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Armstrong DG, Orgill DP, Galiano RD, Glat PM, Kaufman JP, Carter MJ, DiDomenico LA, Zelen CM. A purified reconstituted bilayer matrix shows improved outcomes in treatment of non-healing diabetic foot ulcers when compared to the standard of care: Final results and analysis of a prospective, randomized, controlled, multi-centre clinical trial. Int Wound J 2024; 21:e14882. [PMID: 38606794 PMCID: PMC11010253 DOI: 10.1111/iwj.14882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/27/2024] [Indexed: 04/13/2024] Open
Abstract
As the incidence of diabetic foot ulcers (DFU) increases, better treatments that improve healing should reduce complications of these ulcers including infections and amputations. We conducted a randomized controlled trial comparing outcomes between a novel purified reconstituted bilayer membrane (PRBM) to the standard of care (SOC) in the treatment of non-healing DFUs. This study included 105 patients who were randomized to either of two treatment groups (n = 54 PRBM; n = 51 SOC) in the intent to treat (ITT) group and 80 who completed the study per protocol (PP) (n = 47 PRBM; n = 33 SOC). The primary endpoint was the percentage of wounds closed after 12 weeks. Secondary outcomes included percent area reduction, time to healing, quality of life, and cost to closure. The DFUs that had been treated with PRBM healed at a higher rate than those treated with SOC (ITT: 83% vs. 45%, p = 0.00004, PP: 92% vs. 67%, p = 0.005). Wounds treated with PRBM also healed significantly faster than those treated with SOC with a mean of 42 versus 62 days for SOC (p = 0.00074) and achieved a mean wound area reduction within 12 weeks of 94% versus 51% for SOC (p = 0.0023). There were no adverse events or serious adverse events that were related to either the PRBM or the SOC. In comparison to the SOC, DFUs healed faster when treated with PRBM. Thus, the use of this PRBM is an effective option for the treatment of chronic DFUs.
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Affiliation(s)
- David G. Armstrong
- Division of Surgery, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Dennis P. Orgill
- Division of Plastic SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
| | - Robert D. Galiano
- Division of Plastic Surgery, Feinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Paul M. Glat
- Surgery and PediatricsDrexel University College of Medicine, St. Christopher's Hospital for ChildrenPhiladelphiaPennsylvaniaUSA
| | - Jarrod P. Kaufman
- Department of Surgery, Temple University School of Medicine and McGowan Institute for Regenerative MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
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Zheng SY, Wan XX, Kambey PA, Luo Y, Hu XM, Liu YF, Shan JQ, Chen YW, Xiong K. Therapeutic role of growth factors in treating diabetic wound. World J Diabetes 2023; 14:364-395. [PMID: 37122434 PMCID: PMC10130901 DOI: 10.4239/wjd.v14.i4.364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/16/2023] [Accepted: 03/21/2023] [Indexed: 04/12/2023] Open
Abstract
Wounds in diabetic patients, especially diabetic foot ulcers, are more difficult to heal compared with normal wounds and can easily deteriorate, leading to amputation. Common treatments cannot heal diabetic wounds or control their many complications. Growth factors are found to play important roles in regulating complex diabetic wound healing. Different growth factors such as transforming growth factor beta 1, insulin-like growth factor, and vascular endothelial growth factor play different roles in diabetic wound healing. This implies that a therapeutic modality modulating different growth factors to suit wound healing can significantly improve the treatment of diabetic wounds. Further, some current treatments have been shown to promote the healing of diabetic wounds by modulating specific growth factors. The purpose of this study was to discuss the role played by each growth factor in therapeutic approaches so as to stimulate further therapeutic thinking.
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Affiliation(s)
- Shen-Yuan Zheng
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha 410013, Hunan Province, China
| | - Xin-Xing Wan
- Department of Endocrinology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
| | - Piniel Alphayo Kambey
- Department of Neurobiology and Anatomy, Xuzhou Medical University, Xuzhou 221004, Jiangsu Province, China
| | - Yan Luo
- Clinical Medicine Eight-Year Program, Xiangya School of Medicine, Central South University, Changsha 410013, Hunan Province, China
| | - Xi-Min Hu
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha 410013, Hunan Province, China
| | - Yi-Fan Liu
- Clinical Medicine Eight-Year Program, Xiangya School of Medicine, Central South University, Changsha 410013, Hunan Province, China
| | - Jia-Qi Shan
- Clinical Medicine Eight-Year Program, Xiangya School of Medicine, Central South University, Changsha 410013, Hunan Province, China
| | - Yu-Wei Chen
- Clinical Medicine Eight-Year Program, Xiangya School of Medicine, Central South University, Changsha 410013, Hunan Province, China
| | - Kun Xiong
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha 410013, Hunan Province, China
- Key Laboratory of Emergency and Trauma, College of Emergency and Trauma, Hainan Medical University, Haikou 571199, Hainan Province, China
- Hunan Key Laboratory of Ophthalmology, Central South University, Changsha 410013, Hunan Province, China
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Chiu A, Sharma D, Zhao F. Tissue Engineering-Based Strategies for Diabetic Foot Ulcer Management. Adv Wound Care (New Rochelle) 2023; 12:145-167. [PMID: 34939837 PMCID: PMC9810358 DOI: 10.1089/wound.2021.0081] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/26/2021] [Indexed: 01/13/2023] Open
Abstract
Significance: Diabetic foot ulcers (DFU) are a mounting problem with the increasingly frail population. Injuries that would otherwise heal are kept open by risk factors such as diabetes, obesity, and age-related conditions, which interferes with the natural wound healing processes. Recent Advances: This review summarizes recent advancements in the field of tissue engineering for the treatment of DFUs. FDA-approved approaches, including signaling-based therapies, stem cell therapies, and skin substitutes are summarized and cutting-edge experimental technologies that have the potential to manage chronic wounds, such as skin printing, skin organogenesis, skin self-assembly, and prevascularization, are discussed. Critical Issues: The standard of care for chronic wounds involves wound debridement, wound dressings, and resolving the underlying cause such as lowering the glycemic index and reducing wound pressure. Current DFU treatments are limited by low wound closure rates and poor regrown skin quality. New adjuvant therapies that facilitate wound closure in place of or in conjunction with standard care are critically needed. Future Directions: Tissue engineering strategies are limited by the plasticity of adult human cells. In addition to traditional techniques, genetic modification, although currently an emerging technology, has the potential to unlock human regeneration and can be incorporated in future therapeutics.
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Affiliation(s)
- Alvis Chiu
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - Dhavan Sharma
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - Feng Zhao
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
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Armstrong DG, Orgill DP, Galiano RD, Glat PM, Kaufman JP, Carter MJ, DiDomenico LA, Zelen CM. Use of a purified reconstituted bilayer matrix in the management of chronic diabetic foot ulcers improves patient outcomes vs standard of care: Results of a prospective randomised controlled multi-centre clinical trial. Int Wound J 2022; 19:1197-1209. [PMID: 35001559 PMCID: PMC9284637 DOI: 10.1111/iwj.13715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/14/2021] [Accepted: 10/20/2021] [Indexed: 11/28/2022] Open
Abstract
Diabetic foot infections continue to be a major challenge for health care delivery systems. Following encouraging results from a pilot study using a novel purified reconstituted bilayer matrix (PRBM) to treat chronic diabetic foot ulcers (DFUs), we designed a prospective, multi‐centre randomised trial comparing outcomes of PRBM at 12 weeks compared with a standard of care (SOC) using a collagen alginate dressing. The primary endpoint was percentage of wounds closed after 12 weeks. Secondary outcomes included assessments of complications, healing time, quality of life, and cost to closure. Forty patients were included in an intent‐to‐treat (ITT) and per‐protocol (PP) analysis, with 39 completing the study protocol (n = 19 PRBM, n = 20 SOC). Wounds treated with PRBM were significantly more likely to close than wounds treated with SOC (ITT: 85% vs 30%, P = .0004, PP: 94% vs 30% P = .00008), healed significantly faster (mean 37 days vs 67 days for SOC, P = .002), and achieved a mean wound area reduction within 12 weeks of 96% vs 8.9% for SOC. No adverse events (AEs) directly related to PRBM treatment were reported. Mean PRBM cost of healing was $1731. Use of PRBM was safe and effective for treatment of chronic DFUs.
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Affiliation(s)
- David G Armstrong
- Division of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Dennis P Orgill
- Professional Education and Research Institute, Roanoke, Virginia, USA
| | - Robert D Galiano
- Division of Plastic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Paul M Glat
- Surgery and Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
| | - Jarrod P Kaufman
- Department of Surgery, Temple University School of Medicine and McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Charles M Zelen
- Professional Education and Research Institute, Roanoke, Virginia, USA
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Burgess JL, Wyant WA, Abdo Abujamra B, Kirsner RS, Jozic I. Diabetic Wound-Healing Science. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1072. [PMID: 34684109 PMCID: PMC8539411 DOI: 10.3390/medicina57101072] [Citation(s) in RCA: 167] [Impact Index Per Article: 55.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/28/2021] [Accepted: 10/04/2021] [Indexed: 12/15/2022]
Abstract
Diabetes mellitus is an increasingly prevalent chronic metabolic disease characterized by prolonged hyperglycemia that leads to long-term health consequences. It is estimated that impaired healing of diabetic wounds affects approximately 25% of all patients with diabetes mellitus, often resulting in lower limb amputation, with subsequent high economic and psychosocial costs. The hyperglycemic environment promotes the formation of biofilms and makes diabetic wounds difficult to treat. In this review, we present updates regarding recent advances in our understanding of the pathophysiology of diabetic wounds focusing on impaired angiogenesis, neuropathy, sub-optimal chronic inflammatory response, barrier disruption, and subsequent polymicrobial infection, followed by current and future treatment strategies designed to tackle the various pathologies associated with diabetic wounds. Given the alarming increase in the prevalence of diabetes, and subsequently diabetic wounds, it is imperative that future treatment strategies target multiple causes of impaired healing in diabetic wounds.
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Affiliation(s)
| | | | | | - Robert S. Kirsner
- Wound Healing and Regenerative Medicine Research Program, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (J.L.B.); (W.A.W.); (B.A.A.)
| | - Ivan Jozic
- Wound Healing and Regenerative Medicine Research Program, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (J.L.B.); (W.A.W.); (B.A.A.)
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Functional Properties of a Purified Reconstituted Bilayer Matrix Design Support Natural Wound Healing Activities. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3596. [PMID: 34036030 PMCID: PMC8140771 DOI: 10.1097/gox.0000000000003596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 03/09/2021] [Indexed: 12/26/2022]
Abstract
Biomaterial engineering has produced numerous matrices for use in tissue repair, utilizing various materials and processing methods, which can impact the ability of the products to encourage wound healing. Recently, we observed favorable clinical outcomes, using a novel purified reconstituted bilayer matrix (PRBM; Geistlich Derma-Gide) to treat chronic diabetic foot ulcers.
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Armstrong DG. Comment on "An observational pilot study using a purified reconstituted bilayer matrix to treat non-healing diabetic foot ulcers". Int Wound J 2020; 18:554-555. [PMID: 33241635 PMCID: PMC8273616 DOI: 10.1111/iwj.13514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- David G Armstrong
- Southern Arizona Limb Salvage Alliance, University of Arizona, Tucson, Arizona, USA
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Isaac AL, Tritto M. Comment on "An observational pilot study using a purified reconstituted bilayer matrix to treat non-healing diabetic foot ulcers". Int Wound J 2020; 18:552-553. [PMID: 33089605 PMCID: PMC8273620 DOI: 10.1111/iwj.13513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/28/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Adam L Isaac
- Foot and Ankle Specialists of the Mid-Atlantic, LLC, Rockville, Maryland, USA
| | - Michael Tritto
- Foot and Ankle Specialists of the Mid-Atlantic, LLC, Rockville, Maryland, USA
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Armstrong DG, Orgill DP, Galiano RD, Glat PM, Kaufman JP, Carter MJ, Zelen CM. An observational pilot study using a purified reconstituted bilayer matrix to treat non-healing diabetic foot ulcers. Int Wound J 2020; 17:966-973. [PMID: 32266774 PMCID: PMC7384195 DOI: 10.1111/iwj.13353] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/07/2020] [Accepted: 03/09/2020] [Indexed: 12/18/2022] Open
Abstract
Diabetic foot ulcers (DFUs) have significant clinical impact and carry a substantial economic burden. Patients with DFUs that are refractory to standard wound care are at risk for major complications, including infection and amputation and have an increased risk of mortality. This study evaluated the safety and preliminary efficacy of a novel decellularised purified reconstituted bilayer matrix (PRBM) in treating DFUs. Ten diabetic patients with refractory wounds that failed to heal after at least 4 weeks of standard wound care were studied in this Institutional Review Board approved trial. Ten consecutive wounds were treated weekly with the PRBM for up to 12 weeks. At each weekly visit, the wound was evaluated, photographed, and cleaned, followed by application of new graft if not completely epithelialised. Assessment included measurement of the wound area and inspection of the wound site for signs of complications. The primary outcome measure was wound closure, as adjudicated by independent reviewers. Secondary outcomes included assessment of overall adverse events, time to closure, percent area reduction, and the cost of product(s) used. Nine of 10 patients achieved complete wound closure within 4 weeks, and 1 did not heal completely within 12 weeks. The mean time to heal was 2.7 weeks. The mean wound area reduction at 12 weeks was 99%. No adverse events nor wound complications were observed. These early clinical findings suggest that the PRBM may be an effective tool in the treatment of diabetic foot ulcers.
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Affiliation(s)
- David G Armstrong
- Division of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Dennis P Orgill
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert D Galiano
- Division of Plastic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Paul M Glat
- Professor of Surgery and Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
| | - Jarrod P Kaufman
- Department of Surgery, Temple University School of Medicine and McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Charles M Zelen
- Professional Education and Research Institute, Roanoke, Virginia, USA
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