID: PMC4742987 DOI: 10.1089/wound.2015.0661] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective: Human amniotic membranes have been shown to be effective for healing diabetic foot ulcers clinically and to regulate stem cell activity in vitro and in vivo; however, diabetic stem cells may be impaired as a sequela of the disease. In this study, dehydrated human amnion/chorion membrane (dHACM) allografts (EpiFix®; MiMedx Group) were evaluated for their ability to regulate diabetic stem cells in vitro. Approach: Human adipose-derived stem cells (ADSCs) from normal, type I diabetic, and type II diabetic donors were treated with soluble extracts of dHACM and evaluated for proliferation after 3 days by DNA assay, chemotactic migration after 1 day by transwell assay, cytokine secretion after 3 days by multiplex ELISA, and gene expression after 5 days by reverse transcription-polymerase chain reaction. Results: Although diabetic ADSCs demonstrated decreased responses compared to normal ADSCs, dHACM treatment stimulated diabetic ADSCs to proliferate after 3 days and enhanced migration over 24 h, similar to normal ADSCs. dHACM-treated diabetic ADSCs modulated secretion of soluble signals, including regulators of inflammation, angiogenesis, and healing. All ADSCs evaluated also responded to dHACM treatment with altered expression of immunomodulatory genes, including interleukins (IL)-1α, IL-1β, and IL-1RA. Innovation: This is the first reported case demonstrating that diabetic ADSCs respond to novel amniotic membrane therapies, specifically treatment with dHACM. Conclusion: dHACM stimulated diabetic ADSCs to migrate, proliferate, and alter cytokine expression suggesting that, despite their diabetic origin, ADSCs may respond to dHACM to accelerate diabetic wound healing.
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Abstract
Bloodstream infections (BSI) carry a heavy burden of morbidity and mortality in modern internal medicine wards (IMW). These wards are often filled with elderly subjects with several risk factors for BSI, such as multiple comorbidities, polypharmacy, immunosuppression, and indwelling devices. Diagnosing BSI in such a setting might require a high degree of suspicion, since the clinical presentation could be affected by underlying conditions and concomitant medications, which might delay the administration of an appropriate antimicrobial therapy, an event strongly and unfavorably influencing survival. Furthermore, selecting the appropriate antimicrobial therapy to treat these patients is becoming an increasingly complex task in which all possible benefits and costs should be carefully analyzed from patient and public health perspectives. Only a specialized, continuous, and interdisciplinary approach could really improve the management of IMW patients in an era of increasing antimicrobial resistance and complexity of care.
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Affiliation(s)
- Valerio Del Bono
- a Clinica Malattie Infettive, IRCCS AOU San Martino-IST, Università di Genova , Genova , Italy
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46
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Mills JL. Lower limb ischaemia in patients with diabetic foot ulcers and gangrene: recognition, anatomic patterns and revascularization strategies. Diabetes Metab Res Rev 2016; 32 Suppl 1:239-45. [PMID: 26455728 DOI: 10.1002/dmrr.2753] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 09/17/2015] [Accepted: 10/06/2015] [Indexed: 12/27/2022]
Abstract
The confluence of several chronic conditions--in particular ageing, peripheral artery disease, diabetes, and chronic kidney disease--has created a global wave of lower limbs at risk for major amputation. While frequently asymptomatic or not lifestyle limiting, at least 1% of the population has peripheral artery disease of sufficient severity to be limb threatening. To avoid the critical error of failing to diagnose ischaemia, all patients with diabetic foot ulcers and gangrene should routinely undergo physiologic evaluation of foot perfusion. Ankle brachial index is useful when measurable, but may be falsely elevated or not obtainable in as many as 30% of patients with diabetic foot ulcers primarily because of medial calcinosis. Toe pressures and skin perfusion pressures are applicable to such patients.
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Hinchliffe RJ, Brownrigg JRW, Andros G, Apelqvist J, Boyko EJ, Fitridge R, Mills JL, Reekers J, Shearman CP, Zierler RE, Schaper NC. Effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review. Diabetes Metab Res Rev 2016; 32 Suppl 1:136-44. [PMID: 26342204 DOI: 10.1002/dmrr.2705] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Symptoms or signs of peripheral artery disease (PAD) can be observed in up to 50% of the patients with a diabetic foot ulcer and is a risk factor for poor healing and amputation. In 2012, a multidisciplinary working group of the International Working Group on the Diabetic Foot published a systematic review on the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. This publication is an update of this review and now includes the results of a systematic search for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980 to June 2014. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 56 articles were eligible for full-text review. There were no randomized controlled trials, but there were four nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70-89%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular techniques. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of conservatively treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.
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Affiliation(s)
- R J Hinchliffe
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J R W Brownrigg
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | - G Andros
- Amputation Prevention Center, Valley Presbyterian Hospital, Los Angeles, CA, USA
| | - J Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - E J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, WA, USA
| | - R Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - J L Mills
- Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, USA
| | - J Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - C P Shearman
- Department of Vascular Surgery, Southampton University Hospitals NHS Trust, Southampton, UK
| | - R E Zierler
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - N C Schaper
- Division Endocrinology, MUMC+, CARIM Institute, Maastricht, The Netherlands
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48
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Suh HS, Oh TS, Hong JP. Innovations in diabetic foot reconstruction using supermicrosurgery. Diabetes Metab Res Rev 2016; 32 Suppl 1:275-80. [PMID: 26813618 DOI: 10.1002/dmrr.2755] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 07/31/2015] [Accepted: 10/06/2015] [Indexed: 11/08/2022]
Abstract
The treatment of diabetic foot ulceration is complex with multiple factors involved, and it may often lead to limb amputation. Hence, a multidisciplinary approach is warranted to cover the spectrum of treatment for diabetic foot, but in complex wounds, surgical treatment is inevitable. Surgery may involve the decision to preserve the limb by reconstruction or to amputate it. Reconstruction involves preserving the limb with secure coverage. Local flaps usually are able to provide sufficient coverage for small or moderate sized wound, but for larger wounds, soft tissue coverage involves flaps that are distantly located from the wound. Reconstruction of distant flap usually involves microsurgery, and now, further innovative methods such as supermicrosurgery have further given complex wounds a better chance to be reconstructed and limbs salvaged. This article reviews the microsurgery involved in reconstruction and introduces the new method of supermicrosurgery.
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Affiliation(s)
- Hyun Suk Suh
- Department of Plastic and Reconstructive Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - Tae Suk Oh
- Department of Plastic and Reconstructive Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, South Korea
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Karri VVSR, Kuppusamy G, Talluri SV, Yamjala K, Mannemala SS, Malayandi R. Current and emerging therapies in the management of diabetic foot ulcers. Curr Med Res Opin 2016; 32:519-42. [PMID: 26643047 DOI: 10.1185/03007995.2015.1128888] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Diabetic foot ulcers are one of the major causes of mortality in diabetic patients. Very few drugs and therapies have regulatory approval for this indication and several agents from diverse pharmacological classes are currently in various phases of clinical trials for the management of diabetic foot ulcers. SCOPE The purpose of this review is to provide concise information of the drugs and therapies which are approved and present in clinical trials. REVIEW METHODS This review was carried out by systematic searches of relevant guidelines, patents, published articles, reviews and abstracts in PubMed/Medline, Web of Science, clinicaltrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Google Scholar of all English language articles up to 1 March 2015. The following search terms were used: diabetes, diabetic foot, diabetic foot ulcer, diabetic wound, diabetic foot infections, wound management, randomized controlled trials, approved treatments, new treatments and clinical trials. CONCLUSIONS The various drugs and therapies for the management of diabetic foot ulcers comprise antibiotics, neuropathic drugs, wound dressings, skin substitutes, growth factors and inflammatory modulators. The majority of these therapies target the treatment of diabetic foot ulcers to address the altered biochemical composition of the diabetic wound. However, no single treatment can be definitively recommended for the treatment of diabetic foot ulcers.
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Affiliation(s)
| | - Gowthamarajan Kuppusamy
- a a Department of Pharmaceutics, JSS College of Pharmacy, Ootacamund , JSS University , Mysore , India
| | | | - Karthik Yamjala
- b b Department of Pharmaceutical Analysis, JSS College of Pharmacy, Ootacamund , JSS University , Mysore , India
| | - Sai Sandeep Mannemala
- b b Department of Pharmaceutical Analysis, JSS College of Pharmacy, Ootacamund , JSS University , Mysore , India
- c c Department of Pharmacy, Faculty of Engineering and Technology , Annamalai University , Annamalai Nagar, Tamil Nadu , India
| | - Rajkumar Malayandi
- d d Pharmacokinetic Research and Development, Sun Pharmaceutical Industries Ltd , Baroda , India
- e e JSS College of Pharmacy, Ootacamund , JSS University , Mysore , India
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50
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Brownrigg JRW, Schaper NC, Hinchliffe RJ. Diagnosis and assessment of peripheral arterial disease in the diabetic foot. Diabet Med 2015; 32:738-47. [PMID: 25764390 DOI: 10.1111/dme.12749] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2015] [Indexed: 01/20/2023]
Abstract
Approximately half of all patients with a diabetic foot ulcer have co-existing peripheral arterial disease. Identifying peripheral arterial disease among patients with foot ulceration is important, given its association with failure to heal, amputation, cardiovascular events and increased risk of premature mortality. Infection, oedema and neuropathy, often present with ulceration, may adversely affect the performance of diagnostic tests that are reliable in patients without diabetes. Early recognition and expert assessment of peripheral arterial disease allows measures to be taken to reduce the risk of amputation and cardiovascular events, while determining the need for revascularization to promote ulcer healing. When peripheral arterial disease is diagnosed, the extent of perfusion deficit should be measured. Patients with a severe perfusion deficit, likely to affect ulcer healing, will require further imaging to define the anatomy of disease and indicate whether a revascularization procedure is appropriate.
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Affiliation(s)
| | - N C Schaper
- Division of Endocrinology, Department of Medicine, Maastricht University Medical Centre, The Netherlands
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