Wound Closure in Smoking Peripheral Arterial Disease Patients With Treatment-Refractory Ulcerations: A 12-Month Follow-up Case Series

Plantar thermography predicts freedom from major amputation after endovascular therapy in critical limb ischemic patients

Although plantar thermography can evaluate the immediate perfusion result after an endovascular therapy (EVT) has been performed, a relevant wound outcome study is still lacking.This study was to investigate whether angiosome-based plantar thermography could predict wound healing and freedom from major amputation after EVT in patients with critical limb ischemia (CLI).All 124 patients with CLI (Rutherford category 5 and 6) who underwent EVT from January 2017 to February 2019 were prospectively enrolled. All patients received thermography both before and after EVT. Both wound healing and freedom from major amputation at the 6-month follow-up period were recorded. There were 61 patients in the healing group and 63 patients in the non-healing group, whereas the major amputation total was 14 patients. The mean pre- and post-EVT temperature of the foot was significantly higher in the healing group than in the non-healing group (30.78 °C vs 29.42 °C, P = .015; and 32.34 °C vs 30.96 °C, P = .004, respectively). DIFF2 was significantly lower in the non-healing group (-1.38 vs -0.90, P = .009). DIFF1 and DIFF2 were significantly lower in the amputation group (-1.85 °C vs -1.11 °C, P = .026; and -1.82 °C vs -1.08 °C, P = .004). Multivariate analysis showed that DIFF2 stood out as an independent predictor for freedom from major amputation (hazard ratio 0.51, P = .045). Receiver operating characteristic curve analysis showed a DIFF2 cut-off value of -1.30 °C, which best predicts freedom from major amputation.Plantar thermography is associated with wound healing and helps predict freedom from major amputation in CLI patients undergoing EVT.

Photodynamic Topical Antimicrobial Therapy for Infected Diabetic Foot Ulcers in Patients With Diabetes: A Case Series

Diabetic foot ulcers (DFUs) are common, complex, costly complications, associated with frequent recurrences and increased morbidity and mortality. DFUs can be prevented and their healing can be mostly influenced by appropriately and aggressively managing any infection, but the role of antiseptic therapies in reducing healing time lacks sufficient evidence. Several therapeutic interventions have been developed based on the principles of photomedicine to overcome the issue of poor drug circulation in infected areas, with the aim of killing microbial agents while leaving the surrounding host cells unharmed. Such techniques use absorption of photons by specific chromophores. Among these, RLP068 is a tetracationic Zn(II) phthalocyanine derivative activated by exposure to red light, used as a topical treatment for superficial bacterial and fungal infections. The photoactivation of RLP068 results in the production of singlet oxygen and other reactive oxygen species, able to affect a range of cellular targets, including cell membrane and/or wall, cytoplasm, and cellular components, resulting in a rapid, broad range, bactericidal and fungicidal effect. The phase IIa study showed that photoactivated RPL068 is capable of inducing a dose-dependent reduction in total and pathogen microbial load in infected diabetic foot ulcers. In this article, a case series of 22 DFU treated with photoactivated RLP068 at 5 different centers in Italy is presented. Considering microbial agents reduction, ulcer healing facilitation, healing rate (9 DFUs out of 22), and amputation rate (only 1 case over 22), the decrease in the cost of DFU seems to be a point in favor of RLP068 and its cost-effectiveness.

Wound Closure Outcomes Suggest Clinical Equivalency Between Lyopreserved and Cryopreserved Placental Membranes Containing Viable Cells

Objective: To evaluate the clinical outcomes of lyopreserved placental membrane containing viable cells (vLPM) in the treatment of nonhealing wounds of various etiologies, and to compare them to those previously reported for cryopreserved placental membrane containing viable cells (vCPM).

Approach: Patients with nonhealing wounds who qualified to receive advanced wound therapies were consecutively enrolled and treated weekly with vLPM plus standard of care (SOC) at five centers. Data were de-identified and retrospectively analyzed. Outcomes included closure, time to closure, number of vLPM applications, and adverse events (AEs).

Results: Seventy-eight patients with 98 wounds (41 diabetic foot ulcers [DFUs], 19 venous leg ulcers [VLUs], 10 surgical, and 28 others) with an average size of 13.3 cm² and 8.7 months duration were treated. Fifty-eight of the 98 wounds (59.2%) achieved complete closure with median time to closure of 63 days and 6 vLPM applications. The closure by wound etiology was 63% for DFUs, 47% for VLUs, 70% for surgical wounds, and 57% for other types of wounds. Similar closure rates have been previously demonstrated for vCPM. Wound duration was the main predictor of closure: 65.8% versus 30.0% (p = 0.004) closure was achieved for wounds of ≤12 and >12 months duration, respectively. There were no AEs related to vLPM application.

Innovation: This is the first multicenter case series evaluating the clinical outcomes of vLPM in a real-world setting.

Conclusion: These results support clinical equivalency between the two placental membrane formulations with the added convenience of room-temperature storage for vLPM, allowing it to be used in any wound-care setting.

Treatment of Diabetic Foot Gangrene Using the STAGE Principle: A Case Series

Diabetic foot gangrene with lower extremity ischemia can preclude amputation. However, wound treatment principles based on the Wagner classification system are lacking. We proposed the STAGE principle for the surgical management of diabetic foot wounds. The STAGE principle guides surgical intervention during the wound treatment of diabetic foot ulcers and emphasizes that "based on anatomical layers, the management focuses on blood supply and includes layer-by-layer incision to the infected area, maintenance of effective wound drainage, and step-by-step treatment of the wound." We applied the STAGE principle for the treatment of 7 patients with an ankle brachial index <0.5 and Wagner grade 4 diabetic foot gangrene. The average ankle brachial index was 0.42 (0.32-0.48; SD = 0.06), and male patients smoked an average of 1.28 packs/day (0.4-2; SD = 0.63). The average wound duration was 45.86 days (14-63 days; SD = 18.46). The average wound healing time was 8.86 months (5-13 months; SD = 2.36). The follow-up time was 37.71 months (3-84 months; SD = 25.04; median = 36 months). Patient 1 received endovascular interventional therapy twice for the lower extremity artery, and the wound healed. After 3 months of follow-up, the patient exhibited recurrence. After the third application of endovascular interventional therapy for the lower extremity artery, the blood supply was improved, and the wound healed after 1 month. In summary, the treatment of 7 cases of diabetic foot gangrene with severe lower extremity ischemia using the STAGE principle resulted in remarkable efficacy.

Management of a chronic radiation necrosis wound with lyopreserved placental membrane containing viable cells

This case report describes management of a chronic radiation wound in a patient with multiple comorbidities using a lyopreserved placental membrane containing viable cells (vLPM). Positive outcomes suggest that vLPM provides a good conservative management option for patients with compromised wound healing due to radiation and comorbidities.

A multicenter, randomized, single-blind trial comparing the efficacy of viable cryopreserved placental membrane to human fibroblast-derived dermal substitute for the treatment of chronic diabetic foot ulcers

Randomized controlled clinical trials, the gold standard to determine treatment efficacy against control, have demonstrated advantages of skin substitutes for the treatment of chronic diabetic foot ulcers in comparison to standard of care. However, randomized controlled clinical trials comparing efficacy between two or more skin substitutes are very limited. With growing numbers of new skin substitutes, such studies are essential for treatment and policy-making decisions by wound care providers and payers. In this study, we analyzed clinical outcomes and product cost between a viable cryopreserved placental membrane (vCPM) and a human fibroblast-derived dermal substitute (hFDS) for the treatment of chronic diabetic foot ulcers in a prospective, multicenter, single-blind study. The outcomes of 62 patients were analyzed: 31 patients in the vCPM treatment group and 31 patients in the hFDS treatment group. Utilizing a non-inferiority trial design and the established treatment regimen of 8 applications for hFDS, we demonstrated that vCPM was not inferior to hFDS for the proportion of patients achieving complete wound closure (9.68, 90% CI: [10.67, 28.94]). However, preliminary findings show that vCPM may have better outcomes for wounds ≤ 5 cm² : 81.3% (13/16) of wounds in the vCPM group vs. 37.5% (6/16) of wounds in the hFDS group reached complete closure at the end of treatment (p = 0.0118). A preliminary product cost analysis for wounds ≤ 5 cm² may show significant savings for patients treated with vCPM. Average per-patient costs during the course of treatment were $3,846 and $7,968 (p < 0.0001) for vCPM and hFDS patients, respectively. These results may be used as guidance to wound care providers and payers.

Meta-analysis on the treatment of diabetic foot ulcers with autologous stem cells

Over the last decade, many studies have indicated a therapeutic potential for treating diabetic lower extremity ulcers with autologous stem cells. The aim of the current study was to conduct a systematic review and meta-analysis of the treatment of diabetic foot ulcers (DFUs) with autologous stem cells. The search strategy included the Pubmed, EMBASE, Web of Science, and Cochrane’s Library databases. The endpoint measured was the healing of DFUs.

Six eligible randomized controlled trial (RCT) studies were screened from related published studies and reviewed for meta-analysis. The overall meta-analysis showed that stem cell administration was significantly favorable for healing diabetic ulcers (mean difference (MD) 0.52, 95% confidence interval (CI) 0.38–0.65; p < 0.00001). Subgroup analyses indicated that stem cells seemed to exert similar beneficial effects on patients with ulcer size ≥ 5 cm² (MD 0.76, 95% CI 0.55–0.97; p < 0.00001) and < 5 cm² (MD 0.43, 95% CI 0.31–0.54; p < 0.00001). Furthermore, stem cells had similar effects on patients aged ≥ 70 years (MD 0.61, 95% CI 0.14–1.08; p = 0.01) and < 70 years (MD 0.47, 95% CI 0.35–0.58; p < 0.00001). This systematic review and meta-analysis suggests a promising role for stem cells in DFU treatment. This review will pave the way to further study on the long-term effects of stem cell-based therapy and large-scale RCTs.