Identification, influencing factors and outcomes of time delays in the management pathway of diabetic foot: A systematic review

OBJECTIVE

A systematic review was conducted to evaluate the time delays in the management of diabetic foot and explore influencing factors of these delays and potential outcomes.

METHODS

The researchers searched several electronic databases (Pubmed, Web of Science, Cochrane Library, EMbase, CNKI, WanFang, CBM and VIP) for English and Chinese studies that examined time delays in the management pathway of diabetic foot. Two authors independently screened and extracted data, and assessed the quality of the included studies using the Newcastle-Ottawa Scale and the Agency for Health Research and Quality checklist. Due to heterogeneity among the studies, descriptive analysis was performed.

RESULTS

The review included 28 articles, comprising 20 cohort studies and 8 cross-sectional studies, that met the inclusion criteria. Among these, 14 were deemed of high quality. The median times from symptom onset to primary health care or specialist care varied from 3 to 46.69 days. The median delay in referral by primary care specialists ranged from 7 to 31 days, and subsequent median times to definitive treatment ranged from 6.2 to 56 days. Multiple complex factors were found to contribute to these delays, including patient demographics (older age, lower education level and income level) and poor patient health-seeking behaviors (inaccurate self-treatment, incorrect recognition and interpretation of symptoms), inaccurate assessment or initial treatment by health primary professionals, complex referral pathways and clinical characteristics of diabetic foot (number of foot ulcers, Wagner grade scale, and hemoglobin A1c index). Negative outcomes associated with these delays included increased risk of major amputation and mortality, decreased wound healing rate, prolonged hospital stay, and increased hospital costs.

CONCLUSIONS

Time delays in the diabetic foot management pathway were both common and serious, contributing to negative health outcomes for patients with diabetic foot. Many complex factors related to patient's poor patient health-seeking behaviors, health system, and clinical characteristics of diabetic foot are responsible for these delays. Therefore, it is necessary to develop new strategies for standard referral practices and strengthen patient awareness of seeking care.

Acellular Dermal Matrix for Treatment of Diabetic Foot Ulcer: An Overview of Systematic Reviews

Aims: To evaluate the reliability of the methodological quality and outcome measures of systematic reviews (SRs)/metaanalyses (MAs) of the acellular dermal matrix (ADM) for diabetic foot ulcer (DFU). Methods: We searched and retrieved SRs and MAs on the application of ADM for DFU from PubMed, Web of Science, The Cochrane Library, EMBASE, CNKI, CBM, WanFang, and VIP databases. We employed AMSTAR 2 to assess methodological quality, Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to grade, and the strength of evidence of included SRs/MAs. We excluded the overlapping randomized controlled trials (RCTs) and conducted a re-MA of the primary RCTs. Results: A total of 7 SRs/MAs were included. Results from the AMSTAR 2 evaluation revealed a low overall quality; the GRADE system showed that the evidence was of moderate to very low quality. Our re-MA showed that ADM was superior to standard of care (SOC), with regards to complete wound healing rate at 12 weeks (RR = 1.74, 95% CI:1.34-2.25, P < .0001), complete wound healing rate at 16 weeks (RR = 1.50, 95% CI: 1.26-1.77, P ＜ .00001); healing time (MD = -2.06, 95% CI: -2.57 to -1.54, P < .00001) and adverse events (RR = 0.62, 95% CI: 0.49-0.80, P = .0002). However, a consensus has not yet been reached between ADM and SOC groups with regard to outcome indicators of the reduction of ulcer area and quality of life; and subgroup analyses showed no statistically significant differences between the xenograft ADM and SOC groups (RR = 1.36, 95% CI: 0.95-1.93, P = .09) at 12 weeks. Conclusion: Current evidence suggests that ADM is more effective than the standard of care in the treatment of DFU, particularly for full-thickness, noninfected, and nonischemic foot ulcers, but with low evidence quality. Therefore, the results of this overview should be interpreted dialectically and prudently, and the role of ADM in DFU needs further exploration.

New skin tissue engineering scaffold with sulfated silk fibroin/chitosan/hydroxyapatite and its application

Repairing skin wounds has always been challenging in clinical practice. The new skin tissue engineering scaffold provides innovative ways to address these challenges with a good chance of success because of its stable mechanical properties, biodegradability, and antibacterial properties. This paper presents the fabrication and evaluation of a three-dimensional composite scaffold made with sulfated silk fibroin, chitosan, and hydroxyapatite (SSF/CS/HAP). An electron microscope shows that the scaffold has an aperture of 15-20 μm, while an absorption performance test shows that its expansion index reaches 779%. The co-culture of L929 cells and the CCK-8 experiments demonstrated good cell compatibility and low scaffold cytotoxicity, respectively. Meanwhile, in vivo experiments demonstrate that rats with SSF/CS/HAP scaffold-treated neck wounds heal faster. In the wound skin tissue of the SSF/CS/HAP scaffold group, immunohistochemistry indicates a more rapid and mature development of hair follicles. This study successfully developed a novel skin tissue engineering scaffold material with high moisture retention, high tissue compatibility, and low cytotoxicity, demonstrating its ability to improve wound repair with promising potential for tissue engineering applications.

Hedyotis Diffusa Willd. Extracts Inhibit the Proliferation and Migration of Ovarian Cancer Cells by Modulating the AKT/ERK Signaling Pathway

Hedyotis diffusa Willd. (HDW) is a traditional Chinese medicine used for the treatment of colorectal cancer. The aim of this study was to investigate the molecular mechanism of inhibitory effects of HDW on the growth of ovarian cancer cells. Treatment of ovarian cancer cells with increasing doses of HDW for 48 or 72 h resulted in a significant reduction in the viability and colony formation of cancer cells. In HDW-treated cancer cells, the cell cycle was blocked at the G0/G1 phase and cell apoptosis was 4- to 5-fold higher than that of control group. HDW treatment also markedly inhibited the migration and invasion of ovarian cancer cells. Mechanistically, the phosphorylation levels of AKT and ERK were down-regulated in HDW-treated ovarian cancer cells. Therefore, HDW is likely to become a promising therapeutic agent for ovarian cancer treatment.