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

Can acupuncture increase microcirculation in peripheral artery disease and diabetic foot syndrome? - a pilot study

Background

Globally, diabetes mellitus (DM) and peripheral artery disease (PAD) have an increasing incidence and a high prevalence and are both associated with high morbidity and complication rates, e.g., as chronic non-healing peripheral ulcers. Impaired macro- and microcirculation and peripheral neuropathy lead to an increased risk of foot ulcers and infections. These complications are difficult to treat, have a high risk of becoming chronic and often lead to lower limb amputation. The aim of this planned study was to investigate the potential effects of acupuncture on improving microcirculation in patients with Diabetic Foot Syndrome (DFS) and PAD.

Materials and methods

In 18 patients with chronic non-healing peripheral ulcers and diagnosed DM or PAD, data on 8 microcirculatory parameters were collected simultaneously on intact skin close to the wound margin. Microcirculation was assessed using an O2C device combining laser Doppler shift and white light spectroscopy (LEA Medizintechnik GmbH, Giessen, Germany). Unilateral and bilateral acupuncture was performed on the connecting line between acupuncture points Stomach 14 and Stomach 15.

Results

After unilateral acupuncture (ipsilateral to the wound side), a statistically significant improvement in 7 out of 8 microcirculatory parameters was demonstrated compared to baseline measurements before acupuncture. After bilateral acupuncture, there was an additional improvement and statistical significance in all parameters in both DFS and PAD patients.

Discussion

These results show an improvement in the microcirculation and peripheral blood flow at the edges of the wound. As impaired micro- and macrocirculation is considered to be a critical prognostic factor for the healing of a peripheral lesion, the intervention could have a positive impact on the healing of (chronic) peripheral wounds.

Co-Delivery of Bioengineered Exosomes and Oxygen for Treating Critical Limb Ischemia in Diabetic Mice

Diabetic patients with critical limb ischemia face a high rate of limb amputation. Regeneration of the vasculature and skeletal muscles can salvage diseased limbs. Therapy using stem cell-derived exosomes that contain multiple proangiogenic and promyogenic factors represents a promising strategy. Yet the therapeutic efficacy is not optimal because exosomes alone cannot efficiently rescue and recruit endothelial and skeletal muscle cells and restore their functions under hyperglycemic and ischemic conditions. To address these limitations, we fabricated ischemic-limb-targeting stem cell-derived exosomes and oxygen-releasing nanoparticles and codelivered them in order to recruit endothelial and skeletal muscle cells, improve cell survival under ischemia before vasculature is established, and restore cell morphogenic function under high glucose and ischemic conditions. The exosomes and oxygen-releasing nanoparticles, delivered by intravenous injection, specifically accumulated in the ischemic limbs. Following 4 weeks of delivery, the exosomes and released oxygen synergistically stimulated angiogenesis and muscle regeneration without inducing substantial inflammation and reactive oxygen species overproduction. Our work demonstrates that codelivery of exosomes and oxygen is a promising treatment solution for saving diabetic ischemic limbs.

A scientometrics analysis and visualisation of diabetic foot research from 1955 to 2022

Diabetic foot (DF) has become a serious health problem in modern society, and it has been a hotspot of research for a long time. However, little scientometric analysis has been carried out on DF. In the present study, we analysed 8633 literature reports on DF in the Web of Science Core Collection from database inception until April 23, 2022. VOSviewer (Centre for Science and Technology Studies at Leiden University, Leiden, the Netherlands) and CiteSpace (College of Computing and Informatics, Drexel University, Philadelphia, United States) were employed to address high-impact countries and institutions, journals, references, research hotspots, and key research fields in DF research. Our analysis findings indicated that publications on DF have increased markedly since 2016 and were primarily published in the United States of America. The recent studies focus on the amniotic membrane, foot ulcers, osteomyelitis, and diabetic wound healing. The five keyword clusters, which included DF ulcer and wound healing therapies, management and guidelines, neuropathy and plantar pressure, amputation and ischemia, and DF infection and osteomyelitis, are helpful for enhancing prevention, standardising treatment, avoiding complications, and improving prognosis. These findings indicated a method for future therapies and research in DF.

Rheocarna® as an alternative therapeutic option for patients with chronic limb-threatening ischemia: A case report

Recently, a new low-density lipoprotein apheresis device (Rheocarna^®; Kaneka Corporation, Osaka, Japan), a blood purification therapy, was approved in Japan for managing chronic limb-threatening ischemia with refractory ulcers. Here, we describe a case of chronic limb-threatening ischemia that was treated with the Rheocarna. A 65-year-old Asian man with an ulcer on the right heel was admitted to our hospital. Angiography revealed chronic total occlusion with severe calcification of the anterior tibial, peroneal, and posterior tibial arteries. The patient underwent distal bypass of the saphenous vein; however, the bypass was occluded in the early postoperative period. The Rheocarna was used, and the ulcers improved significantly postoperatively. Although endovascular treatment was eventually performed on the occluded bypass graft to completely heal the ulcer, the Rheocarna could be an alternative treatment option in challenging cases of chronic limb-threatening ischemia.

Small extracellular vesicles from mesenchymal stem cells: A potential Weapon for chronic non-healing wound treatment

Chronic non-healing wounds have posed a severe threat to patients mentally and physically. Behavior dysregulation of remaining cells at wound sites is recognized as the chief culprit to destroy healing process and hinders wound healing. Therefore, regulating and restoring normal cellular behavior is the core of chronic non-healing wound treatment. In recent years, the therapy with mesenchymal stem cells (MSCs) has become a promising option for chronic wound healing and the efficacy has increasingly been attributed to their exocrine functions. Small extracellular vesicles derived from MSCs (MSC-sEVs) are reported to benefit almost all stages of wound healing by regulating the cellular behavior to participate in the process of inflammatory response, angiogenesis, re-epithelization, and scarless healing. Here, we describe the characteristics of MSC-sEVs and discuss their therapeutic potential in chronic wound treatment. Additionally, we also provide an overview of the application avenues of MSC-sEVs in wound treatment. Finally, we summarize strategies for large-scale production and engineering of MSC-sEVs. This review may possibly provide meaningful guidance for chronic wound treatment with MSC-sEVs.