Hyperbaric Oxygen for the Treatment of Diabetic Foot Ulcers: A Systematic Review

Wound, pressure ulcer, and burn guidelines - 3: Guidelines for the diagnosis and treatment of diabetic ulcers and gangrene, second edition

The Japanese Dermatological Association aimed to prepare a second edition of guidelines for the management of diabetic ulcer/gangrene with emphasis on the diagnosis and treatment of skin symptoms. This new edition serves as a tool to improve the quality of the diagnosis and treatment in each patient and, further, to improve the level of care for such skin conditions. All sections have been updated by collecting documents published since the publication of the first edition. In the antibacterial drug treatment for bacterial infection of ulcers, oral administration was added after consideration. In the treatment of antibacterial drugs for bacterial infection of ulcers, not only infusion but also oral administration was mentioned. In addition, clinical questions (CQs) for imaging tests for diagnosing ischemia of the limbs were newly created. The titles of some CQs were changed to conform to the actual clinical setting. (i) The content has been updated by adding and collecting documents for all sections; (ii) we have additionally included oral antibiotic treatment for bacterial infection of ulcers; (iii) we have added CQs pertaining to imaging tests for diagnosing ischemia of the limbs; and (iv) we have revised the titles of some CQs to conform to the actual clinical setting. In particular, the recommendation levels of dressing materials newly covered by Japanese national health insurance are mentioned. In addition, CQs regarding the initial treatment of electrical (CQ15) and chemical burns (CQ16), and the use of escharotomy (CQ22) have been created.

Hyperbaric oxygen therapy attenuated limb ischemia in mice with high-fat diet by restoring Sirtuin 1 and mitochondrial function

Hyperbaric oxygen therapy (HBO) shows promise as a treatment for peripheral artery disease (PAD), particularly when complicated by metabolic syndrome and diabetes. However, its precise effects on endothelial function remain unclear. This study explored the impact of HBO on angiogenesis and apoptosis in high-fat diet (HFD)-fed mice with limb ischemia, focusing on the role of sirtuin 1 (SIRT1). After 8 weeks on a chow or HFD, mice underwent unilateral femoral artery ligation and received HBO (3 ATA, 1 h/day for 5 days). HBO improved blood flow, enhanced vascular density, and reduced apoptosis in ischemic calf muscles of HFD-fed mice. In vitro, human umbilical vein endothelial cells (HUVECs) were subjected to high-glucose and oxygen-glucose deprivation (OGD) conditions, with or without HBO. HBO restored cell proliferation, migration, and tube formation under these conditions, reduced mitochondrial dysfunction, and decreased reactive oxygen species (ROS) production. However, these benefits were reversed by treatment with sirtinol, a SIRT1 inhibitor. HBO also increased SIRT1 expression and shifted mitochondrial dynamics toward fusion. Additionally, HBO upregulated angiogenesis-related proteins (VEGF, VEGFR, and SIRT1) while downregulating apoptosis-associated proteins (Bax, caspase-3, and p53). Collectively, these findings suggest that HBO enhances angiogenesis and reduces apoptosis in both in vivo and in vitro ischemia models, primarily through SIRT1 activation.

Placenta-derived biomaterials vs. standard care in chronic diabetic foot ulcer healing: A systematic review and meta-analysis

INTRODUCTION

This study explored the effectiveness of current placenta-derived biomaterials therapies in ulcer healing in DFU compared to standard of care (SOC).

METHODS

The systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard. The electronic databases of PubMed, EMBASE, and Web of Science (WoS) internet were searched for the outcome rate of complete ulcer healing. The risk of bias assessment was conducted using the tool recommended by the Cochrane Collaboration. Statistical analysis included the individual and combined result of the studies, heterogeneity test, the effect size, sensitivity analysis, and publication bias tests.

RESULTS

Twelve randomized controlled trials (RCTs) with a total of 833 patients were included in this study. This meta-analysis showed a higher rate of complete ulcer healing in groups receiving placenta-derived biomaterials therapies (OR = 6.247 [4.425, 8.819], p < 0.01, I2 = 41 %) compared to control groups.

CONCLUSION

Placenta-derived biomaterials therapies have been shown to be more effective for achieving complete ulcer healing compared to current conventional treatments in DFU.

IMPLICATIONS FOR CLINICAL PRACTICE

The utilization of placenta-derived biomaterials in therapies for wound healing, particularly in chronic DFU, presents promising implications for clinical practice. These biomaterials offer a rich source of growth factors, cytokines, and extracellular matrix components, which can stimulate tissue regeneration and angiogenesis. Incorporating such therapies into clinical practice holds the potential to accelerate wound closure, reduce infection rates, and improve overall healing outcomes in people with diabetic chronic foot ulcers. Furthermore, the availability of these biomaterials can offer clinicians a readily-accessible and cost-effective alternative to traditional wound care approaches, ultimately enhancing patient care and quality of life. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The effect of hyperbaric oxygen therapy on oxidative stress and inflammation in patients with diabetic foot ulcers: A preliminary study

Introduction

Patients with an uncontrolled glycemic index develop a wide variety of pathologies associated with diabetes, such as diabetic foot ulcers (DFUs). Hyperbaric oxygen therapy (HBOT) is an adjunctive therapy used to heal wounds and prevent lower extremity amputations in this population.

Objective

This preliminary study aimed to evaluate how HBOT impacts inflammation in patients with Wagner stages 2-4 DFUs by analyzing its effect on the gene expression of key oxidative stress regulators SOD1, SOD2, and GPX2, of pro-inflammatory cytokines TNFα, IL-1β, IL-4, and IL-12, and of the NLRP3 inflammasome.

Methods

The effect of HBOT was assessed in 15 patients with Wagner stages 2-4 DFUs that underwent 30 sessions in the hyperbaric chamber. This protocol is registered on Clinical Trials under the title Hyperbaric Oxygen Therapy in Diabetic Foot (July 15, 2024) with the number NCT06502808. Blood samples were collected, and relative gene expression was assessed by quantitative real-time polymerase chain reaction (qPCR).

Results

The hyperbaric chamber treatment increased the expression of SOD1 and GPX2 genes (0.4 and 3 times, respectively) after 30 sessions compared to baseline levels. Similarly, the gene expression of pro-inflammatory cytokines IL-1β, IL-12, IL-4, and NLRP3 increased after 30 sessions (2.1, 0.4, 1.5, and 1.2, respectively), while the expression of the TNFα gene decreased (0.5 times). Clinically, the patients' lesions were fully resolved.

Conclusions

HBOT directly influences the gene expression of several potent antioxidants and pro-inflammatory cytokines, thus favoring angiogenesis and blood circulation in the extremities.

Hyperbaric Oxygen Therapy Improved Neovascularisation Following Limb Ischaemia-The Role of ROS Mitigation

Hyperbaric oxygen (HBO) therapy has emerged as a potential treatment, shown to enhance blood flow and angiogenesis. However, specific effects and mechanisms of HBO on limb ischaemia responding to a hypoxic environment remain largely unknown. We aimed to investigate the therapeutic potential of HBO in the treatment of limb ischaemia. Following limb ischaemia surgery, we evaluated the angiogenic capacity in wild-type C57BL/6J mice subjected to HBO treatment (100% oxygen at 3 ATA for 1 h/day for five consecutive days) compared to untreated controls. Notably, through laser Doppler perfusion imaging and CD31 staining mice receiving HBO postlimb ischaemia surgery exhibited significantly enhanced angiogenic capability and reduced ROS expression compared to nontreated counterparts. Additionally, in vitro experiments were conducted to investigate whether HBO could mitigate endothelial cell dysfunction and reactive oxygen species (ROS) production triggered by oxygen-glucose deprivation (OGD). HBO treatment rescued the impaired proliferation, migration and tube formation of endothelial cells following OGD. Mechanistically, HBO upregulated the expression of proangiogenic proteins, including vascular endothelial growth factor (VEGF), haem oxygenase-1 (HO-1), hypoxia-inducible factor 1 (HIF-1) and nuclear factor erythroid 2-related factor 2 (Nrf2). Collectively, HBO treatment shows promise in augmenting the endogenous angiogenic potential and suppressing ROS levels in limb ischaemia.

Timolol in the treatment of hard-to-heal wounds: a comprehensive review

OBJECTIVE

The aims of this study were to ascertain the effectiveness and safety of the off-label use of topical timolol as an adjunct treatment for hard-to-heal (chronic) wounds. Furthermore, to review and analyse the existing literature regarding the use of topical timolol on wounds of varying aetiologies.

METHOD

A systematic review of literature in the English language published between May 1961-May 2021 on the application of topical timolol for hard-to-heal wounds in adults was performed. Each research study was evaluated by two reviewers independently. Studies eligible for inclusion in the review were randomised controlled trials (RCTs), clinical trials, observational studies of at least 4 weeks' duration, case series and case studies. Search strategies were performed according to PRISMA guidelines and included MeSH terms and keyword searches.

RESULTS

An initial 878 articles were identified from a search of PubMed, Ovid Medline, Embase, Cochrane, and SCOPUS. Of these, 699 were reviewed for eligibility, 19 were read in full-text, and 12 were selected for inclusion in the review. In total, two RCTs and 10 observational studies, including five case studies, were analysed. All studies demonstrated efficacy and safety of topical timolol; however, statistical analysis remained limited by lack of blinding and small sample sizes.

CONCLUSION

This review concludes with all currently available evidence that topical timolol may be considered as an effective and safe adjunct treatment for refractory wounds, primarily venous leg ulcers and diabetic foot ulcers. Given the overall safety, low cost and ease of application of topical timolol, this review provides evidence in favour of off-label use and should prompt further, more rigorous studies.

Quality of evidence supporting the role of hyperbaric oxygen therapy for diabetic foot ulcers

The goal of this overview of systematic reviews (SRs) and meta-analyses (MAs) was to methodically gather, evaluate and summarize the data supporting the use of hyperbaric oxygen therapy (HBOT) to treat diabetic foot ulcers (DFUs). The Cochrane Library, Embase, PubMed, Web of Science and Embase were all searched thoroughly to identify SRs/MAs that qualified. AMSTAR-2 tool, PRISMA checklists and GRADE system were applied by two reviewers independently to assess the methodological quality, reporting and evidence quality of the included SRs/MAs, respectively. Eleven SRs/MAs were enrolled in this overview. According to AMSTAR-2, a very low methodological quality assessment was given to the included SRs/MAs due to the limitations of items 2, 4 and 7. For the PRISMA, the overall quality of reporting is not satisfactory due to missing reporting on protocol, search, as well as additional analysis. The majority of outcomes had low- to moderate-quality evidence, and no high-quality evidence was found to support the role of HBOT for DFUs, according to GRADE. To conclude, the potential of HBOT in treating DFUs is supported by evidence of low to moderate quality. More rigorously designed, high-level studies are needed in the future to determine the evidence for HBOT for DFU, including the timing, frequency and duration of HBOT interventions.

A Narrative Review of Diabetic Macroangiopathy: From Molecular Mechanism to Therapeutic Approaches

Diabetic macroangiopathy, a prevalent and severe complication of diabetes mellitus, significantly contributes to the increased morbidity and mortality rates among affected individuals. This complex disorder involves multifaceted molecular mechanisms that lead to the dysfunction and damage of large blood vessels, including atherosclerosis (AS) and peripheral arterial disease. Understanding the intricate pathways underlying the development and progression of diabetic macroangiopathy is crucial for the development of effective therapeutic interventions. This review aims to shed light on the molecular mechanism implicated in the pathogenesis of diabetic macroangiopathy. We delve into the intricate interplay of chronic inflammation, oxidative stress, endothelial dysfunction, and dysregulated angiogenesis, all of which contribute to the vascular complications observed in this disorder. By exploring the molecular mechanism involved in the disease we provide insight into potential therapeutic targets and strategies. Moreover, we discuss the current therapeutic approaches used for treating diabetic macroangiopathy, including glycemic control, lipid-lowering agents, and vascular interventions.

Hyperbaric Oxygen Therapy for Diabetic Foot Ulcers Based on Wagner Grading: A Systematic Review and Meta-analysis

Background

Diabetic foot ulcers (DFUs) are common complications of uncontrolled diabetes mellitus that can result in infection and amputation of the lower extremities. This study compared the benefits and risks of hyperbaric oxygen therapy with those of other DFU treatments, based on the Wagner grading system.

Methods

Systematic searches for randomly controlled trials using hyperbaric oxygen therapy for DFUs were performed using PubMed, the Cochrane Library, and Embase. Data regarding demographics, wound healing, minor and major amputations, operative debridement, nonhealing wounds, and adverse effects were analyzed based on Wagner grades, using RevMan 5.4.1 and Microsoft Excel.

Results

Hyperbaric oxygen therapy was significantly superior to other treatments for wound healing rates 8 or more weeks after the final treatment (RR = 2.39; 1.87-3.05; P < 0.00001) minor/distal amputations (RR = 0.58; 0.43-0.80; P < 0.007), and major/proximal amputations (RR = 0.31; 0.18-0.52; P < 0.00001) for the 14 studies analyzed. In addition, this therapy increased the rate of complete wound healing for Wagner grades II (RR = 21.11; 3.05-146.03; P = 0.002), III (RR = 19.58; 2.82-135.94, P = 0.003), and IV (RR = 17.53; 2.45-125.44; P = 0.004); decreased the minor/distal amputation rate for grade III (RR = 0.06; 0.01-0.29; P = 0.0004) and the major/proximal amputation rate on for grade IV (RR = 0.08; 0.03-0.25; P < 0.0001); and decreased the operative debridement rate for Wagner grade II (RR = 0.09; 0.01-0.60; P = 0.01).

Conclusions

Moderate-quality evidence revealed that adjunctive hyperbaric oxygen therapy improved DFU wound healing for Wagner grades II, III, and IV; prevented minor and major amputations for grades III and IV, respectively; and prevented operative debridement in grade II wounds.

Autologous platelet-rich plasma (APRP) in diabetes foot disease: a meta-analysis

INTRODUCTION

This study will explore the effectiveness of autologous platelet-rich plasma in the treatment of diabetic foot disease compared to conventional treatments, based on the ulcer healing rate.

METHODS

The electronic databases of PubMed, EMBASE, and WOS internet were searched. Evaluated outcome rate of complete ulcer healing. Statistical analysis was performed with RevMan 5.0 software and SPSS 25.0.

RESULTS

Eleven RCTs with 828 patients were included in this study. The meta-analysis showed a higher complete ulcer healing rate (OR = 3.69, 95 % CI 2.62 to 5.20, P < 0.01, I2 = 0 %) in growth factors based in autologous platelech-rich plasma (aPRP) group compared with control. Mixed evidence was seen for publication bias, but analyses by using the trim-and-fill method did not appreciably alter results.

CONCLUSION

Autologous platelet-rich plasma can improve the complete healing rate of the ulcer compared to current conventional treatments in diabetic foot ulcer patients.

Hyperbaric Oxygen Therapy in Ophthalmology: A Narrative Review

Hyperbaric oxygen therapy (HBOT) has been used for the past 50 years for conditions such as decompression disease and wound healing. It has promising effects in the treatment of vision-threatening diseases, such as retinal artery occlusion, retinal vein occlusion, diabetic macular edema, and acute optic neuropathy; however, HBOT has not been approved for use in these conditions by regulatory authorities. This paper provides an overview of the theoretical effectiveness and most recent indications for HBOT in ophthalmology. The fundamental aspects of the physiology of choroidal circulation and metabolism are provided together with the clinical aspects that should be accounted for when selecting patients for this therapy. The paper also presents case reports of when HBOT was successfully implemented. The goals of this review were to explore the indications and benefits of HBOT and to evaluate the effectiveness of HBOT as an intervention in treating ophthalmology disorders. Lastly, the paper details the side-effects and discusses the safety issues of HBOT.

Physical therapy in diabetic foot ulcer: Research progress and clinical application

Diabetes foot ulcer (DFU) is one of the most intractable complications of diabetes and is related to a number of risk factors. DFU therapy is difficult and involves long-term interdisciplinary collaboration, causing patients physical and emotional pain and increasing medical costs. With a rising number of diabetes patients, it is vital to figure out the causes and treatment techniques of DFU in a precise and complete manner, which will assist alleviate patients' suffering and decrease excessive medical expenditure. Here, we summarised the characteristics and progress of the physical therapy methods for the DFU, emphasised the important role of appropriate exercise and nutritional supplementation in the treatment of DFU, and discussed the application prospects of non-traditional physical therapy such as electrical stimulation (ES), and photobiomodulation therapy (PBMT) in the treatment of DFU based on clinical experimental records in ClinicalTrials.gov.

Thermosensitive and antioxidant wound dressings capable of adaptively regulating TGFβ pathways promote diabetic wound healing

Various therapies have been utilized for treating diabetic wounds, yet current regiments do not simultaneously address the key intrinsic causes of slow wound healing, i.e., abnormal skin cell functions (particularly migration), delayed angiogenesis, and chronic inflammation. To address this clinical gap, we develop a wound dressing that contains a peptide-based TGFβ receptor II inhibitor (PTβR2I), and a thermosensitive and reactive oxygen species (ROS)-scavenging hydrogel. The wound dressing can quickly solidify on the diabetic wounds following administration. The released PTβR2I inhibits the TGFβ1/p38 pathway, leading to improved cell migration and angiogenesis, and decreased inflammation. Meanwhile, the PTβR2I does not interfere with the TGFβ1/Smad2/3 pathway that is required to regulate myofibroblasts, a critical cell type for wound healing. The hydrogel's ability to scavenge ROS in diabetic wounds further decreases inflammation. Single-dose application of the wound dressing significantly accelerates wound healing with complete wound closure after 14 days. Overall, using wound dressings capable of adaptively modulating TGFβ pathways provides a new strategy for diabetic wound treatment.

Update on Medical Management of Diabetes: Focus on Relevance for Orthopedic Surgeons

Diabetes mellitus affects more than 30 million US adults and 537 million people worldwide and accounts for major complications, including more than 100,000 lower extremity amputations annually in the United States. Peripheral neuropathy, peripheral vascular disease, and foot ulcers are frequent findings in diabetes patients at risk for amputation. Suboptimal care of early foot lesions increases the risk of amputation. Studies have shown that these complications can be prevented in people with type 1 and type 2 diabetes by optimizing glycemic control and comorbid risk factors. This review focuses on evaluating and managing diabetes, which should interest orthopedic surgeons.

DIONYSIUS trial: "Does increasing oxygen nurture your symptomatic ischaemic ulcer sufficiently?" Study protocol for an international multicentre randomised trial

INTRODUCTION

Diabetic foot ulcers (DFUs) are a major complication of diabetes and often associated with peripheral arterial occlusive disease. Current available evidence shows hyperbaric oxygen therapy (HBOT) can reduce the risk of major amputation, but clinicians remain sceptical about the (cost-)effectiveness and feasibility of HBOT for ischaemic DFUs in clinical practice. Therefore, vascular surgeons and HBOT physicians worldwide feel a strong need for a sufficiently powered clinical trial to determine whether and how many HBOT sessions may be a (cost-)effective adjunctive treatment to ischaemic DFUs.

METHODS

An international, multicentre, multi-arm multi-stage design is chosen to conduct an efficient randomised clinical trial. Patients will be randomised to receive standard care (wound treatment and surgical interventions following international guidelines) with either 0, 20, 30 or at least 40 sessions of HBOT. These sessions will comprise 90-120 min of HBOT at a pressure of 2.2-2.5 atmospheres absolute according to international standards. Based on a planned interim analysis, the best performing study arm(s) will continue. Primary end point is major amputation (ie, above ankle) rate after 12 months. Secondary end points are amputation-free survival, wound healing, health-related quality of life and cost-effectiveness.

ETHICS AND DISSEMINATION

All patients enrolled in this trial will receive maximum vascular, endovascular or conservative treatment and local wound care according to best practice and (inter)national guidelines. HBOT therapy is added to the standard treatment and is regarded as a low-risk to moderate-risk therapy. The study is approved by the medical ethics committee of the Amsterdam University Medical Centers, location University of Amsterdam.

TRIAL REGISTRATION NUMBER

2020-000449-15, NL9152, NCT05804097.

Hyperbaric Oxygen Therapy Reduces Oxidative Stress and Inflammation, and Increases Growth Factors Favouring the Healing Process of Diabetic Wounds

Hyperbaric oxygen therapy (HBOT) is the clinical application of oxygen at pressures higher than atmospheric pressure. HBOT has been effectively used to manage diverse clinical pathologies, such as non-healing diabetic ulcers. The aim of the present study was to analyse the effects of HBOT on the plasma oxidative and inflammation biomarkers and growth factors in patients with chronic diabetic wounds. The participants received 20 HBOT sessions (five sessions/week), and blood samples were obtained at sessions 1, 5 and 20, before and 2 h after the HBOT. An additional (control) blood sample was collected 28 days after wound recovery. No significant differences were evident in haematological parameters, whereas the biochemical parameters progressively decreased, which was significant for creatine phosphokinase (CPK) and aspartate aminotransferase (AST). The pro-inflammatory mediators, tumour necrosis factor alpha (TNF-α) and interleukin 1β (IL-1β), progressively decreased throughout the treatments. Biomarkers of oxidative stress--plasma protein levels of catalase, extracellular superoxide dismutase, myeloperoxidase, xanthine oxidase, malondialdehyde (MDA) levels and protein carbonyls--were reduced in accordance with wound healing. Plasma levels of growth factors--platelet-derived growth factor (PDFG), transforming growth factor β (TGF-β) and hypoxia-inducible factor 1-alpha (HIF-1α)-- were increased as a consequence of HBOT and reduced 28 days after complete wound healing, whereas matrix metallopeptidase 9 (MMP9) progressively decreased with the HBOT. In conclusion, HBOT reduced oxidative and pro-inflammatory mediators, and may participate in activating healing, angiogenesis and vascular tone regulation by increasing the release of growth factors.

Hyperbaric Oxygen Therapy in Plastic, Aesthetic, and Reconstructive Surgery: Systematic Review

Introduction: Hyperbaric oxygen therapy (HBOT) has been used over the past six decades to treat multiple conditions. This systematic review aims to identify and evaluate the clinical outcomes of hyperbaric oxygen therapy in the field of plastic, reconstructive, and aesthetic surgery, found in the literature from the year 2000 to the present. Methods: A systematic review of the literature focused on the conceptual and methodological aspects of the PRISMA Declaration. The search for clinical trials focused on the results of hyperbaric therapy in plastic, reconstructive, and cosmetic surgery. The Newcastle–Ottawa scale suggested by the Cochrane manual was applied to each study. The study was carried out with a defined protocol and was registered in PROSPERO, with code CRD42022301261. Results: From the 170 articles identified, 6 were selected. Five of them showed that hyperbaric oxygen therapy favored the reduction of the size of skin ulcers and increased the formation of granulation tissue (two trials; p < 0.05), increased the partial pressure of transcutaneous oxygen in patients with free flaps (one trial; p < 0.001), reduced perfusion in keloid scarring disorder (one trial; p < 0.01), and accelerated both the fading of melanin pigmentation and the decrease in age spot size (one trial; p < 0.05). The methodological quality was moderate in all cases because there was no blinding method reported. One study failed to find differences in flap survival, time to resolution of venous congestion, resolution of edema, and postoperative recovery period (p > 0.05). Conclusions: Hyperbaric oxygen therapy has been increasingly used in the field of plastic and reconstructive surgery, and has shown potential benefits in promoting wound healing, reducing the risk of infection, and improving the survival of tissues used in reconstructive procedures. Further research with more rigorous clinical trials is needed to fully understand the efficacy and optimal use of this therapy in the field of plastic and reconstructive surgery.

Nanoenzyme-chitosan hydrogel complex with cascade catalytic and self-reinforced antibacterial performance for accelerated healing of diabetic wounds

The significant disability and fatality rate of diabetes chronic wounds necessitates the development of efficient diabetic wound healing techniques. The present oxygen treatments for wound healing is restricted by issues such as poor penetration, inadequate supply, and absorption difficulties as well as tanglesome diabetic wound microenvironment issues such as hyperglycemia, excessive reactive oxygen species (ROS), and hypoxia. Herein, we designed a multifunctional glucose oxidase (GOx) and catalase (CAT) nanoenzyme-chitosan (GCNC) hydrogel complex to improve the microenvironment of diabetic wounds and provide continuous oxygen delivery for efficient wound healing. By simultaneously forming the GOx-CAT nanoenzyme (GCNE) composite, the GCNC hydrogel complex could effectively reduce glucose and ROS (H₂O₂) concentrations in diabetic wounds through cascade catalytic reactions and achieve continuous oxygen supply, which promoted cell proliferation, migration, and angiogenesis, thereby accelerating diabetic wound healing. In addition, the byproduct gluconic acid produced by the cascade reaction can activate the amino group of chitosan to reinforce the antibacterial performance and prevent microbial infection. This multifunctional GCNC hydrogel complex with continuous oxygen supply, self-reinforcing antibacterial properties, and byproduct-free features provides a general strategy for repairing the extensive tissue damage in diabetes.

Effect of leukocyte-platelet fibrin-rich wound reconstruction followed by full-thickness skin grafting in the treatment of diabetic foot Wagner grade 4 ulcer gangrene (toe area)

This study investigated the effect of L-PRF on promoting full-thickness skin grafting for the treatment of diabetic foot ulcer wounds and attempted to characterize the mechanism. In a retrospective study, we centrifugated 10-20 ml of venous blood at 1006.2 g for 20 min. The fibrin clot between the top oligocellular plasma layer and the bottom erythrocyte layer was extracted and directly used, without compression, to cover the wound after debridement. Patients who received L-PRF before skin grafting underwent surgery earlier than patients in the control group. Skin necrosis occurred in 7 patients (28%) in the L-PRF group and 16 (64%) in the control group. The difference was statistically significant, P < .05. The postoperative infection rate in the control group (56%) was significantly higher than that in the L-PRF group (24%), P < .05. During a mean follow-up of 1 year, ulcer recurrence occurred in 9 patients (36%) in the control group compared with 4 patients (16%) in the L-PRF group, P < .05. The final amputation rate was also higher in the control group (48%) than in the L-PRF group (20%). The difference is statistically significant, P < .05. The Maryland scale score and SF-36 score of the two groups of patients after treatment were significantly better than those before treatment, and the difference was statistically significant (P < .05). The L-PRF group (94.80 ± 4.14) had better foot scores at the last follow-up after treatment than the control group (88.84 ± 5.22) (P < .05). The results showed that L-PRF played a positive role in the treatment of Wagner grade 4 ulcer gangrene with free full-thickness skin grafts.

[Hyperbaric oxygen therapy : Selected indications in the discipline of otorhinolaryngology]

Hyperbaric oxygenation (HBO) represents the controlled exposure to positive pressure with simultaneous inhalation of pure oxygen. It is considered to be an effective treatment option for diseases with restricted blood flow as oxygen not only binds chemically to hemoglobin but also physically dissolves in blood plasma. With the help of a hyperbaric chamber the ambient pressure of a patient can be modified and the physiological characteristics in positive pressure can be medically used. The indications relevant to otorhinolaryngology are necrotizing otitis externa and skull base osteomyelitis, other forms of osteomyelitis, gangrene, wound healing disorders and sudden loss of hearing. When choosing a treatment, not only the availability and costs of HBO treatment play a role but also the patient's tolerance of overpressure. The risks of treatment, e.g., due to oxygen toxicity or barotrauma of the middle ear or the paranasal sinuses, must be weighed up against the potential benefits.

Local Hyperbaric Oxygen Therapy in the Treatment of Diabetic Foot Ulcers

Background: Diabetes mellitus is one of the most common metabolic diseases. The most serious complication of diabetes is diabetic foot ulcer, which affects several million people around the world each year. In recent years, increasingly modern methods of physical medicine including hyperbaric oxygen therapy have been used often in the complex therapy of this complication. Methods: This study included 45 patients, 24 male (53.3%) and 21 female (46.6%), whose age was between 49 and 83 years (mean age: 66.7 ± 8.8 years) with diabetes lasting for 1.5-18 years, who underwent local hyperbaric oxygen therapy at the pressure of 2.5 ATA (30 exposures for 30 min each) due to diabetic foot ulcers. The progress in wound healing before and after the end of therapy was evaluated by computerized planimetry, and the pain intensity was assessed with the use of a VAS. Results: The analysis of results showed a statistically significant reduction in the wound surface area after the treatment, from 8.54 ± 3.34 cm to 4.23 ± 3.23 cm² (p = 0.000001). In 5 patients (11.1%), the wounds were healed completely. In 25 patients (55.5%), the topical state of the wound surface was significantly decreased by 50% on average. There was also a significant reduction in the perceived pain on the VAS in all examined patients from 4.64 ± 1.68 points before treatment to 1.51 ± 0.92 points after treatment (p = 0.000001). Conclusions: The application of local HBO therapy in the treatment of diabetic foot ulcers accelerates the ulcer healing process, as judged in objective planimetric assessment, and reduces the intensity of perceived pain ailments.

Therapeutic Alternatives in Diabetic Foot Patients without an Option for Revascularization: A Narrative Review

BACKGROUND

The healing of foot wounds in patients with diabetes mellitus is frequently complicated by critical limb threatening ischemia (neuro-ischemic diabetic foot syndrome, DFS). In this situation, imminent arterial revascularization is imperative in order to avoid amputation. However, in many patients this is no longer possible ("too late", "too sick", "no technical option"). Besides conservative treatment or major amputation, many alternative methods supposed to decrease pain, promote wound healing, and avoid amputations are employed. We performed a narrative review in order to stress their efficiency and evidence.

METHODS

The literature research for the 2014 revision of the German evidenced-based S3-PAD-guidelines was extended to 2020.

RESULTS

If revascularization is impossible, there is not enough evidence for gene- and stem-cell therapy, hyperbaric oxygen, sympathectomy, spinal cord stimulation, prostanoids etc. to be able to recommend them. Risk factor management is recommended for all CLTI patients. With appropriate wound care and strict offloading, conservative treatment may be an effective alternative. Timely amputation can accelerate mobilization and improve the quality of life.

CONCLUSIONS

Alternative treatments said to decrease the amputation rate by improving arterial perfusion and wound healing in case revascularization is impossible and lack both efficiency and evidence. Conservative therapy can yield acceptable results, but early amputation may be a beneficial alternative. Patients unfit for revascularization or major amputation should receive palliative wound care and pain therapy. New treatment strategies for no-option CLTI are urgently needed.

Efficacy of hyperbaric oxygen therapy for diabetic foot ulcers: An updated systematic review and meta-analysis

The present systematic review and meta-analysis was performed to evaluate the efficacy of hyperbaric oxygen therapy (HBOT) in the treatment of diabetic foot ulcers (DFUs). Relevant articles were retrieved from PubMed, the Cochrane Library, EMBASE and other databases through November 2020. A total of 20 randomized clinical trials and 1263 trials were included in the meta-analysis. For each trial, the average difference, odds ratio and 95% confidence interval were calculated to evaluate the efficacy. Hyperbaric oxygen therapy increased the healing rate of diabetic foot ulcers (relative risk, 1.901; 95% CI = 1.484-2.435, p < 0.0001), shortened the healing time (MD = -19.360; 95% CI = -28.753~-9.966, p < 0.001), and reduced the incidence of major amputation (relative risk, 0.518, 95% CI = 0.323-0.830, P < 0.01). In summary, our meta-analysis confirmed that hyperbaric oxygen therapy offers great benefits in the treatment of DFU and the reduction of amputation. In addition, larger and well-designed randomized controlled trials need to be planned and conducted to verify this conclusion.

Hyperbaric oxygen influences chronic wound healing – a cellular level review

Chronic wound is a serious medical issue due to its high prevalence and complications; hyperbaric oxygen therapy (HBOT) is also considered in comprehensive treatment. Clinical trials, including large meta-analyses bring inconsistent results about HBOT efficacy. This review is summarizing the possible effect of HBOT on the healing of chronic wound models at the cellular level. HBOT undoubtedly escalates the production of reactive oxygen and nitrogen radicals (ROS and RNS), which underlie both the therapeutic and toxic effects of HBOT on certain tissues. HBOT paradoxically elevates the concentration of Hypoxia inducible factor (HIF) 1 by diverting the HIF-1 degradation to pathways that are independent of the oxygen concentration. Elevated HIF-1 stimulates the production of different growth factors, boosting the healing process. HBOT supports synthesis of Heat shock proteins (HSP), which are serving as chaperones of HIF-1. HBOT has antimicrobial effect, increases the effectiveness of some antibiotics, stimulates fibroblasts growth, collagen synthesis and suppresses the activity of proteolytic enzymes like matrix metalloproteinases. All effects of HBOT were investigated on cell cultures and animal models, the limitation of their translation is discussed at the end of this revie

Overcoming ischemia in the diabetic foot: Minimally invasive treatment options

As the global burden of diabetes is rapidly increasing, the incidence of diabetic foot ulcers is continuously increasing as the mean age of the world population increases and the obesity epidemic advances. A significant percentage of diabetic foot ulcers are caused by mixed micro and macro-vascular dysfunction leading to impaired perfusion of foot tissue. Left untreated, chronic limb-threatening ischemia has a poor prognosis and is correlated with limb loss and increased mortality; prompt treatment is required. In this review, the diagnostic challenges in diabetic foot disease are discussed and available data on minimally invasive treatment options such as endovascular revascularization, stem cells, and gene therapy are examined.

Combined Treatment With Hyperbaric Oxygen Therapy and Endovascular Therapy for Patients With Chronic Limb-Threatening Ischemia - Study Protocol for the HOTFOOT Multicenter Randomized Controlled Trial

Background: Hyperbaric oxygen therapy (HBOT) is regarded as one of the therapeutic options added to standard care to improve lower-limb outcomes in patients with chronic limb-threatening ischemia (CLTI). However, the current guidelines specify that HBOT should not be offered instead of revascularization to prevent limb loss in CLTI patients. The aim of the HOTFOOT study is to examine the impact of HBOT on wound healing in CLTI patients after successful endovascular therapy (EVT).

Methods and Results: The HOTFOOT study is a multicenter prospective randomized open blinded-endpoint trial that is to be conducted at 10 trial centers in Japan between February 2021 and February 2022. This study will enroll 140 patients with CLTI receiving successful EVT. Eligible participants will be allocated 1 : 1 to either the EVT+HBOT or EVT group; participants in the EVT+HBOT group will receive 30 HBOT sessions. The primary outcome is the time to complete wound healing over the 6-month follow-up. Secondary outcomes during the 6-month follow-up are the proportion of patients who achieved complete wound healing, freedom from major lower-limb amputation, amputation-free survival, and freedom from target lesion reintervention.

Conclusions: This study is expects to assess whether HBOT, in combination with successful EVT, can improve lower-limb outcomes in CLTI patients.

Hyperbaric oxygen adjuvant therapy in severe mangled extremities

BACKGROUND

Mangled Extremity Severity Score (MESS) was first described more than 30 years ago by attempting to predict the need for empiric amputation. In severe traumatic crush and blast injuries, achieving satisfactory limb salvage may be difficult. Notably, a MESS of 7 or higher is consistently predictive of amputation. Additionally, Hyperbaric Oxygen Therapy (HBOT) has been described for many purposes, and related studies have reported HBOT showed benefits in wound healing properties.

OBJECTIVE

The study aimed to evaluate the results of a prospective series of a new modality of adjuvant HBOT for severe mangled extremities.

METHOD

A total of 18 patients were evaluated for clinical and radiographic review. Current standard treatments followed by adjuvant HBOT were administered, and the mean follow-up period was 22 months. Time to wound closure, the number of surgeries and adjuvant HBOT treatment were analyzed for patient clinical evaluation. Complications and limb amputation rates were also recorded.

RESULT

Most clinical findings on follow-up were good to excellent after adjunctive HBOT. Minimal soft tissue infection was recorded, and limb salvage was successful in most cases. Only 1 patient (5.56 %) needed limb amputation because of a dying limb with chronic refractory osteomyelitis.

CONCLUSION

HBOT is an excellent adjunctive option in severely mangled extremities. Nevertheless, the main treatments are eliminating infection and managing surgery, and are promising in the recovery of severe extremity injuries. Although the MESS was evaluated at 7 or higher, limb salvage procedures followed by HBOT should be considered.

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.

Predicting hyperbaric oxygen therapy success using the decision tree approach

Introduction

Hyperbaric oxygen therapy (HBOT), a procedure that involves the patient inhaling 100% oxygen gas under pressure, is currently used as an adjunctive treatment option for certain inflammatory conditions. HBOT can improve wound healing by increasing the rate of angiogenesis in injured tissue by increasing levels of vascular endothelial growth factor (VEGF). VEGF causes re-epithelialization, the migration of endothelial cells, and the formation of granulation tissue, which are involved in the wound healing process.

Methods

This study contains secondary data analyses of information previously collected in two separate studies, each concerning the effects of HBOT on diabetic foot ulcers and crush injury fractures at Prof. Dr. R. D. Kandou Hospital Manado and Siloam Hospital Manado from 2019 to early 2020.

Results

Based on the classification tree analysis, the predictors of HBOT success were leukocytes level (34%), platelet count (32%), and age (26%). The conditional inference tree analysis also indicated significant leukocyte levels, age, and platelet counts (p < 0.001), with which the interpretation of these results was the same as the classification tree analysis method. The results obtained from the random forest analysis revealed that the mean value of Gini reduction for leukocytes (207.3), platelets (110.2), age (97.9), and hemoglobin (57.9) can be used as indicators of successful HBOT. These three methods support that age, leukocytes, and platelets are determinants of HBOT success, while hemoglobin levels were only significant in one analysis method. Therefore, a new, proposed algorithm containing these factors was assembled from the results of this study.

Conclusion

HBOT cannot be separated from specific variables that contribute to and can predict its success.

Assessment of the hyperbaric oxygen therapy effects in distal femoral necrosis using hyperspectral imaging

Introduction. Hyperbaric oxygen therapy is a treatment option for an increasing number of conditions. The aim of this study was to assess its therapeutic effects in femoral condylar necrosis as well as in normal tissue using hyperspectral imaging. Material and method. A 47-year-old female patient diagnosed with avascular necrosis of the medial femoral condyle was included in this study. The patient received hyperbaric oxygen therapy for two consecutive days (the first day: three stages of 30 min each, separated by two breaks of 5 min at pO2 = 2 ATA; the second day: three stages of 30 min each, separated by two breaks of 5 min at pO2 = 2.4 ATA). The effects of hyperbaric oxygen therapy on the affected area (patient’s knee) and normal (patient’s hand) tissues oxygenation were assessed before and after each treatment session using hyperspectral imaging. Results and discussions. The results showed that hyperspectral imaging is quite good for monitoring the hyperbaric oxygen therapy efficacy in affected areas, even with deep tissue problems. Conclusions. In conclusion, the hyperspectral imaging-based approach for monitoring hyperbaric oxygen therapy could support physicians in extracting prognostic information and making the right treatment decisions. Keywords: bone necrosis, image analysis, maps, oxyhemoglobin, deoxyhemoglobin, oxygen saturation,

Hyperbaric oxygen therapy for chronic diabetic foot ulcers: An overview of systematic reviews

OBJECTIVES

Hyperbaric oxygen therapy in the treatment of diabetic foot ulcer has been widely used in medical practice, but its clinical effect is not clear. The purpose of this overview of systematic reviews is to evaluate the clinical evidence of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers.

METHODS

PubMed, Cochrane Library, Web of Knowledge, Embase, MEDLINE, Chinese National Knowledge Infrastructure Database, the Chongqing VIP Database, Chinese Biomedical Database, and Wanfang Database were searched in 1st December 2020. Systematic reviews (SRs) evaluating the effects of Hyperbaric oxygen therapy in people with diabetic foot ulcer were included. Methodological quality of the included SRs was assessed using the AMSTAR-2 tool. The quality of evidence of the primary studies was assessed using GRADE. The integrity of the included SRs was assessed using PRISMA. The bias risk of each SR was assessed using ROBIS evaluation tool.

RESULTS

Eleven SRs/MAs met all inclusion criteria. According to the results of the AMSTAR-2, only 1 included review were rated critically as being of high quality, 6 included review were rated critically as being of medium quality. With PRISMA, the reporting checklist was relatively complete, but some reporting weaknesses remained in the topics of the protocol and registration, search strategy, and additional analyses. Based on the ROBIS tool, only five SRs/MAs had a low risk of bias. With the GRADE system, no high-quality evidence was found, and only 13 outcomes provided moderate-quality evidence.

CONCLUSIONS

There is limited clinical evidence to support hyperbaric oxygen therapy in the treatment of diabetic foot ulcers, it is not recommended to routinely apply hyperbaric oxygen therapy to all patients with diabetic foot ulcers, especially those with non-ischemic diabetic foot ulcers. Hyperbaric oxygen therapy has certain potential to promote ulcer healing and reduce amputation rate in patients with ischemic diabetic foot ulcers, but due to the low quality and small quantity of the SRs/MAs supporting these results, high-quality studies with rigorous study designs and larger samples are needed before widespread recommendations can be made.

Efficacy of Hyperbaric Oxygen Therapy on Central Corneal Thickness, Intraocular Pressure, and Nerve Fiber Layer in Patients with Type 2 Diabetes: A Prospective Cohort Study

PURPOSE

To evaluate the effect of hyperbaric oxygen therapy (HBOT) on central corneal thickness (CCT), intraocular pressure (IOP), and the retinal nerve fiber layer (RNFL) thickness in patients with type 2 diabetes mellitus.

METHODS

This prospective non-randomized cohort study consisted of type 2 diabetes mellitus patients who received 30 sessions of HBOT for diabetic foot ulcer. The CCT, IOP, and RNFL measured at baseline, after the 10th session of HBOT, after the 20th session of HBOT, after the 30th session of HBOT, and after the 3 months of the last session of HBOT. We gained the superior-nasal, superior-temporal, inferior-nasal, inferior-temporal, nasal and temporal quadrant RNFL values with a spectral-domain optical coharence tomography.

RESULTS

Forty-six eyes of 46 patients included in the study. During the study period, a statistically significant increase in mean IOP values compared to baseline was observed (p < 0.001). We found no significant changes at CCT and all quadrants of RNFL values during HBOT and after 3 months of the treatment (p > 0.05). During the study period, the IOP levels increased over 21 mmHg (between 22 and 28 mmHg) in seven eyes (15.2%). The mean hemoglobin A1c values of these patients with IOP >21 mmHg were 8.2 ± 0.9 mg/dL, and there was significant differences compared with those of patients with IOP values ≤21 mmHg (7.4 ± 2.8 mg/dL) (p = 0.001).

CONCLUSIONS

HBOT increase IOP in type 2 diabetic patients especially in ones with impaired blood glucose regulation. However, it does not cause any changes in CCT and RNFL. As diabetic retinopathy and diabetic foot ulcer are in common pathologies, thus this brief report concludes a need for further studies with longer follow-up periods to explore the potential interaction of HBOT on CCT, IOP, and RNFL.

Efficacy of hyperbaric oxygen therapy for diabetic foot ulcer, a systematic review and meta-analysis of controlled clinical trials

Studies have suggested that hyperbaric oxygen therapy (HBOT) is effective in the healing of diabetic foot ulcer (DFU); however, there is a lack of consensus. Therefore, to assess the efficacy of HBOT on diabetic foot ulcer among diabetic patients, controlled clinical trials were searched through PubMed, EMBASE, Clinical key, Ovid Discovery, ERMED, Clinical Trials.gov databases for randomized controlled trials (RCTs) and other sources until 15 September 2020. Studies that evaluated the effect of HBOT on diabetic foot ulcer, complete healing, amputation, adverse events, ulcer reduction area, and mortality rate were included. Of 1984 study records screened, 14 studies (768 participants) including twelve RCTs, and two CCTs were included as per inclusion criteria. The results with pooled analysis have shown that HBOT was significantly effective in complete healing of diabetic foot ulcer (OR = 0.29; 95% CI 0.14-0.61; I² = 62%) and reduction of major amputation (RR = 0.60; 95% CI 0.39-0.92; I² = 24%). Although, it was not effective for minor amputations (RR = 0.82; 95% CI 0.34-1.97; I² = 79%); however, less adverse events were reported in standard treatment group (RR = 1.68; 95% CI 1.07-2.65; I² = 0%). Nevertheless, reduction in mean percentage of ulcer area and mortality rate did not differ in HBOT and control groups. This review provides an evidence that hyperbaric oxygen therapy is effective as an adjunct treatment measure for the diabetes foot ulcers. These findings could be generalized cautiously by considering methodological flaws within all studies.

Managing Diabetic Foot Ulcers: Pharmacotherapy for Wound Healing

Historically, there has been a scarcity of evidence-based topical therapy to hasten the healing of diabetic foot ulcers. But recently new evidence-based treatments have emerged from multicentre, randomised, controlled trials. This article highlights those trials, and describes the current pharmacological management of the diabetic foot ulcer and the advances that have been made in wound therapy to date. It provides an overview of topical and systemic pharmacotherapies in current use and those in development for future use in managing the diabetic foot. For each treatment, proposed mechanisms of action and evidence available to support their clinical use are presented. There is supporting randomised, controlled evidence for sucrose octasulfate in the treatment of neuro-ischaemic ulcers, and multi-layered patch of autologous leucocytes, platelets and fibrin in ulcers with or without ischaemia. There is also evidence for placentally derived products and for topical and systemic oxygen therapy in the healing of diabetic foot ulcers. Growth factors, bio-engineered tissues, stem cell therapy, gene therapy and peptide therapy also have some supporting evidence in the healing of diabetic foot ulcers. Nonsurgical debriding agents may be useful when the optimum approach of sharp debridement is not possible, and immunomodulators may be helpful for their antimicrobial effects, but robust data is still required to strengthen the case for general use. The review does not cover antimicrobials as their primary role are as anti-infectives and not in wound healing. The development of nanotechnology has created a means of prolonging the bioavailability of target molecules at the wound site, with the use of glass/hydrogel nanoparticles, polyethylene glycol and hyaluronic acid. Looking forward, novel therapies, including traction force-activated payloads, local delivery of short-interfering RNA and finally hydrogels incorporating bioactive agents or cells may provide possibilities for pharmacotherapy in the future.

Comparison of the efficacy of topical hyperbaric oxygen therapy alone vs a combination of physical methods including topical hyperbaric oxygen therapy, magnetotherapy, and low-energy light therapy in the treatment of venous leg ulcers

The aim of the study was to compare the therapeutic efficacy of topical hyperbaric oxygen therapy alone vs a combination of physical methods including topical hyperbaric oxygen therapy, magnetotherapy and low-energy light therapy in the treatment of venous leg ulcers. Thirty-six patients were treated with topical oxygen hyperbaria and 29 patients were treated with a combination of physical methods. The assessment of ulcer surface area with use of a planimetric method, pain intensity with use of Laitinen scale and quality of life by means of EuroQol scale were performed. In both groups a statistically significant (P < .05) reduction of ulcer surface area has been obtained, but in patients treated with combined physical therapy average percentage reduction of ulcer surface area (36.44% ± 11.04%) was statistically significantly (P = .00001) bigger as compared to other group (13.65% ± 8.32%). In both groups of patients statistically significant (P < .05) reduction of frequency and intensity of pain, reduced intake of analgesic drugs and reduction of limitations of physical activity, as well as statistically significant improvement of quality of life have been observed, but in patients treated with combined physical therapy an average increase in the score in EuroQoL scale (61.03 ± 7.14) was statistically significantly (P = .00001) bigger as compared to other group (25.27 ± 8.16). It was concluded that topical hyperbaric oxygen therapy alone and a combination of physical methods cause significant reduction of ulcer surface area, reduction of pain intensity, as well as improvement of the quality of life, but a combination of physical methods is more efficient.

Evaluation of the Efficacy of Hyperbaric Oxygen Therapy in the Management of Diabetic Ulcer Using Bates-Jensen Wound Assessment Tool

Background and Aims:

Hyperbaric oxygen therapy (HBOT) has been used as a treatment modality for diabetic wound ulcers recently. The aim of the present study was to evaluate the efficacy of HBOT in the management of diabetic ulcer using Bates-Jensen Wound Assessment Tool.

Materials and Methods:

A total of 50 patients with diabetic ulcer were included in this prospective, randomized, controlled study. Patients were randomly divided into two equal-sized (n = 25) study groups. Patients in Group CT received only conventional therapy and in Group HT received HBOT along with conventional therapy. Wound ulcers were analyzed on 0, 10^th, 20^th, and 30^th sessions using Bates-Jensen Wound Assessment Tool. Statistical analysis was performed using Microsoft (MS) Office Excel Software with the Chi-square test (level of significance, P = 0.05).

Results:

The healing recovery rate as changes in the Bates-Jensen Wound Assessment Tool from the 0^th to 10^th session in Group CT 0.88 ± 1.09 as compared to Group HT 9.96 ± 2.73 improved significantly with P = 0.0001. The grading score recorded from the 10^th to 20^th session in Group CT 3.73 ± 2.55 as compared to Group HT 10.40 ± 2.47 improved statistically significant, P = 0.0001. The grading score recorded from 20th to 30th session in Group CT 6.16 ± 2.01 as compared to Group HT 6.46 ± 2.19, P = 0.646 was not significant.

Conclusion:

HBOT has a definitive adjunctive treatment option in healing diabetic ulcers and improving quality of life.

Randomized controlled clinical trial evaluating the efficacy of hyperbaric oxygen therapy in facilitating the healing of chronic foot ulcers in diabetic patients: the study protocol

Background

Diabetic limb ulcers are highly prevalent and contribute to a significant increase in cost for the treatment of these patients in health services. However, healing of these wounds is a major health problem and may even lead to amputation. The primary aim of the current study is to evaluate the efficacy of hyperbaric oxygen therapy (HBOT) in facilitating the healing of diabetic foot ulcers, in addition to secondarily evaluating whether it reduces the number of amputations and improves the quality of life in these patients.

Methods

A non-blind randomized clinical study will be conducted in the city of Imperatriz, Maranhão state, Brazil, from 2019 to 2020, in diabetic patients with chronic foot ulcers (classified as Wagner grades 2, 3 and 4, persisting for more than 1 month). The outpatient follow-up for diabetic foot patients will be done at the Unified Health System, with a sample size of 120 patients (the randomization allocation will be 1:1, being 60 patients for each arm). Half of the patients will receive standard treatment, i.e. dressings, debridement, antibiotics and load relief, along with HBOT (HBOT group), and the other half will receive only standard treatment (control group). The patients of the HBOT group will be evaluated upon admission, after 10, 20, 30 and 35 HBOT sessions, and after 6 months and 1 year. The patients of the control group will also be evaluated at equivalent periods (upon admission, after 2, 4, 6 and 7 weeks, 6 months and 1 year). The SF-36 quality of life questionnaire will be filled upon admission and after 3 months of follow-up in both groups. The primary and secondary endpoints will be assessed with 1 year of follow-up.

Discussion

Diabetic foot ulcers are a highly prevalent complication of diabetes with serious consequences. A study to assess the efficacy of HBOT in healing the ulcers and reducing the rate of amputations in diabetic patients is justified, which will eventually aid in the development of guidelines for treating these ulcers.

Trial registration

Registration number RBR-7bd3xy. Registered on 17 July 2019—Retrospectively registered.

Ghrelin system is involved in improvements in glucose metabolism mediated by hyperbaric oxygen treatment in a streptozotocin‑induced type 1 diabetes mouse model

Type 1 diabetes mellitus (T1DM) is an autoimmune disorder for which the only effective therapy is insulin replacement. Hyperbaric oxygen (HBO) therapy has demonstrated potential in improving hyperglycemia and as a treatment option for T1DM. Ghrelin and HBO have been previously reported to exert proliferative, anti-apoptotic and anti-inflammatory effects in pancreatic cells. The present study investigated the mechanism underlying HBO- and ghrelin system-mediated regulation of glucose metabolism. Male C57BL/6 mice were intraperitoneally injected with streptozotocin (STZ; 150 mg/kg) to induce T1DM before the diabetic mice were randomly assigned into the T1DM and T1DM + HBO groups. Mice in the T1DM + HBO group received HBO (1 h; 100% oxygen; 2 atmospheres absolute) daily for 2 weeks. Significantly lower blood glucose levels and food intake were observed in mice in the T1DM + HBO group. Following HBO treatment, islet β-cell area were increased whereas those of α-cell were decreased in the pancreas. In addition, greater hepatic glycogen storage in liver was observed, which coincided with higher pancreatic glucose transporter 2 (GLUT2) expression levels and reduced hepatic GLUT2 membrane trafficking. There were also substantially higher total plasma ghrelin concentrations and gastric ghrelin-O-acyl transferase (GOAT) expression levels in mice in the T1DM + HBO group. HBO treatment also abolished reductions in pancreatic GOAT expression levels in T1DM mice. Additionally, hepatic growth hormone secretagogue receptor-1a levels were found to be lower in mice in the T1DM + HBO group compared with those in the T1DM group. These results suggest that HBO administration improved glucose metabolism in a STZ-induced T1DM mouse model. The underlying mechanism involves improved insulin-release, glucose-sensing and regulation of hepatic glycogen storage, an observation that was also likely dependent on the ghrelin signalling system.

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

Effects of adding adjunctive hyperbaric oxygen therapy to standard wound care for diabetic foot ulcers: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

Diabetic foot ulcer represents a major health problem globally. Preliminary studies have indicated that systemic treatment of diabetic foot ulcer patients with hyperbaric oxygen therapy have beneficial effects on wound healing, risk of amputation, glycaemic control, atherosclerosis, inflammatory markers and other clinical and laboratory parameters. This protocol for a systematic review aims at identifying the beneficial and harmful effects of adding hyperbaric oxygen therapy to standard wound care for diabetic foot ulcers.

METHODS AND ANALYSIS

This protocol was performed following the recommendations of the Cochrane Collaboration and the eight-step assessment procedure suggested by Jakobsen and colleagues. We plan to include all relevant randomised clinical trials assessing the effects of hyperbaric oxygen therapy in the treatment of diabetic foot ulcer versus any control group with any intervention defined as standard wound care or similar, together with sham interventions. Our primary outcome will be: all-cause mortality, serious adverse events and quality of life. Our secondary outcomes will be: healing of index wound, major amputation and wound infection. Any eligible trial will be assessed and classified as either high risk of bias or low risk of bias, and our conclusions will be based on trials with low risk of bias. The analyses of the extracted data will be performed using Review Manager 5 and Trial Sequential Analysis. For both our primary and secondary outcomes, we will create a 'Summary of Findings' table and use GRADE (Grading of Recommendations Assessment, Development and Evaluation) assessment to assess the quality of the evidence.

ETHICS AND DISSEMINATION

We use publicly accessible documents as evidence, there is no participant involvement at an individual level and an institutional ethics approval is not required. The results of the review will be sought published in a peer-reviewed journals, also in the event of insignificant results or null results, and thereby it will be disseminated to clinicians and public available.

PROSPERO REGISTRATION NUMBER

CRD42019139256.

Hyperbaric oxygen therapy as an adjuvant to standard therapy in the treatment of diabetic foot ulcers

Background and Aims:

Chronic diabetic foot ulcers pose a major problem because of associated limb threatening complications. The aim of the present study was to evaluate the efficacy of hyperbaric oxygen therapy (HBOT) as an adjuvant to standard therapy for treatment of diabetic foot ulcers.

Material and Methods:

A total of 54 patients with diabetic foot ulcer of Wagner grade II–IV were recruited in this prospective, randomized, double blind study. Patients were randomized to receive HBOT along with standard therapy (group H; n = 28) or standard therapy alone (group S; n = 26). Patients were given 6 sessions per week for 6 weeks and followed up for 1 year. Outcomes were measured in terms of healing, and need for amputation, grafting or debridement. Parametric continuous variables were analyzed using Student unpaired t-test and categorical variables were analyzed using Chi square test.

Results:

The diabetic ulcers in 78% patients in Group H completely healed without any surgical intervention while no patient in group S healed without surgical intervention (P = 0.001). 2 patients in group H required distal amputation while in Group S, three patients underwent proximal amputation.

Conclusion:

The present study shows that hyperbaric oxygen therapy is a useful adjuvant to standard therapy and is a better treatment modality if combined with standard treatment rather than standard treatment alone for management of diabetic foot ulcers.

Oxygen therapy: evidence base

The evidence base for the different methods of oxygen therapy ranges from systematic reviews and meta-analyses to case series evaluations. A common thread running through the assorted evidence is that oxygen therapy accelerates healing and reduces healing times. This article summarises the clinical evidence produced on this therapy.