Comparative efficacy of nine different dressings in healing diabetic foot ulcer: A Bayesian network analysis

Mechanism of wound repair in diabetic rats using nanosilver-free alginate dressing

OBJECTIVE

Nanosilver-alginate dressing can effectively promote the healing of diabetic wounds in rats. However, due to the potential toxicity of nanosilver, its widespread application in hard-to-heal wound healing is limited. In the present study, the role and potential mechanism of nanosilver-free alginate gel (NSFAG) in the healing process of diabetic wounds were explored.

METHOD

A diabetic rat skin wound model was established, and wounds were treated with saline (NC group), nanosilver gel (NSG group) or nanosilver-free alginate gel (NSFAG group) for seven consecutive days.

RESULTS

NSFAG significantly promoted wound healing and increased the content of protein and hydroxyproline in granulation tissues, and was superior to NSG (p<0.05). Immunohistochemical analyses revealed that the skin wound tissue structure of the NSFAG group was intact, and the number of skin appendages in the dermis layer was significantly higher compared with the NC group and the NSG group (p<0.05). Western blot analysis found that the protein expression of the epidermal stem cell marker molecules CK19 and CK14 as well the proliferation marker of keratinocytes Ki67 in the NSFAG group was significantly higher compared with the NC group or NSG group (p<0.05). Additionally, the proliferation marker of keratinocytes Ki67 in the NSFAG group was significantly higher compared with the NC or NSG group (p<0.05). Immunofluorescence staining analyses indicated that the CK19- and CK14-positive cells were mainly distributed around the epidermis and the newly formed appendages in the NSFAG group, and this result was not observed in the NC or NSG groups.

CONCLUSION

The present findings demonstrate that NSFAG can effectively accelerate wound healing in diabetic rats by promoting epidermal stem cell proliferation and differentiation into skin cells, as well as formation of granulation tissue, suggesting that it can be a potential dressing for diabetic wounds.

Assessment framework for the selection of a potential interactive dressing material for diabetic foot ulcer

Diabetic foot ulcer is a chronic health issue leading to lower leg amputations in approximately 15% of patients with diabetics. There are many factors directly or indirectly involved in the physiology of wound healing but being a multisystem disorder, wound healing in diabetic patients retard or worsen with heavy exudates and severe microbial infections. Wound management is of prime importance and is an emerging area to incorporate wound regenerative materials in natural or synthetic dressing materials along with proper microbial control. The article aim to identify suitable dressing materials which exhibit inherent wound healing properties at the same time flexible to be used as drug carriers for slow, consistent and effective delivery of 'functional drugs' to the wound environment. The authors selected nine materials from the popular and well accepted dressings of patient choice, analyzed them using graph theoretic approach and ranked them on the basis of graph index values obtained. A critical review has also been done on the basis of their ranking, providing insights to the advantages, disadvantage and potential of top 5 ranked candidate materials. Alginate, Honey, Medifoam, Saline, and Hydrogel dressings were the top five candidate materials ranked respectively, even then, the authors suggests that 'modified hydrogels' can have the potential to be used as a future candidate in DFU treatment as it is the only material (among the top ranked ones) which can effectively used as regenerative drug carrier, while providing all other wound healing properties in relative proportions. The proposed framework can be modified and applied in the selection and ranking of materials for any kind of applications both in industry and medical fields by identifying factors influencing the final outcome of study and by listing the characteristics of the materials selected.

Prospective randomised placebo-controlled trial assessing the efficacy of silver dressings to enhance healing of acute diabetes-related foot ulcers

AIMS/HYPOTHESIS

Silver dressings are used for their antimicrobial properties but there is limited evidence of clinical benefit when managing diabetes-related foot ulcers (DFUs). We aimed to assess whether silver dressings in acute DFUs increased the proportion of ulcers healed compared with non-silver dressings.

METHODS

In this open-labelled, randomised controlled trial, consecutive individuals who presented to a tertiary multidisciplinary diabetic foot service with a DFU without osteomyelitis or tendon on view of <6 weeks' duration were randomised 1:1 via a computer-generated randomisation process to receive Acticoat (Smith & Nephew, England) dressing (silver group) or dressing without silver (control group) in addition to standard care. Stratified randomisation was performed to ensure that the presence of peripheral arterial disease and infection were equally managed within the two groups. The primary outcome was the proportion of ulcers healed at 12 weeks. Secondary outcomes included time to heal and to 50% ulcer reduction, rates of osteomyelitis and amputation, and need for and duration of antibiotics.

RESULTS

Seventy-six ulcers (55 participants) in the control group and 91 ulcers (63 participants) in the silver group were included. There was no difference in the proportion of ulcers healed by 12 weeks in the control vs silver group (75% vs 69%, p=0.49). After adjustment for presence of peripheral arterial disease, infection and initial ulcer size, silver dressing was not associated with odds of healing (OR 0.92; CI 0.26, 3.22; p=0.53). There was no difference in time to healing, progression to osteomyelitis, need for amputation, or duration of or need for antibiotic treatment.

CONCLUSIONS/INTERPRETATION

In individuals with acute DFUs without osteomyelitis or tendon on view, Acticoat silver dressings did not improve wound healing or reduce need for antibiotics compared with non-silver dressings.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12614001234606 FUNDING: Australian Diabetes Society-unrestricted research award.

The Promising Hydrogel Candidates for Preclinically Treating Diabetic Foot Ulcer: A Systematic Review and Meta-Analysis

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.

Recent advances of the nanocomposite hydrogel as a local drug delivery for diabetic ulcers

Diabetic ulcer is a serious complication of diabetes. Compared with that of healthy people, the skin of patients with a diabetic ulcer is more easily damaged and difficult to heal. Without early intervention, the disease will become increasingly serious, often leading to amputation or even death. Most current treatment methods cannot achieve a good wound healing effect. Numerous studies have shown that a nanocomposite hydrogel serves as an ideal drug delivery method to promote the healing of a diabetic ulcer because of its better drug loading capacity and stability. Nanocomposite hydrogels can be loaded with one or more drugs for application to chronic ulcer wounds to promote rapid wound healing. Therefore, this paper reviews the latest progress of delivery systems based on nanocomposite hydrogels in promoting diabetic ulcer healing. Through a review of the recent literature, we put forward the shortcomings and improvement strategies of nanocomposite hydrogels in the treatment of diabetic ulcers.

An Overview of Diabetic Foot Ulcers and Associated Problems with Special Emphasis on Treatments with Antimicrobials

One of the most significant challenges of diabetes health care is diabetic foot ulcers (DFU). DFUs are more challenging to cure, and this is particularly true for people who already have a compromised immune system. Pathogenic bacteria and fungi are becoming more resistant to antibiotics, so they may be unable to fight microbial infections at the wound site with the antibiotics we have now. This article discusses the dressings, topical antibacterial treatment, medications and debridement techniques used for DFU and provides a deep discussion of DFU and its associated problems. English-language publications on DFU were gathered from many different databases, such as Scopus, Web of Science, Science Direct, Springer Nature, and Google Scholar. For the treatment of DFU, a multidisciplinary approach involving the use of diagnostic equipment, skills, and experience is required. Preventing amputations starts with patient education and the implementation of new categorization systems. The microbiota involved in DFU can be better understood using novel diagnostic techniques, such as the 16S-ribosomal DNA sequence in bacteria. This could be achieved by using new biological and molecular treatments that have been shown to help prevent infections, to control local inflammation, and to improve the healing process.

Effect of Hydrogel Use on Healing Diabetic Foot Ulcers: Systematic Review

Background The prevalence of diabetic foot ulcers in Indonesia with an amputation rate of 15%, a mortality rate of 32% and diabetic ulcers as the cause of hospitalization is 80%. One of the treatments for diabetic foot ulcers is using a hydrogel dressing. Purpose this systematic review aims to determine the effect of using hydrogel on the healing of diabetic foot ulcers. The design in this scientific paper is a systematic review by searching using an electronic database, namely Semantic Scholar and Pubmed. Methode The keywords used in the search are; Diabetic foot ulcer OR diabetic foot wound AND hydrogel dressing OR hydrogel use AND wound healing. With accessible inclusion criteria, the subject is patients with diabetic foot ulcers, Fulltext manuscript, the language used is Indonesian and English, published in the last 10 years, according to the research topic. Based on a review of the systematic review of 2 articles, it shows that healing of diabetic foot ulcers using hydrogel is quite short, 7-9 days good changes have been seen, starting to have granulation tissue, namely the color of the wound is bright red, the edges of the wound are clearly visible. Results of the systematic review show that hydrogel can help heal diabetic foot ulcers.

Diabetic foot ulcer, antimicrobial remedies and emerging strategies for the treatment

According to the International Diabetes Federation's 2015 study, diabetes affects over 415 million people globally (5 million of whom die each year), and the incidence of diabetes is expected to climb to over 640 million (1 in 10) by 2040. (IDF 2015). Diabetes foot ulcers (DFU) are one of the most significant diabetic health consequences. Antimicrobial treatments, such as dressings, topical therapies, medicines, drugs, debridement procedures, molecular, cellular, and gene therapies, plant extracts, antimicrobial peptides, growth factors, devices, ozone, and energy-based therapies, would be the focus of this study. Scopus, Web of Science, Bentham Science, Science Direct, and Google Scholar were among the sources used to compile the English-language publications on DFU. DFU treatment requires a multidisciplinary approach that includes the use of proper diagnostic tools, competence, and experience. To prevent amputations, this starts with patient education and the use of new categories to steer treatment. New diagnostic methods, such as the 16S ribosomal DNA sequence in bacteria, should become available to acquire a better knowledge of the microbiota in DFUs. 

Effect of the Kanghuier Transparent Hydrocolloid Dressing in Preventing Central Venous Catheter Infection and Phlebitis after Cardiac Surgery

Background

As cardiac surgery is complicated, time-consuming, and traumatic, it may cause great damage to the patient's body. Therefore, postoperative indwelling venous catheters are required for hemodynamic monitoring and rapid fluid replenishment. Intravenous catheterization infection can easily lead to phlebitis, which not only affects the success of the operation and patient recovery but may also lead to death in severe cases. Good perioperative care is key to reducing postoperative infection in patients, and the choice of dressings for patients with catheterization plays an important role in reducing catheter infection.

Objective

The Kanghuier transparent hydrocolloid dressing is known to effectively prevent and treat wound infections. This study is aimed at exploring whether it can reduce the incidence of postoperative catheter infection and phlebitis in patients undergoing cardiac surgery.

Methods

A total of 196 patients undergoing cardiac surgery in the Department of Cardiothoracic Surgery of Zhuhai People's Hospital (Zhuhai Hospital Affiliated with Jinan University) from January 2020 to June 2020 were selected. Among them, 98 patients receiving Kanghuier transparent dressing intervention were selected as group A, and the remaining 98 patients receiving traditional sterile gauze intervention were selected as group B. The incidence of infection and related complications, phlebitis, inflammatory factors, pain at the infusion site, nursing comfort and satisfaction, and quality of life were analyzed and compared between the two groups.

Results

It was found that compared with group B, the postoperative central venous catheter infection rate and the incidence of phlebitis were significantly lower in group A. In addition, the inflammatory response of patients in group A was better relieved. Moreover, the nursing comfort and satisfaction and the quality of life of patients in group A were significantly improved.

Conclusion

This study suggests that the Kanghuier transparent hydrocolloid dressing is effective in the prevention and treatment of central venous catheter infection and phlebitis in patients after heart surgery.

Emergence of microneedles as a potential therapeutics in diabetes mellitus

Diabetes mellitus is a severe condition in which the pancreas produces inadequate insulin or the insulin generated is ineffective for utilisation by the body; as a result, insulin therapy is required for control blood sugar levels in patients having type 1 diabetes and is widely recommended in advanced type 2 diabetes patients with uncontrolled diabetes despite dual oral therapy, while subcutaneous insulin administration using hypodermic injection or pump-mediated infusion is the traditional route of insulin delivery and causes discomfort, needle phobia, reduced adherence, and risk of infection. Therefore, transdermal insulin delivery has been extensively explored as an appealing alternative to subcutaneous approaches for diabetes management which not only is non-invasive and easy, but also avoids first-pass metabolism and prevents gastrointestinal degradation. Microneedles have been commonly investigated in human subjects for transdermal insulin administration because they are minimally invasive and painless. The different types of microneedles developed for the transdermal delivery of anti-diabetic drugs are discussed in this review, including solid, dissolving, hydrogel, coated, and hollow microneedles. Numerous microneedle products have entered the market in recent years. But, before the microneedles can be effectively launched into the market, a significant amount of investigation is required to address the numerous challenges. In conclusion, the use of microneedles in the transdermal system is an area worth investigating because of its significant benefits over the oral route in the delivery of anti-diabetic medications and biosensing of blood sugar levels to assure improved clinical outcomes in diabetes management.

Novel therapeutic targets for diabetes-related wounds or ulcers: an update on preclinical and clinical research

INTRODUCTION

Diabetes-related wounds, particularly diabetes-related foot ulcers, are mainly caused by lack of foot sensation and high plantar tissue stress secondary to peripheral neuropathy, ischemia secondary to peripheral artery disease, and dysfunctional wound healing. Current management of diabetes-related wounds involves the offloading of high foot pressures and the treatment of ischemia through revascularization. Despite these treatments, the global burden of diabetes-related wounds is growing, and thus, novel therapies are needed. The normal wound healing process is a coordinated remodeling process orchestrated by fibroblasts, endothelial cells, phagocytes, and platelets, controlled by an array of growth factors. In diabetes-related wounds, these coordinated processes are dysfunctional. The past animal model and human research suggest that prolonged wound inflammation, failure to adequately correct ischemia, and impaired wound maturation are key therapeutic targets to improve diabetes-related wound healing.

AREAS COVERED

This review summarizes recent preclinical and clinical research on novel diabetes-related wound treatments. Animal models of diabetes-related wounds and recent studies testing novel therapeutic agents in these models are described. Findings from clinical trials are also discussed. Finally, challenges to identifying and implementing novel therapies are described.

EXPERT OPINION

Given the growing volume of promising drug therapies currently under investigation, it is expected within the next decade, that diabetes-related wound treatment will be transformed.

Treatment of diabetic foot ulcers

Background: Diabetic foot ulcers (DFUs), a risk factor for infection, remain a difficult clinical complication. Infected DFUs may be associated with lower extremity amputation. To achieve wound healing and avoid amputation, an assortment of dressing materials and negative pressure wound therapy (NPWT) have been used on soft tissue injuries resulting from infected DFUs. A great deal of interest about the use of dressing materials and NPWT in the treatment of DFUs has arisen. However, there have only been a few high-quality studies regarding this topic.Current Concepts: Ideal dressing materials should satisfy certain conditions to alleviate symptoms of DFU infection and enhance the wound healing process. A single dressing material cannot fulfill all of these requirements. Based on clinical trials, different dressing materials must be chosen according to the status of the individual wound environment, including the amount of exudate, degree of pain, severity of the infection, and cost-effectiveness. However, there has been no clear evidence that advanced wound dressing materials are superior to basic dressing materials in wound healing. Recently, NPWT has been used to cover the soft tissue defects of infected DFU with granulation tissue. NPWT may contribute to changing growth factor expression, micro- and macro-deformation, vascular flow, amount of exudate, and the bacterial environment in DFU, despite the unclear mechanism of its role in wound repair.Discussion and Conclusion: Further research to obtain high-quality evidence regarding the benefits of using dressing materials and NPWT is needed. The optimal protocol for DFU and cost-effectiveness should be included in these future studies.

The tip of the iceberg: an overview of diabetic foot disease

Diabetic foot disease is the leading cause of lower-extremity amputation globally and imposes a significant burden for healthcare services and patients alike. The main pathology is ulceration, due to neuropathy or peripheral arterial disease. The most frequent sign is ulceration on the foot. Ulceration needs to be referred to the multidisciplinary diabetic foot team promptly for a comprehensive management plan to be developed. Delay in referral is associated with poor outcomes. Management of diabetic foot ulceration is multifaceted, including offloading, revascularisation, infection control, debridement, glycaemic control and wound care. Management plans need to be patient focused and developed collaboratively across primary and secondary care settings.

Nonpharmacological Management of Diabetic Foot Ulcers: An Update

Diabetic foot ulcers (DFUs) are a common and serious complication of diabetes mellitus that is associated with increased morbidity and mortality, as well as substantial economic burden for the health care system. The standard of care for DFUs includes pressure off-loading, sharp debridement, and wound moisture balance, along with infection control and management of peripheral arterial disease. A variety of advanced modalities that target distinct pathophysiological aspects of impaired wound healing in diabetes are being studied as possible adjunct therapies for difficult to heal ulcers. These modalities include growth factors, stem cells, cultured fibroblasts and keratinocytes, bioengineered skin substitutes, acellular bioproducts, human amniotic membranes, oxygen therapy, negative pressure wound therapy, and energy therapies. Additionally, the use of advanced biomaterials and gene delivery systems is being investigated as a method of effective delivery of substances to the wound bed. In the present narrative review, we outline the latest advances in the nonpharmacological management of DFUs and summarize the efficacy of various standard and advanced treatment modalities.

Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)

In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.

Registry number: IPGRP-2020cn124

Comparative prevention potential of 10 mouthwashes on intolerable oral mucositis in cancer patients: A Bayesian network analysis

BACKGROUND

There is a wide variety of mouthwashes currently available for the prevention of intolerable oral mucositis (OM) onset. Because of a lack of evidence from head-to-head randomized controlled trials (RCTs), the relative effects of these mouthwashes in intolerable OM patients remain unclear. This study compared the preventive effect of ten mouthwashes in intolerable OM.

METHODS

A literature search was performed of the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and MEDLINE (PubMed) databases. Reports published from 1990 to 2019 focusing on mouthwashes for preventing OM were identified. Authors assessed the studies' risk of bias in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, and followed the PRISMA for Network Meta-Analyses Statement. Authors estimated summary odds ratios (ORs) using pairwise and Bayesian network meta-analysis with random effects.

RESULTS

Thirty-six RCTs, with a total of 2594 patients, were included in the present study. Bayesian network analysis showed that honey (Odd Ratio [OR] 0.17, 95%CI 0.09 to 0.30), chamomile (OR 0.09, 95% CI 0.01 to 0.52), curcumin (OR 0.23, 95% CI 0.08 to 0.67) and benzydamine (OR 0.26, 95% CI 0.12 to 0.54) mouthwashes were superior to placebo. Honey mouthwashes were more efficacious than chlorhexidine (OR 0.34, 95% CI 0.12 to 0.92), sucralfate (OR 0.26, 95% CI 0.06 to 0.96) and povidone-iodine (OR 0.30, 95% CI 0.11 to 0.82) mouthwashes. Other mouthwashes showed no significant differences.

CONCLUSIONS

According to the analysis of rank probabilities, chamomile, honey, curcumin and benzydamine mouthwashes may be the most advantageous in terms of the prevention of intolerable OM.