The use of an extract of Hypericum perforatum and Azadirachta indica in advanced diabetic foot: an unexpected outcome

Limonoids from neem (Azadirachta indica A. Juss.) are potential anticancer drug candidates

Neem (Azadirachta indica A. Juss.), a versatile evergreen tree recognized for its ethnopharmacological value, is a rich source of limonoids of the triterpenoid class, endowed with potent medicinal properties. Extracts of neem have been documented to display anticancer effects in diverse malignant cell lines as well as in preclinical animal models that has largely been attributed to the constituent limonoids. Of late, neem limonoids have become the cynosure of research attention as potential candidate agents for cancer prevention and therapy. Among the various limonoids found in neem, azadirachtin, epoxyazadiradione, gedunin, and nimbolide, have been extensively investigated for anticancer activity. Azadirachtin, a potent biodegradable pesticide, exhibits profound antiproliferative effects by preventing mitotic spindle formation and cell division. The antiproliferative activity of gedunin has been demonstrated to be mediated primarily via inhibition of heat shock protein90 and its client proteins. Epoxyazadiradione inhibits pro-inflammatory and kinase-driven signaling pathways to block tumorigenesis. Nimbolide, the most potent cytotoxic neem limonoid, inhibits the growth of cancer cells by regulating the phosphorylation of keystone kinases that drive oncogenic signaling besides modulating the epigenome. There is overwhelming evidence to indicate that neem limonoids exert anticancer effects by preventing the acquisition of hallmark traits of cancer, such as cell proliferation, apoptosis evasion, inflammation, invasion, angiogenesis, and drug resistance. Neem limonoids are value additions to the armamentarium of natural compounds that target aberrant oncogenic signaling to inhibit cancer development and progression.

Efficacy and safety of unilateral tibial cortex transverse transport on bilateral diabetic foot ulcers: A propensity score matching study

Background

Tibial Cortex Transverse Transport (TTT) has been demonstrated to be an effective treatment for unilateral diabetic foot ulcers (UDFUs). However, this retrospective study was designed to compare the efficacy and safety of unilateral TTT on bilateral diabetic foot ulcers (BDFUs).

Methods

This retrospective study included a review of patients with TTT treated from January 2017 to August 2019, Propensity Score Matching (PSM) was performed to compare patients with BDFUs to those with UDFUs. Ulcer healing, recurrence, and major amputation rates were evaluated at 1-year follow-up. Changes in foot vessels were assessed in the BDFUs group using computed tomography angiography (CTA).

Results

A total of 140 patients with DFUs (106 UDFUs and 34 BDFUs) were included in the study. UDFUs and BDFUs were matched in a 1:1 ratio (34 in each group) using PSM. No significant difference was observed at 1-year-follow-up [91.2% (31/34) vs. 76.5% (26/34), OR 0.315 (95% CI 0.08 to 1.31), P ​= ​0.10] and 6-month-follow-up [70.6% (24/34) vs. 50.0% (17/34), OR 0.85 (95% CI 0.15 to 1.13), P ​= ​0.08] in two groups. Significant differences in rates of major amputation and recurrence between the groups (P ​> ​0.05) were not observed. The BDFUs group appeared more angiogenesis of the foot by CTA after 8 weeks of operation.

Conclusion

Results of this study suggest that severe BDFUs can be effectively treated by unilateral TTT. TTT is easy to operate and effective, which may be a good alternative for treating severe BDFUs.

The translational potential of this article

In previous retrospective clinical studies, TTT has demonstrated promising clinical outcomes in the management of diabetic foot ulcers. In this current study, we aim to investigate the potential use of TTT in treating distant tissue defects by evaluating the limited availability and safety of TTT for the management of bilateral diabetic foot. While additional basic and clinical research is necessary to fully elucidate the underlying mechanisms, our study offers insight into the potential therapeutic use of TTT for this condition.

Traditional complementary and alternative medicine (TCAM) for diabetic foot ulcer management: A systematic review

Diabetic Foot Ulcers (DFUs) are a devastating micro-vascular complication of diabetes with an increased prevalence and incidence and high rate of morbidity and mortality. Since antibiotics are frequently used to treat DFU, managing the condition has proven to be extremely challenging and may eventually lead to the development of antibiotic resistance. Scientists from around the world are working to develop an alternative solution to the problem of drug resistance by exploring complementary and alternative medicines that may be obtained from natural sources. Hence, the review aims to comprehensively report the information on the natural treatments and therapy used to manage DFU. All of the information described in the current study was gathered from electronic scientific resources, including Google Scholar, PubMed, Scopus, Science Direct, and Springer Link. Findings from the current review revealed the pre-clinical and clinical utility of 18 medicinal plants, 1 isolated compound, 7 polyherbal formulations including herbal creams, a few micronutrients including vitamins and minerals, insect products such as propolis, honey and, Maggot debridement therapy for the treatment and management of DFU. Natural therapies possess better efficacy, low cost, and shorter duration of treatment when compared with the conventional treatments; hence, all information made available about them is crucial to alter the direction of treatment. Furthermore, the data presented in this review are up to date on the potential efficacy of natural complementary medicines for alleviating DFU problems in in vitro and in vivo tests, as well as clinical studies.

Plant Leaves Extract Irrigation on Wound Healing in Diabetic Foot Ulcers

Purpose

We aimed to evaluate and compare the efficacy of neem leaves extract with normal saline irrigation practice in wound dressing on healing outcome and clinic-physiological parameters among individuals with diabetic foot ulcer (DFU).

Methods

A quasiexperimental with repeated measures design was used on two study groups. One group received neem leaf extract wound irrigation and another group received normal saline wound irrigation. Study participants were randomly assigned to each group from 100 DFU individuals. Demographic and clinical data sheets were used to collect baseline information. Random blood sugar and HbA1C measurement was performed on the initial day of visit for all participants. We used the PUSH tool for wound assessment (wound surface area, exudate amount, and tissue type), and clinic physiological parameters (temperature, pulse rate, respiration, blood pressure, wound pain, wound infection, and local warmth) assessment was performed at baseline and then at the end of each week till four weeks were completed. Participants attended a foot clinic every 3rd or 4th day for wound care.

Results

Reduction of wound healing score (PUSH score) and other wound variables improved significantly in the neem leaves extract group (p < 0.001). There were no significant changes in the clinic-physiological parameters.

Conclusion

Neem leaves extract irrigation for foot ulcers is considered to be very safe as it did not cause any complication systematically during the study. Neem leaf extract solution can be used as an alternative solution for normal saline. Managing DFU requires continuous foot care and early risk identification of ulcer.

Traditionally Used Natural Products in Preventing Ionizing Radiation-Induced Dermatitis: First Review on the Clinical Studies

In the treatment of cancer, the use of ionizing radiation is an important modality. However, on the downside, radiation, when used for curative purposes, causes acute dermatitis or radiodermatitis at the site of radiation in most individuals. From a clinical viewpoint, severe dermatitis causes a burning and itching sensation is very painful, and severely affects the quality of life of the individual undergoing treatment. In worse situations, acute radiation dermatitis can cause gaps or breaks in the planned treatment and this can adversely affect the treatment objective and outcome.

BACKGROUND

In various traditional and folk systems of medicine, plants and plant products have been used since time immemorial for treating various skin ailments. Further, many cosmeceutical creams formulated based on knowledge from ethnomedicinal use are marketed and used to treat various ailments. In the current review, an attempt is made at summarizing the beneficial effects of some plants and plant products in mitigating acute radiation dermatitis in humans undergoing curative radiotherapy. Additionally, the emphasis is also placed on the mechanism/s responsible for the beneficial effects.

OBJECTIVE

The objective of this review is to summarize the clinical observations on the prevention of radiodermatitis by plant products. In this review, the protective effects of Adlay (Coix lachryma-jobi L.) bran extract, Aloe vera, Calendula officinalis, Cucumis sativus, green tea constituent the epigallocatechin-3-gallate, honey, Achillea millefolium, Matricaria chamomilla, olive oil and some polyherbal creams are addressed by also addressing on the mechanism of action for the beneficial effects.

METHODS

Two authors' data mined for information in Google Scholar, PubMed, Embase and the Cochrane Library for publications in the field from 1901 up to July 2020. The focus was on acute radiation dermatitis, ionizing radiation, curative radiotherapy, human cancer. The articles were collected and analyzed.

RESULTS

For the first time, this review addresses the usefulness of natural products like adlay bran, Aloe vera, Calendula officinalis, Cucumis sativus, green tea constituent the epigallocatechin-3-gallate, honey, Achillea millefolium, Matricaria chamomilla, olive oil and some experimentally constituted and commercially available polyherbal creams as skincare agents against the deleterious effects of ionizing radiation on the skin. The protective effects are possibly due to the free radical scavenging, antioxidant, anti-inflammatory, wound healing and skin protective effects.

CONCLUSION

The authors suggest that these plants have been used since antiquity as medicinal agents and require in-depth investigation with both clinical and preclinical validated models of study. The results of these studies will be extremely useful to cancer patients requiring curative radiotherapy, the dermatology fraternity, agro-based and pharmaceutical sectors at large.

Protective Role of St. John's Wort and Its Components Hyperforin and Hypericin against Diabetes through Inhibition of Inflammatory Signaling: Evidence from In Vitro and In Vivo Studies

Diabetes mellitus is a very common chronic disease with progressively increasing prevalence. Besides the well-known autoimmune and inflammatory pathogenesis of type 1 diabetes, in many people, metabolic changes and inappropriate lifestyle favor a subtle chronic inflammatory state that contributes to development of insulin resistance and progressive loss of β-cell function and mass, eventually resulting in metabolic syndrome or overt type 2 diabetes. In this paper, we review the anti-inflammatory effects of the extract of Hypericum perforatum L. (St. John's wort, SJW) and its main active ingredients firstly in representative pathological situations on inflammatory basis and then in pancreatic β cells and in obese or diabetic animal models. The simultaneous and long-lasting inhibition of signal transducer and activator of transcription (STAT)-1, nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and mitogen-activated protein kinases (MAPKs)/c-jun N-terminal kinase (JNK) signaling pathways involved in pro-inflammatory cytokine-induced β-cell dysfunction/death and insulin resistance make SJW particularly suitable for both preventive and therapeutic use in metabolic diseases. Hindrance of inflammatory cytokine signaling is likely dependent on the hyperforin content of SJW extract, but recent data reveal that hypericin can also exert relevant protective effects, mediated by activation of the cyclic adenosine monophosphate (cAMP)/protein kinase cAMP-dependent (PKA)/adenosine monophosphate activated protein kinase (AMPK) pathway, against high-fat-diet-induced metabolic abnormalities. Actually, the mechanisms of action of the two main components of SJW appear complementary, strengthening the efficacy of the plant extract. Careful quantitative analysis of SJW components and suitable dosage, with monitoring of possible drug-drug interaction in a context of remarkable tolerability, are easily achievable pre-requisites for forthcoming clinical applications.

Use of Neem oil and Hypericum perforatum for treatment of calcinosis-related skin ulcers in systemic sclerosis

Objective

This study evaluated Neem oil and Hypericum perforatum (Holoil®) for treatment of scleroderma skin ulcers related to calcinosis (SU-calc).

Procedure: We retrospectively analyzed 21 consecutive systemic sclerosis (SSc) patients with a total of 33 SU-calcs treated daily with Holoil® cream compared with a control group of 20 patients with 26 SU-calcs. Holoil® was directly applied to skin lesions, while the control group received only standard medication.

Results

Application of Holoil® either resulted in crushing and complete resolution of calcium deposits or facilitated sharp excision of calcinosis during wound care sessions in 27/33 cases (81.8%). Complete healing of SU-calc occurred in 15/33 (45%) of cases within a time period of 40.1 ± 16.3 (mean ± SD) days, while 18/33 (55%) of lesions improved in terms of size, erythema, fibrin and calcium deposits. Patients reported a reduction of pain (mean numeric rating scale 7.3 ± 1.9 at baseline versus 2.9 ± 1.4 at follow-up) The control group had longer healing times and a higher percentage of infections.

Conclusions

The efficacy of local treatment with neem oil and Hypericum perforatum suggest that Holoil® could be a promising tool in the management of SSc SU-calc.

Diabetic Foot Ulcers: Current Advances in Antimicrobial Therapies and Emerging Treatments

Diabetic foot ulcers (DFUs) are very important diabetes-related lesions that can lead to serious physical consequences like amputations of limbs and equally severe social, psychological, and economic outcomes. It is reported that up to 25% of patients with diabetes develop a DFU in their lifetime, and more than half of them become infected. Therefore, it is essential to manage infection and ulcer recovery to prevent negatives outcomes. The available information plays a significant role in keeping both physicians and patients aware of the emerging therapies against DFUs. The purpose of this review is to compile the currently available approaches in the managing and treatment of DFUs, including molecular and regenerative medicine, antimicrobial and energy-based therapies, and the use of plant extracts, antimicrobial peptides, growth factors, ozone, devices, and nano-medicine, to offer an overview of the assessment of this condition.

Neem (Azadirachta indica): An indian traditional panacea with modern molecular basis

BACKGROUND

For centuries, agents derived from natural sources (mother nature), especially plants have been the primary source of medicine. Neem, also referred to as Azadirachta indica is one such plant that has been so named because it provides freedom from all diseases, and used for thousands of years in Indian and African continents. Different parts of the plant including flowers, leaves, seeds and bark have been used to treat both acute and chronic human diseases; and used as insecticide; antimicrobial, larvicidal, antimalarial, antibacterial, antiviral, and spermicidal.

PURPOSE

What is there in neem and how it manifests its wide variety of effects is the focus of this review. How neem and its constituents modulate various cellular pathways is discussed. The animal and human studies carried out with neem and its constituents is also discussed.

CONCLUSION

Over 1000 research articles published on neem has uncovered over 300 structurally diverse constituents, one third of which are limonoids including nimbolide, azadarachtin, and gedunin. These agents manifest their effects by modulating multiple cell signaling pathways.

A multidisciplinary approach to scars: a narrative review

The purpose of this article is to carry out a narrative review regarding the approach to scars through complementary and alternative medicine focusing on osteopathy, naturopathy, and other minor methods and traditional rehabilitative medicines, such as physiotherapy and manual therapies. We analyzed the existing literature regarding the possible influences of techniques relaxing the diaphragm – both manual and psychophysical relaxing techniques – and the consequent local response to events leading to scar tissue healing. The objective of the study is to become a useful instrument of knowledge for those manual therapists and professionals who deal with patients affected by discontinuity of the skin surface due to trauma or surgery. This article also intends to stimulate research in order to find and propose new methods of scar treatment, taking into consideration the information gained so far from other complementary and alternative disciplines.

Hypericum perforatum and neem oil for the management of acute skin toxicity in head and neck cancer patients undergoing radiation or chemo-radiation: a single-arm prospective observational study

BACKGROUND

Radiation dermatitis is common in patients treated with combined radiotherapy and chemotherapy for head and neck malignancies. Its timely and adequate management is of uttermost importance for both oncological outcomes and global quality of life. We prospectively evaluated the role of hypericum perforatum and neem oil (Holoil®; RIMOS srl, Mirandola, Italy) in the treatment of acute skin toxicity for patients undergoing radiotherapy or chemo-radiotherapy for head and neck cancer.

METHODS

A consecutive series of 28 head and neck cancer patients submitted to radiotherapy (RT) was enrolled onto this mono-institutional single-arm prospective observational study. Patients undergoing both definitive or post-operative radiotherapy were allowed, either as exclusive modality or combined with (concomitant or induction) chemotherapy. We started Holoil treatment whenever bright erythema, moderate oedema or patchy moist desquamation were observed. Holoil® was used during all RT course and during follow up time, until acute skin toxicity recovery.

RESULTS

The maximum detected acute skin toxicity was Grade 1 in 7% of patients, Grade 2 in 68%, Grade 3 in 25%, while at the end of RT was Grade 0 in 3.5%, Grade 1 in 32%, Grade 2 in 61%, Grade 3 in 3.5%. For patients having G2 acute skin toxicity, it mainly started at weeks 4-5; for those having G3, it began during weeks 5-6. Median times spent with G2 or G3 toxicity were 17.5 and 11 days. Patients having G2 acute skin toxicity had a dermatitis worsening in 27% of case (median occurrence time: 7 days). G3 events were reconverted to a G2 profile in all patients (median time: 7 days). Those experiencing a G2 skin event were converted to a G1 score in 23% of cases (median time: 14 days). Time between maximum acute skin toxicity and complete skin recovery after RT was 27 days.

CONCLUSIONS

Holoil® proved to be a safe and active option in the management of acute skin toxicity in head and neck cancer patients submitted to RT or chemo-radiotherapy. A prophylactic effect in the prevention of moist desquamation may be hypothesized for hypericum and neem oil and need to be tested within a prospective controlled study.

The use of an extract of Hypericum perforatum and Azadirachta indica in a neuropathic patient with advanced diabetic foot

The successful use of an extract of Hypericum flowers (Hypericum perforatum) and nimh oil (Azadirachta indica; Hyperoil) in foot wounds with exposed bone in a patient with bilateral advanced diabetic ulcers, has been reported previously. It was hypothesised that this amelioration was linked with the improved glycaemic control and peripheral microvascular circulation. In this case report, the surprisingly successful outcome of another patient using Hyperoil for infection damaged diabetic foot, without prior use of surgical procedure, is described. The patient had no macrovascular pattern impairment. Diabetic foot healing paralleled with controlled local infection and enhanced glycaemic control. The outcome of this patient suggests that the effectiveness of this inexpensive therapy using Hyperoil for diabetic foot is not only linked with the presence of severe microvascular disorder, but also with the appropriate local treatment for ulcer being a must for its recovery.