Clinical and economic assessment of diabetic foot ulcer debridement with collagenase: results of a randomized controlled study

Narrative review on nanoparticles based on current evidence: therapeutic agents for diabetic foot infection

Diabetes's effects on wound healing present a major treatment challenge and increase the risk of amputation. When traditional therapies fail, new approaches must be investigated. With their submicron size and improved cellular internalisation, nanoparticles present a viable way to improve diabetic wound healing. They are attractive options because of their innate antibacterial qualities, biocompatibility, and biodegradability. Nanoparticles loaded with organic or inorganic compounds, or embedded in biomimetic matrices such as hydrogels, chitosan, and hyaluronic acid, exhibit excellent anti-inflammatory, antibacterial, and antioxidant properties. Drug delivery systems (DDSs)-more precisely, nanodrug delivery systems (NDDSs)-use the advantages of nanotechnology to get around some of the drawbacks of traditional DDSs. Recent developments show how expertly designed nanocarriers can carry a variety of chemicals, transforming the treatment of diabetic wounds. Biomaterials that deliver customised medications to the wound microenvironment demonstrate potential. Delivery techniques for nanomedicines become more potent than ever, overcoming conventional constraints. Therapeutics for diabetes-induced non-healing wounds are entering a revolutionary era thanks to precisely calibrated nanocarriers that effectively distribute chemicals. This review highlights the therapeutic potential of nanoparticles and outlines the multifunctional nanoparticles of the future that will be used for complete wound healing in diabetics. The investigation of novel nanodrug delivery systems has the potential to revolutionise diabetic wound therapy and provide hope for more efficient and focused therapeutic approaches.

Bibliometric analysis of systematic review and meta-analysis on diabetic foot ulcer

Many clinical management strategies have been proposed to deal with diabetic foot ulcers. However, the occurrence and recurrence of foot ulcers remain the major problems for diabetics. This study aims to identify, visualize, and characterize the meta-analyses on diabetic foot ulcer research. Articles published online were retrieved from the Web of Science core collection database using a search query incorporating MeSH terms and topics related to diabetic foot ulcers and meta-analysis. The publications were then analyzed for basic characteristics, including publication year, countries, topics covered, references, and keywords discussed in the articles. Data visualization was performed using CiteSpace. 334 meta-analyses and systematic reviews on diabetic foot ulcers were identified. The number of publications has experienced rapid growth in recent years (nearly 6-fold since 2016). The United States, China, Netherlands, England, and Australia had a strong collaboration in the contribution of publication. 7 primary topics were summarized from the top 100 highly cited publications: #1 Interventions (proportion: 59%), #2 Risk factors and Prevention (22%), #3 Epidemiology analysis (6%), #4 Cost-effectiveness of interventions (5%), #5 Long-term prognosis (3%), #6 Quality of life analysis (3%), and #7 Economic burden analysis (2%). Footwear and offloading interventions, multidisciplinary care, hyperbaric oxygen, platelet-rich plasma, and negative pressure wound therapies are highly regarded in terms of intervention. Diabetic foot osteomyelitis, peripheral diabetic neuropathy, chronic limb-threatening ischemia, and infections are the main comorbidities. In recent years, offloading interventions, debridement, telemedicine, long-term prognosis, and economic burden analyses have gradually received attention. Individualized treatment, multidisciplinary collaboration, quality of life considerations, and economic burden analyses are the long-term concerns.

Effectiveness of interventions to enhance healing of chronic foot ulcers in diabetes: A systematic review

BACKGROUND

It is critical that interventions used to enhance the healing of chronic foot ulcers in diabetes are backed by high-quality evidence and cost-effectiveness. In previous years, the systematic review accompanying guidelines published by the International Working Group of the Diabetic Foot performed 4-yearly updates of previous searches, including trials of prospective, cross-sectional and case-control design.

AIMS

Due to a need to re-evaluate older studies against newer standards of reporting and assessment of risk of bias, we performed a whole new search from conception, but limiting studies to randomised control trials only.

MATERIALS AND METHODS

For this systematic review, we searched PubMed, Scopus and Web of Science databases for published studies on randomised control trials of interventions to enhance healing of diabetes-related foot ulcers. We only included trials comparing interventions to standard of care. Two independent reviewers selected articles for inclusion and assessed relevant outcomes as well as methodological quality.

RESULTS

The literature search identified 22,250 articles, of which 262 were selected for full text review across 10 categories of interventions. Overall, the certainty of evidence for a majority of wound healing interventions was low or very low, with moderate evidence existing for two interventions (sucrose-octasulfate and leucocyte, platelet and fibrin patch) and low quality evidence for a further four (hyperbaric oxygen, topical oxygen, placental derived products and negative pressure wound therapy). The majority of interventions had insufficient evidence.

CONCLUSION

Overall, the evidence to support any other intervention to enhance wound healing is lacking and further high-quality randomised control trials are encouraged.

Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update)

AIMS

Principles of wound management, including debridement, wound bed preparation, and newer technologies involving alternation of wound physiology to facilitate healing, are of utmost importance when attempting to heal a chronic diabetes-related foot ulcer. However, the rising incidence and costs of diabetes-related foot ulcer management necessitate that interventions to enhance wound healing of chronic diabetes-related foot ulcers are supported by high-quality evidence of efficacy and cost effectiveness when used in conjunction with established aspects of gold-standard multidisciplinary care. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on wound healing interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.

MATERIALS AND METHODS

We followed the GRADE approach by devising clinical questions and important outcomes in the Patient-Intervention-Control-Outcome (PICO) format, undertaking a systematic review, developing summary of judgements tables, and writing recommendations and rationale for each question. Each recommendation is based on the evidence found in the systematic review and, using the GRADE summary of judgement items, including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability, we formulated recommendations that were agreed by the authors and reviewed by independent experts and stakeholders.

RESULTS

From the results of the systematic review and evidence-to-decision making process, we were able to make 29 separate recommendations. We made a number of conditional supportive recommendations for the use of interventions to improve healing of foot ulcers in people with diabetes. These include the use of sucrose octasulfate dressings, the use of negative pressure wound therapies for post-operative wounds, the use of placental-derived products, the use of the autologous leucocyte/platelet/fibrin patch, the use of topical oxygen therapy, and the use of hyperbaric oxygen. Although in all cases it was stressed that these should be used where best standard of care was not able to heal the wound alone and where resources were available for the interventions.

CONCLUSIONS

These wound healing recommendations should support improved outcomes for people with diabetes and ulcers of the foot, and we hope that widescale implementation will follow. However, although the certainty of much of the evidence on which to base the recommendations is improving, it remains poor overall. We encourage not more, but better quality trials including those with a health economic analysis, into this area.

Collagenase-based wound debridement agent induces extracellular matrix supporting phenotype in macrophages

Macrophages assume diverse phenotypes and functions in response to cues from the microenvironment. Earlier we reported an anti-inflammatory effect of Collagenase Santyl® Ointment (CSO) and the active constituent of CSO (CS-API) on wound macrophages in resolving wound inflammation indicating roles beyond debridement in wound healing. Building upon our prior finding, this study aimed to understand the phenotypes and subsets of macrophages following treatment with CS-API. scRNA-sequencing was performed on human blood monocyte-derived macrophages (MDM) following treatment with CS-API for 24 h. Unbiased data analysis resulted in the identification of discrete macrophage subsets based on their gene expression profiles. Following CS-API treatment, clusters 3 and 4 displayed enrichment of macrophages with high expression of genes supporting extracellular matrix (ECM) function. IPA analysis identified the TGFβ-1 pathway as a key hub for the CS-API-mediated ECM-supportive phenotype of macrophages. Earlier we reported the physiological conversion of wound-site macrophages to fibroblasts in granulation tissue and impairment of such response in diabetic wounds, leading to compromised ECM and tensile strength. The findings that CSO can augment the physiological conversion of macrophages to fibroblast-like cells carry significant clinical implications. This existing clinical intervention, already employed for wound care, can be readily repurposed to improve the ECM response in chronic wounds.

Kick-Starting Wound Healing: A Review of Pro-Healing Drugs

Cutaneous wound healing consists of four stages: hemostasis, inflammation, proliferation/repair, and remodeling. While healthy wounds normally heal in four to six weeks, a variety of underlying medical conditions can impair the progression through the stages of wound healing, resulting in the development of chronic, non-healing wounds. Great progress has been made in developing wound dressings and improving surgical techniques, yet challenges remain in finding effective therapeutics that directly promote healing. This review examines the current understanding of the pro-healing effects of targeted pharmaceuticals, re-purposed drugs, natural products, and cell-based therapies on the various cell types present in normal and chronic wounds. Overall, despite several promising studies, there remains only one therapeutic approved by the United States Food and Drug Administration (FDA), Becaplermin, shown to significantly improve wound closure in the clinic. This highlights the need for new approaches aimed at understanding and targeting the underlying mechanisms impeding wound closure and moving the field from the management of chronic wounds towards resolving wounds.

Diabetic Foot Ulcer Management and Treatment: An Overview of Published Patents

BACKGROUND

One of the most challenging effects of diabetes is diabetic foot ulceration (DFU). DFU may occur in up to one-third of individuals with diabetes mellitus (D.M.) at some point in their lives. The major cause of morbidity in D.M. patients is DFU. The length of treatment is difficult, and DFU recurrence is common.

OBJECTIVE

The most crucial element for the treatment and prevention of DFUs require a multidisciplinary approach. Patients who are at risk should be identified, depending on the type of risk, prophylactic actions etc. It is imperative to identify at-risk patients and take preventative measures accordingly.

METHOD

The at-risk diabetes-related foot ulcer was identified based on the risk category classification, while the foot ulcers were evaluated using Wagner's classification system.

RESULTS

Literature reported that patients with lower limb vascular insufficiency, loss of vibratory sensation, or protective sensation loss have an increased risk of developing foot ulcers. Proper categorization and therapeutic measures will be implemented after the DFU has been formed. The appropriate assessment and management of general health status should include glycemic control, the diagnosis and treatment of vascular disease, standard care for wounds, diagnosis, and infection treatments.

CONCLUSION

The review reflects the updated awareness of the treatment and management of DFU based on the current and past literature and patent analysis.

Comparison of healing effectiveness of different debridement approaches for diabetic foot ulcers: a network meta-analysis of randomized controlled trials

Objectives

The choice of the debridement method is very important for the healing of diabetic foot ulcers (DFUs), but the relative effectiveness of different debridement methods in the healing of DFUs remains unclear. This study conducted a network meta-analysis of the relative healing effectiveness of different debridement methods in patients with DFUs.

Methods

We performed a literature search in PubMed, Embase, and Cochrane Library from database inception up to 30 June 2023 for screening randomized controlled trials on the healing effectiveness of debridement in DFUs. Outcome measures included ulcer healing rate and ulcer area reduction rate. The Cochrane Risk Bias Tool, version 2.0, was used to assess the risk of bias in the included trials. R software was used for performing statistical analysis and GraphPad Prism was used for image plotting.

Results

A total of 19 randomized controlled trials were included, and 900 patients with DFUs were assessed in this analysis. The proteolytic fraction from the latex of Vasconcellea cundinamarcensis (P1G10) in enzymatic debridement showed the best ulcer healing rate (SURCA = 0.919) when compared with the standard of care (SOC) group, with a mean difference (MD) and 95% confidence interval (CI) of 1.40 (0.57, 2.36). Kiwifruit extract demonstrated the best effect on the ulcer area reduction rate (SURCA = 0.931), when compared with that in the SOC group, with an MD and 95% CI of 0.47 (0.27, 0.66).

Conclusion

Enzymatic debridement was superior to other debridement methods in terms of ulcer healing rate and ulcer area reduction rate in patients with DFUs. However, as the quality of the included trials is low, enzymatic debridement can be used as a candidate debridement method in addition to sharp-based debridement in clinical practice.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023441715.

Current Therapeutic Modalities for the Management of Chronic Diabetic Wounds of the Foot

Impaired wound healing is common in patients with diabetes mellitus (DM). Different therapeutic modalities including wound debridement and dressing, transcutaneous electrical nerve stimulation (TENS), nanomedicine, shockwave therapy, hyperbaric (HBOT) and topical (TOT) oxygen therapy, and photobiomodulation (PBM) have been used in the management of chronic diabetic foot ulcers (DFUs). The selection of a suitable treatment method for DFUs depends on the hosts' physiological status including the intricacy and wound type. Effective wound care is considered a critical component of chronic diabetic wound management. This review discusses the causes of diabetic wounds and current therapeutic modalities for the management of DFUs, specifically wound debridement and dressing, TENS, nanomedicine, shockwave therapy, HBOT, TOT, and PBM.

Diabetes mellitus and diabetic foot ulcer: Etiology, biochemical and molecular based treatment strategies via gene and nanotherapy

Diabetes mellitus (DM) is a collection of metabolic and pathophysiological disorders manifested with high glucose levels in the blood due to the inability of β-pancreatic cells to secrete an adequate amount of insulin or insensitivity of insulin towards receptor to oxidize blood glucose. Nevertheless, the preceding definition is only applicable to people who do not have inherited or metabolic disorders. Suppose a person who has been diagnosed with Type 1 or Type 2DM sustains an injury and the treatment of the damage is complicated and prolonged. In that case, the injury is referred to as a diabetic foot ulcer (DFU). In the presence of many proliferating macrophages in the injury site for an extended period causes the damage to worsen and become a diabetic wound. In this review, the scientific information and therapeutic management of DM/DFU with nanomedicine, and other related data were collected (Web of Science and PubMed) from January 2000 to January 2022. Most of the articles revealed that standard drugs are usually prescribed along with hypoglycaemic medications. Conversely, such drugs stabilize the glucose transporters and homeostasis for a limited period, resulting in side effects such as kidney damage/failure, absorption/gastrointestinal problems, and hypoglycemic issues. In this paper, we review the current basic and clinical evidence about the potential of medicinal plants, gene therapy, chemical/green synthesized nanoparticles to improving the metabolic profile, and facilitating the DM and DFU associated complications. Preclinical studies also reported lower plasma glucose with molecular targets in DM and DFU. Research is underway to explore chemical/green synthesized nanoparticle-based medications to avoid such side effects. Hence, the present review is intended to address the current challenges, recently recognized factors responsible for DM and DFU, their pathophysiology, insulin receptors associated with DM, medications in trend, and related complications.

Debridement of diabetic foot ulcers: public health and clinical implications – a systematic review, meta-analysis, and meta-regression

Background

Diabetic foot ulceration (DFU) has devastating complications and a lifetime occurrence of 15%–34%. Debridement of DFU is regarded as an intervention that accelerates ulcer healing and may reduce complications including amputations, infections, and poor quality of life (QoL), which have serious public health and clinical implications. A systematic review (SR) of SRs and of randomized controlled trials (RCTs) with meta-analyses (MAs) on debridement of DFU that synthesizes all human experimental evidence is warranted.

Objectives

Are debridement methods in DFU beneficial over other forms and standard gauze dressings (control condition) in these outcomes?

Study eligibility criteria

All SRs/MAs/RCTs comparing debridement methods for DFU with alternative methods of debridement and with control.

Data sources

Cochrane Wounds Group Specialized Register, Cochrane Central Register of Controlled Trials (Cochrane Library), Ovid MEDLINE, PubMed, EMBASE, EBSCO, CINAHL, and Web of Science.

Participants and interventions

Adults with type 1/2 diabetes with DFU and any debridement method compared with alternative debridement methods or control.

Main Outcomes

Amputation rates, wound infections, QoL, proportion of ulcers healed, time to complete healing, ulcer recurrence, and treatment cost.

Study selection and analysis

Data extraction/synthesis by two independent reviewers pooled using a random-effects model with sensitivity analysis.

Results

10 SRs were retrieved and reported qualitatively. Six SRs included MAs. This SR included 30 studies, with 2654 participants, using 19 debridement combinations. The debridement methods were compared with findings pooled into MAs. Meta-regression (MR) did not identify significant predictors/moderators of outcomes.

Limitations

The studies may have been under-powered. The inclusion/exclusion criteria varied and the increased risk of bias contributed to low-quality evidence.

Discussion/Conclusion

Weak evidence exists that debridement methods are superior to other forms of debridement or control in DFU.

Implications

Researchers should follow standardized reporting guidelines (Consolidated Standards of Reporting Trials). Clinicians/investigators could use the findings from this SR/MA/MR in guiding patient-individualized decision making and designing future RCTs.

Beta-caryophyllene as an antioxidant, anti-inflammatory and re-epithelialization activities in a rat skin wound excision model

The skin is a critical organ for the maintenance of the integrity and protection of the organism. When a wound occurs, a sequence of healing mechanisms is triggered to reconstruct the wounded area. β-caryophyllene is a sesquiterpene in Copaifera langsdorffii oleoresin with antioxidant and anti-inflammatory potential. On the basis of previous studies with C. langsdorffii, β-caryophyllene was selected to evaluate its wound healing potential and pharmacological mechanisms. The excision wound model was used with male Wistar rats and macroscopic, histological, immunohistochemical and biochemical analyses were performed with skin samples, comparing the β-caryophyllene-treated group with reference drugs. The results showed macroscopic retraction of the wounds treated with β-caryophyllene. Biochemical assays revealed the antioxidant and anti-inflammatory mechanisms of the β-caryophyllene-treated group with increasing levels of IL-10 and GPx and decreasing levels of pro-inflammatory molecules, including TNF-α, IFN-γ, IL-1β and IL-6. After β-caryophyllene treatment, immunohistochemical assays showed enhanced re-epithelialization, through the increase in laminin-γ2 and desmoglein-3 immunolabeling. β-caryophyllene also act in the remodeling mechanism, increasing the collagen content in the Masson’s trichrome staining. These findings indicated the wound-healing potential of β-caryophyllene topical formulation in rat skin wounds, mediated by antioxidant, anti-inflammatory and re-epithelialization mechanisms.

Stress-Reducing Psychological Interventions as Adjuvant Therapies for Diabetic Chronic Wounds

BACKGROUND

Diabetic foot ulcers (DFUs) are a major complication of diabetes mellitus and a leading cause of lower limb amputation. Interventions to reduce psychological stress may have the potential to improve self-care and greatly reduce the morbidity and mortality associated with DFU. This review is focused on the consequences of psychological stress in wound healing and reflects on the effects of currently used psychological stress-reducing interventions in patients with DFU, proposing new applications for currently used stress-reduction interventions.

RESULTS

Stress is a natural and fundamental survival mechanism that becomes harmful when chronic. DFU is associated with high levels of anxiety and chronic psychological stress. Chronic stressinduced cortisol and adrenaline release impair wound healing, independently of the stressor. Psychological stress-reducing interventions, such as relaxation with guided imagery, biofeedback-assisted relaxation, mindfulness-based strategies, and hypnosis, can lead to a reduction in perceived stress and improve wound healing by reducing wound inflammation and pain while improving glycemic control. All stress reduction interventions also lead to pain relief and improved patient's quality of life.

CONCLUSION

Psychological stress-reducing interventions are promising adjuvant therapies for DFU. Their clinical application can improve self-care by tackling patient's expectations, anxieties, and fears. They can also help patients manage stress and pain while reducing wound inflammation and improving wound healing.

Flexible Microneedle Array Patch for Chronic Wound Oxygenation and Biofilm Eradication

Chronic nonhealing wounds are a growing socioeconomic problem that affects more than 6 million people annually solely in the United States. These wounds are colonized by bacteria that often develop into biofilms that act as a physical and chemical barrier to therapeutics and tissue oxygenation leading to chronic inflammation and tissue hypoxia. Although wound debridement and vigorous mechanical abrasion techniques are often used by clinical professionals to manage and remove biofilms from wound surfaces, such methods are highly nonselective and painful. In this study, we have developed a flexible polymer composite microneedle array that can overcome the physicochemical barriers (i.e., bacterial biofilm) present in chronic nonhealing wounds and codeliver oxygen and bactericidal agents. The polymeric microneedles are made by using a facile UV polymerization process of polyvinylpyrrolidone and calcium peroxide onto a flexible polyethylene terephthalate substrate for conformable attachment onto different locations of the human body surface. The microneedles effectively elevate the oxygen levels from 8 to 12 ppm once dissolved over the course of 2 h while also providing strong bactericidal effects on both liquid and biofilm bacteria cultures of both Gram-positive (Staphylococcus aureus) and Gram-negative (Pseudomonas aeruginosa) bacterial strains commonly found in dermal wounds. Furthermore, the results from the ex vivo assay on a porcine wound model indicated successful insertion of the microneedles into the tissue while also providing effective bactericidal properties against both Gram-positive and Gram-negative within the complex tissue matrix. Additionally, the microneedles demonstrate high levels of cytocompatibility with less than 10% of apoptosis throughout 6 days of continuous exposure to human dermal fibroblast cells. The demonstrated flexible microneedle array can provide a better approach for increasing the effectiveness of topical tissue oxygenation as well as the treatment of infected wounds with intrinsically antibiotic resistant biofilms.

Development of the BWAT-CUA Scale to Assess Wounds in Patients with Calciphylaxis

Calcific uremic arteriolopathy (CUA; calciphylaxis) is a severe form of vascular calcification with no approved therapies. A standardized wound assessment tool is needed to evaluate changes in calciphylaxis wounds over time. A prospective, single-arm study of 14 patients with calciphylaxis reported improvement for the primary endpoint of wound healing using the 13-item Bates-Jensen Wound Assessment Tool (BWAT), although that tool was developed for assessment of pressure ulcers. This report describes development of BWAT-CUA, an 8-item modification of BWAT focusing on prototypical features of calciphylaxis lesions. The BWAT-CUA has a range of 8 (best) to 40 (worst) and was used ad hoc to analyze BWAT data collected in the prospective study. Using BWAT-CUA, relative improvement in calciphylaxis wounds was 30% overall (from 21.2 to 14.9; p = 0.0016) and 34% in the subset of 12 patients with ulceration at baseline (from 23.3 to 15.3; p = 0.0002). BWAT-CUA is a primary endpoint in an ongoing randomized, placebo-controlled phase 3 study of SNF472 recruiting patients with end-stage kidney disease and at least one ulcerated calciphylaxis lesion. BWAT-CUA, a newly developed tool for assessment of calciphylaxis wound severity and improvements over time, may be used in clinical research and in clinical practice.

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.

Study on the Effect of the Five-in-One Comprehensive Limb Salvage Technologies of Treating Severe Diabetic Foot

Objective: To explore the clinical efficacy and advantages of five-in-one comprehensive limb salvage technologies for the treatment of severe diabetic foot ulcer (DFU). Approach: Clinical data for 120 patients with severe DFU treated between January 2012 and December 2017 were analyzed retrospectively. The control group (48 cases) was treated with traditional therapies, including controlling blood sugar, improving microcirculation, preserving nerve function, and dressing changes, whereas the experimental group (72 cases) was treated with traditional therapy combined with additional techniques, such as early and thorough debridement, negative pressure wound therapy, revascularization, and skin graft or flap. Ankle-brachial index (ABI), transcutaneous oxygen pressure (TcPO₂), wound healing rate, healing time, ulcer recurrence rate, and amputation rate were recorded. Results: Compared with the control group, the experimental group significantly improved wound healing rate (93.1% vs. 72.9%; p < 0.01), decreased wound healing time (16.2 ± 5.4 days vs. 32.2 ± 7.8 days; p < 0.05), reduced major limb amputation rate (1.4% vs. 10.4%, p < 0.05), and ulcer recurrence rate (5.6% vs. 14.6%; p < 0.05). There were no significant differences in amputation rate between experimental and control group (29.2% vs. 33.3%, p = 0.628). After revascularization, the revascularization group showed significantly improved ABI (0.75 ± 0.21 vs. 0.35 ± 0.16, p < 0.05) and TcPO₂ (36 ± 6 mmHg vs. 15 ± 4 mmHg, p < 0.05). Innovation: We propose a five-in-one comprehensive treatment method, which provides a multidisciplinary cooperative model for comprehensive medical and surgical treatments for DFU. Conclusion: The five-in-one comprehensive limb salvage treatment technologies played a vital role in enhancing the healing rate of severe DFU, shortening the healing time, and reducing the rate of recurrence and major amputation, thus improving the overall quality of life.

Retrospective Matched Case-Control Study on the Use of CO2 Laser for the Treatment of Nonhealing Diabetic Foot Ulcers: The DULCIS-2 (Diabetic ULcer, CO2 Laser, and Infections) Study

PURPOSE

Infection, which is one of the possible complications of diabetic foot ulcers (DFUs), makes the treatment of ulcers challenging because of its negative impact on healing processes and the high prevalence of multiresistant germs. This study is aimed at verifying the effect of a surgical CO₂ laser (which reduces the bacterial load and allows a more accurate debridement), as compared with the traditional lancets, on the healing rate of DFU.

METHODS

The present case-control retrospective analysis was performed on patients with chronic (>6 months) DFU with Texas grade >1, treated with 80 W surgical CO₂ laser (DEKA SmartXide2 C80, El.En. Group) and compared with a matched sample of patients with similar characteristics, who were treated with a traditional surgical approach. The debridement was performed trying to achieve the complete removal of nonviable tissues. The principal endpoint was the proportion of patients healed at 6 months. All analyses were carried out with SPSS 25.0. The study protocol was approved by the local ethical committee.

RESULTS

This study included 118 patients (59 cases and 59 controls). At 6 months, the proportion of healing patients was 35% and 18% in cases and controls, respectively (P = .034). The corresponding figure at 1 year was 62% and 38% (P = .009), whereas no difference was observed at 1, 2, and 3 months. No serious adverse event was observed.

CONCLUSIONS

In this article, we show for the first time that CO₂ laser treatment, in comparison with traditional surgical approaches, can be associated with an increased healing rate in patients with DFU.

From Inflammation to Cutaneous Repair: Topical Application of Lupeol Improves Skin Wound Healing in Rats by Modulating the Cytokine Levels, NF-κB, Ki-67, Growth Factor Expression, and Distribution of Collagen Fibers

Skin wound healing is a highly complex event that involves different mediators at the cellular and molecular level. Lupeol has been reported to possess different biological activities, such as anti-inflammatory, antioxidant, antidiabetic, and in vitro wound healing properties, which motivated us to proceed with in vivo studies. We aimed to investigate the wound healing effect of lupeol-based cream for 3, 7, and 14 days. Wound excisions were induced on the thoraco-lumbar region of rats and topically treated immediately after injury induction. Macroscopic, histopathological, and immunohistochemical analyses were performed. Cytokine levels were measured by ELISA and gene expression was evaluated by real-time RT-qPCR. Our results showed a strong wound-healing effect of lupeol-based cream after 7 and 14 days. Lupeol treatment caused a reduction in proinflammatory cytokines (TNF-a, IL-1β, and IL-6) and gene and protein NF-κB expression, and positively altered IL-10 levels, showing anti-inflammatory effects in the three treatment periods. Lupeol treatment showed involvement in the proliferative phase by stimulating the formation of new blood vessels, increasing the immunostaining of Ki-67 and gene expression, and immunolabeling of vascular endothelial growth factor (VEGF) and epidermal growth factor (EGF), and increasing gene expression of transforming growth factor beta-1 (TGF-β1) after seven days of treatment. Lupeol was also involved in the tissue regeneration phase by increasing the synthesis of collagen fibers noted in the three treatment periods analyzed. Our findings suggest that lupeol may serve as a novel therapeutic option to treat cutaneous wounds by regulating mechanisms involved in the inflammatory, proliferative, and tissue-remodeling phases.

Effectiveness of interventions to enhance healing of chronic foot ulcers in diabetes: a systematic review

The management of diabetic foot ulcers (DFU) remains a challenge, and there is continuing uncertainty concerning optimal approaches to wound healing. The International Working Group of the Diabetic Foot (IWGDF) working group on wound healing has previously published systematic reviews of the evidence in 2008, 2012 and 2016 to inform protocols for routine care and to highlight areas which should be considered for further study. The working group has now updated this review by considering papers on the interventions to improve the healing of DFU's published between June 2014 and August 2018. Methodological quality of selected studies was independently assessed by a minimum of two reviewers using the recently published 21-point questionnaire as recommended by IWGDF/European Wound Management Association, as well as the previously incorporated Scottish Intercollegiate Guidelines Network criteria. Of the 2275 papers identified, 97 were finally selected for grading following full text review. Overall, there has been an improvement in study design and a significant rise in the number of published studies. While previous systematic reviews did not find any evidence to justify the use of newer therapies, except for negative pressure wound therapy in post-surgical wounds, in this review we found additional evidence to support some interventions including a sucrose-octasulfate dressing, the combined leucocyte, fibrin and platelet patch as well as topical application of some placental membrane products, all when used in addition to usual best care. Nonetheless, the assessment and comparison of published trials remains difficult with marked clinical heterogeneity between studies: in patient selection, study duration, standard of usual care provision and the timing and description of the clinical endpoints.

Biofilm management using monofilament fibre debridement technology: outcomes and clinician and patient satisfaction

Objective:

Best practice in wound bed preparation and biofilm-based wound management includes debridement to create a clean wound bed and to assist in minimising the redevelopment of biofilm. Biofilm that is not removed inhibits healing and redevelops if not prevented from doing so with topical antimicrobial agents. Monofilament fibre debriding technology (MFDT) is used for effective and rapid mechanical debridement of loose material, slough and biofilm. The objective of this evaluation was to determine the clinical effect and consequential levels of health professional and patient satisfaction with the results of a biofilm pathway that included MFDT to achieve debridement.

Methods:

This non-comparative, open label evaluation was conducted in static and non-static wounds that required debridement. MFDT was used to debride in a two-week evaluation of a biofilm pathway. Wounds were debrided three times in week one and twice in week two. Each debridement was followed by treatment with an antimicrobial dressing. Other care included secondary dressings and compression delivered according to local practice, guidelines and formularies. After the clinical evaluation, health professionals were invited to complete an online survey of the clinical outcomes and their satisfaction with the biofilm pathway.

Results:

There were 706 health professionals who provided answers to the survey questions. Wound types evaluated were leg ulcers (67.4%), pressure ulcers (10%), dehisced surgical wounds (1.7%), diabetic foot ulcers (7.4%) and other wounds (13.4%). Of the wounds, 9% were reported as non-static despite the eligibility criteria. Not all wounds followed the pathway. The most frequently-used antimicrobial was silver. Non-antimicrobial products used included all-in-one dressings, other secondary dressings and compression. There was a change in 77% of wounds overall after two weeks. Change was reported almost equally for both static and non-static wounds. Health professionals who did or did not follow the pathway were ‘completely satisfied’ or ‘satisfied’ with the overall clinical outcome 96% and 95%, respectively. Of the patients, 77% were ‘completely satisfied’ or ‘satisfied’ with healing after following the pathway, as reported by the treating health professional.

Conclusion:

The biofilm pathway that includes MFDT appears effective. Wounds managed on the pathway were debrided effectively and healing progressed to the satisfaction of both health professionals and patients.

Collagenolytic Enzymes and their Applications in Biomedicine

Nowadays, enzymatic therapy is a very promising line of treatment for many different diseases. There is a group of disorders and conditions, caused by fibrotic and scar processes and associated with the excessive accumulation of collagen that needs to be catabolized to normalize the connective tissue content. The human body normally synthesizes special extracellular enzymes, matrix metalloproteases (MMPs) by itself. These enzymes can cleave components of extracellular matrix (ECM) and different types of collagen and thus maintain the balance of the connective tissue components. MMPs are multifunctional enzymes and are involved in a variety of organism processes. However, under pathological conditions, the function of MMPs is not sufficient, and these enzymes fail to deal with disease. Thus, medical intervention is required. Enzymatic therapy is a very effective way of treating such collagen-associated conditions. It involves the application of exogenous collagenolytic enzymes that catabolize excessive collagen at the affected site and lead to the successful elimination of disease. Such collagenolytic enzymes are synthesized by many organisms: bacteria, animals (especially marine organisms), plants and fungi. The most studied and commercially available are collagenases from Clostridium histolyticum and from the pancreas of the crab Paralithodes camtschatica, due to their ability to effectively hydrolyse human collagen without affecting other tissues, and their wide pH ranges of collagenolytic activity. In the present review, we summarize not only the data concerning existing collagenase-based medications and their applications in different collagen-related diseases and conditions, but we also propose collagenases from different sources for their potential application in enzymatic therapy.

Production and characterization of collagenase from a new Amazonian Bacillus cereus strain

A new collagenase producing a strain of Bacillus cereus, isolated from the pollen of a bee of Amazon Region (Brazil), had its enzyme characterized and the production medium composition and culture conditions enhanced. A two-level design on three factors, namely initial medium pH, the substrate (gelatin) concentration and agitation intensity, allowed identifying the first two variables as the most significant ones, while a central composite design (CCD) was subsequently used to identify their optimal levels. Statistics highlighted maximized collagenolytic activity when substrate concentration and initial medium pH were selected at their highest levels (positive effects), whereas agitation intensity at the lowest (negative effect). Triplicate runs performed under predicted optimal conditions (pH 7.8 and 1.7% gelatin concentration) yielded a collagenolytic activity (305.39 ± 5.15 U) 4.6- to 15-fold those obtained with the preliminary design. The enzyme displayed optimum activity at 45 °C and pH 7.2, was stable over wide ranges of pH values and temperatures (7.2-11.0 and 25-50 °C, respectively) and was strongly inhibited by 10 mM phenylmethylsulphonyl fluoride. The zymogram showed two prominent bands at 50 and 76 kDa. These results are a first attempt to elucidate the features of this new collagenase, its production conditions, and possible scale-up.

Fundamental aspects of the local approach to cutaneous ulcers

Ulcers or wounds can be classified as acute or chronic. Their treatment involves overall assessment of the patient and choice of suitable local therapy, and the appropriate indication and use of products. Technological progress in the field of wound treatment has increased rapidly. Constant updating, with emphasis on available scientific evidence, is necessary to offer the best approaches to patients with acute and chronic wounds. A qualitative analysis of literature was conducted to identify scientific publications that update the concepts involved in local wound treatment, to present some resources that can aid the healing process and describe the different types of dressings available. This review includes wound assessment using the acronym TIME (tissue, infection/inflammation, moisture balance and edge of wound), cleaning and debridement, infection/inflammation control, exudate control, dressing types and main indications.

Clinical Outcomes for Diabetic Foot Ulcers Treated with Clostridial Collagenase Ointment or with a Product Containing Silver

Objective: To compare outcomes of diabetic foot ulcers (DFUs) treated with clostridial collagenase ointment (CCO) or silver-containing products, both in combination with sharp debridement as needed.

Approach: One hundred two subjects with qualifying DFUs were randomized to daily treatment with either CCO or a silver-containing product for 6 weeks followed by a 4 -week follow-up period. The primary outcome was the mean percent reduction in DFU area. A secondary outcome was the incidence of ulcer infections between groups.

Results: At the end of treatment, the mean percent reduction in area from baseline of DFUs treated with CCO was 62% (p < 0.0001) and with silver was 40% (p < 0.0001). The difference between groups—22%—was not statistically significant (p = 0.071). Among ulcers closed by the end of treatment, the mean time to closure was 31.1 ± 9.0 days versus 37.1 ± 7.7 days, respectively (not statistically significant). There was a numerically greater incidence of target ulcer infections in the silver group (11, 21.6%) than in the CCO group (5, 9.8%; p = 0.208). No clinically relevant safety signals were identified in either group.

Innovation: CCO treatment can progress a wound toward closure. Ulcer infection prophylaxis may not be sacrificed when treating DFU with CCO in lieu of silver-containing products.

Conclusion: Both CCO and silver-containing products promote significant reduction in DFU area over 6 weeks of treatment with no clinically relevant safety concerns. Mean percent reduction in lesion area was numerically (22%) but not significantly greater with CCO compared to silver, as was time to ulcer closure, with an incidence of ulcer infection at least as low as for silver-containing products.

New trends in the orthopaedic management of diabetic foot

Although there are various types of therapeutic footwear currently used to treat diabetic foot ulcers (DFUs), recent literature has enforced the concept that total-contact casts are the benchmark.Besides conventional clinical tests and imaging modalities, advanced MRI techniques and high-sensitivity nuclear medicine modalities present several advantages for the investigation of diabetic foot problems.The currently accepted principles of DFU care are rigorous debridement followed by modern wound dressings to provide a moist wound environment. Recently, hyperbaric oxygen and negative pressure wound therapy have aroused increasing attention as an adjunctive treatment for patients with DFUs.For DFU, various surgical treatments are currently available, including resection arthroplasty, metatarsal osteotomies and metatarsal head resections.In the modern management of the Charcot foot, surgery in the acute phase remains controversial and under investigation. While conventional fixation techniques are frequently insufficient to keep alignment postoperatively, superconstruct techniques could provide a successful fixation.Retrograde intramedullary nailing has been a generally accepted method of achieving stability. The midfoot fusion bolt is a current treatment device that maintains the longitudinal columns of the foot. Also, Achilles tendon lengthening remains a popular method in the management of Charcot foot. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170073.

Update on management of diabetic foot ulcers

Diabetic foot ulcers (DFUs) are a serious complication of diabetes that results in significant morbidity and mortality. Mortality rates associated with the development of a DFU are estimated to be 5% in the first 12 months, and 5-year morality rates have been estimated at 42%. The standard practices in DFU management include surgical debridement, dressings to facilitate a moist wound environment and exudate control, wound off-loading, vascular assessment, and infection and glycemic control. These practices are best coordinated by a multidisciplinary diabetic foot wound clinic. Even with this comprehensive approach, there is still room for improvement in DFU outcomes. Several adjuvant therapies have been studied to reduce DFU healing times and amputation rates. We reviewed the rationale and guidelines for current standard of care practices and reviewed the evidence for the efficacy of adjuvant agents. The adjuvant therapies reviewed include the following categories: nonsurgical debridement agents, dressings and topical agents, oxygen therapies, negative pressure wound therapy, acellular bioproducts, human growth factors, energy-based therapies, and systemic therapies. Many of these agents have been found to be beneficial in improving wound healing rates, although a large proportion of the data are small, randomized controlled trials with high risks of bias.

Pathophysiologic Mechanisms and Current Treatments for Cutaneous Sequelae of Burn Wounds

Burn injuries are a pervasive clinical problem. Extensive thermal trauma can be life-threatening or result in long-lasting complications, generating a significant impact on quality of life for patients as well as a cost burden to the healthcare system. The importance of addressing global or systemic issues such as resuscitation and management of inhalation injuries is not disputed but is beyond the scope of this review, which focuses on cutaneous pathophysiologic mechanisms for current treatments, both in the acute and long-term settings. Pathophysiological mechanisms of burn progression and wound healing are mediated by highly complex cascades of cellular and biochemical events, which become dysregulated in slow-healing wounds such as burns. Burns can result in fibroproliferative scarring, skin contractures, or chronic wounds that take weeks or months to heal. Burn injuries are highly individualized owing to wound-specific differences such as burn depth and surface area, in addition to patient-specific factors including genetics, immune competency, and age. Other extrinsic complications such as microbial infection can complicate wound healing, resulting in prolonged inflammation and delayed re-epithelialization. Although mortality is decreasing with advancements in burn care, morbidity from postburn deformities continues to be a challenge. Optimizing specialized acute care and late burn outcome intervention on a patient-by-patient basis is critical for successful management of burn wounds and the associated pathological scar outcome. Understanding the fundamentals of integument physiology and the cellular processes involved in wound healing is essential for designing effective treatment strategies for burn wound care as well as development of future therapies. Published 2018. Compr Physiol 8:371-405, 2018.

Clinical Update on Nursing Home Medicine: 2017

This is the 11th annual Clinical Update from the AMDA meeting article. This year the topics covered are hypertension after the Systolic Blood Pressure Intervention Trial; chronic obstructive pulmonary disease risk factors, diagnosis and management including end-of-life planning, and the difficulties with exacerbations such as breathlessness; diagnosis and treatment of cognitive impairment and dementia; and wound care and pressure ulcer management.

Comparative cost and clinical effectiveness of clostridial collagenase ointment for chronic dermal ulcers

Chronic dermal ulcers affect approximately 2.4-4.5 million people in the USA and are associated with loss of function, decreased quality of life and significant economic burden. Debridement is a critical component of wound care involving removal of nonviable tissue from chronic wounds to stimulate the granulation and epithelialization process. Clostridial collagenase ointment has been used as a method of wound debridement for more than 50 years and is currently the only enzymatic debriding ointment with US FDA approval. This review discusses the results of recent real-world studies that build upon the evidence demonstrating the clinical effectiveness, cost-effectiveness and safety of clostridial collagenase ointment across wound types and care settings.

Wound-Healing Peptides for Treatment of Chronic Diabetic Foot Ulcers and Other Infected Skin Injuries

As the incidence of diabetes continues to increase in the western world, the prevalence of chronic wounds related to this condition continues to be a major focus of wound care research. Additionally, over 50% of chronic wounds exhibit signs and symptoms that are consistent with localized bacterial biofilms underlying severe infections that contribute to tissue destruction, delayed wound-healing and other serious complications. Most current biomedical approaches for advanced wound care aim at providing antimicrobial protection to the open wound together with a matrix scaffold (often collagen-based) to boost reestablishment of the skin tissue. Therefore, the present review is focused on the efforts that have been made over the past years to find peptides possessing wound-healing properties, towards the development of new and effective wound care treatments for diabetic foot ulcers and other skin and soft tissue infections.

Clinical and morphological characteristics of wound healing in diabetic foot syndrome

Aim. To assess the clinical and morphological characteristics of neuropathic diabetic foot ulcers (DFUn) Materials and Methods.Forty-three specimens of DFUn were analysed. Depending on the outcome, samples were divided into 2 groups: group 1healed ulcers (30 samples), group 2unhealed ulcers (13 samples). The following characteristics were analysed: age, sex, glycated haemoglobin (HbA1c), ulcer duration, time of admission to the specialised clinic, severity of neuropathy, presence of late complications, plantar localisation, percentage of necrotic tissue, granulation and fibrotic tissue and, Ki-67expression. Results. Patients were similar in age, HbA1c, severity of late complications and plantar localisation. There was a significant difference in the time of admission to the specialised clinic [50 vs 132 days, p = 0.03], percentage of granulation [61 25 vs 32 21 %, р = 0.001] and fibrotic tissue [24 24 vs 49 22 %, р = 0.002], the granulation/fibrosis coefficient [7.5 8.1 vs 1.9 4.6 (%), р = 0,02] and expression of Ki-67 [15 8 vs 21 (%), р = 0.001] between groups. A multidimensional model revealed granulation tissue as the main parameter influencing healing. The probability of healing was 1.0 if the percentage of granulation tissue was 50%. If the percentage of granulation tissue was 50%, the prognosis of healing was determined by the expression of Ki-67. When Ki-67 levels were 7%, the probability of healing was 0.75. For Ki-67 levels 7%, the probability of healing was 0.17 and the probability of not healing was 0.83. Conclusion. The time at which a patient was admitted to the specialised clinic and the percentage of granulation tissue were key factors affecting the prognosis of wound healing in DFUn.

Enzymatic debridement with collagenase in wounds and ulcers: a systematic review and meta-analysis

Enzymatic debridement with collagenase is a technique that is commonly used in clinical practice. This systematic review examines the effect of collagenase on all kinds of wounds, compared to an alternative therapy, on wound healing, wound bed characteristics, cost-effectiveness and the occurrence of adverse events. We conducted a systematic literature search on available literature in Cochrane databases, MEDLINE, EMBASE and CINAHL. Two investigators independently assessed the titles and abstracts of all randomised controlled trials obtained involving collagenase of all kinds of wounds based on inclusion criteria. Of the 1411 citations retrieved, 22 studies reported outcomes with the use of collagenase either for wound healing or wound debridement. Results support the use of collagenase for enzymatic debridement in pressure ulcers, diabetic foot ulcers and in conjunction with topical antibiotics for burns. However, studies presented a high risk of bias. Risk ratio of developing an adverse event related to collagenase versus the alternative treatment was statistically significant (for 10 studies, RR: 1·79, 95% CI 1·24-2·59, I² =0%, P = 0·002). There is very limited data on the effect of collagenase as an enzymatic debridement technique on wounds. More independant research and adequate reporting of adverse events are warranted.

Characterization of Novel Collagenolytic Proteases

Collagenolytic proteases have many potential applications in different areas of science, industry, and medicine. The determination of the activity of such proteins is paramount to their application. Here, we describe methods which can be applied to determine the activity and some basic characteristics of potential collagenases.

Wound healing and treating wounds: Chronic wound care and management

In the United States, chronic ulcers--including decubitus, vascular, inflammatory, and rheumatologic subtypes--affect >6 million people, with increasing numbers anticipated in our growing elderly and diabetic populations. These wounds cause significant morbidity and mortality and lead to significant medical costs. Preventative and treatment measures include disease-specific approaches and the use of moisture retentive dressings and adjunctive topical therapies to promote healing. In this article, we discuss recent advances in wound care technology and current management guidelines for the treatment of wounds and ulcers.

Identification and Characterization of Novel Matrix-Derived Bioactive Peptides: A Role for Collagenase from Santyl® Ointment in Post-Debridement Wound Healing?

Debridement, the removal of diseased, nonviable tissue, is critical for clinicians to readily assess wound status and prepare the wound bed for advanced therapeutics or downstream active healing. Removing necrotic slough and eschar through surgical or mechanical methods is less specific and may be painful for patients. Enzymatic debridement agents, such as Clostridial collagenase, selectively and painlessly degrade devitalized tissue. In addition to its debriding activities, highly-purified Clostridial collagenase actively promotes healing, and our past studies reveal that extracellular matrices digested with this enzyme yield peptides that activate cellular migratory, proliferative and angiogenic responses to injury in vitro, and promote wound closure in vivo. Intriguingly, while collagenase Santyl® ointment, a sterile preparation containing Clostridial collagenases and other non-specific proteases, is a well-accepted enzymatic debridement agent, its role as an active healing entity has never been established. Based on our previous studies of pure Clostridial collagenase, we now ask whether the mixture of enzymes contained within Santyl® produces matrix-derived peptides that promote cellular injury responses in vitro and stimulate wound closure in vivo. Here, we identify novel collagen fragments, along with collagen-associated peptides derived from thrombospondin-1, multimerin-1, fibronectin, TGFβ-induced protein ig-h3 and tenascin-C, generated from Santyl® collagenase-digested human dermal capillary endothelial and fibroblastic matrices, which increase cell proliferation and angiogenic remodeling in vitro by 50-100% over controls. Using an established model of impaired healing, we further demonstrate a specific dose of collagenase from Santyl® ointment, as well as the newly-identified and chemically-synthesized ECM-derived peptides significantly increase wound re-epithelialization by 60-100% over saline-treated controls. These results not only confirm and extend our earlier studies using purified collagenase- and matrix-derived peptides to stimulate healing in vitro and in vivo, but these Santyl®-generated, matrix-derived peptides may also represent exciting new opportunities for creating advanced wound healing therapies that are enabled by enzymatic debridement and potentially go beyond debridement.

Matrix- and plasma-derived peptides promote tissue-specific injury responses and wound healing in diabetic swine

Background

Non-healing wounds are a major global health concern and account for the majority of non-traumatic limb amputations worldwide. However, compared to standard care practices, few advanced therapeutics effectively resolve these injuries stemming from cardiovascular disease, aging, and diabetes-related vasculopathies. While matrix turnover is disrupted in these injuries, debriding enzymes may promote healing by releasing matrix fragments that induce cell migration, proliferation, and morphogenesis, and plasma products may also stimulate these processes. Thus, we created matrix- and plasma-derived peptides, Comb1 and UN3, which induce cellular injury responses in vitro, and accelerate healing in rodent models of non-healing wounds. However, the effects of these peptides in non-healing wounds in diabetes are not known. Here, we interrogated whether these peptides stimulate healing in a diabetic porcine model highly reminiscent of human healing impairments in type 1 and type 2-diabetes.

Methods

After 3–6 weeks of streptozotocin-induced diabetes, full-thickness wounds were surgically created on the backs of adult female Yorkshire swine under general anesthesia. Comb1 and UN3 peptides or sterile saline (negative control) were administered to wounds daily for 3–7 days. Following sacrifice, wound tissues were harvested, and quantitative histological and immunohistochemical analyses were performed for wound closure, angiogenesis and granulation tissue deposition, along with quantitative molecular analyses of factors critical for angiogenesis, epithelialization, and dermal matrix remodeling.

Results

Comb1 and UN3 significantly increase re-epithelialization and angiogenesis in diabetic porcine wounds, compared to saline-treated controls. Additionally, fluorescein-conjugated Comb1 labels keratinocytes, fibroblasts, and vascular endothelial cells in porcine wounds, and Far western blotting reveals these cell populations express multiple fluorescein-Comb1-interacting proteins in vitro. Further, peptide treatment increases mRNA expression of several pro-angiogenic, epithelializing, and matrix-remodeling factors, importantly including balanced inductions in matrix metalloproteinase-2, -9, and tissue inhibitor of metalloproteinases-1, lending further insight into their mechanisms.

Conclusions

Comb1 and UN3 stimulate wound resolution in diabetic Yorkshire swine through upregulation of multiple reparative growth factors and cytokines, especially matrix metalloproteinases and inhibitors that may aid in reversing the proteolytic imbalance characteristic of chronically inflamed non-healing wounds. Together, these peptides should have great therapeutic potential for all patients in need of healing, regardless of injury etiology.

Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a systematic review

The outcome of management of diabetic foot ulcers remains a challenge, and there remains continuing uncertainty concerning optimal approaches to management. It is for these reasons that in 2008 and 2012, the International Working Group of the Diabetic Foot (IWGDF) working group on wound healing published systematic reviews of the evidence to inform protocols for routine care and to highlight areas, which should be considered for further study. The same working group has now updated this review by considering papers on the interventions to improve the healing of chronic ulcers published between June 2010 and June 2014. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network criteria. Selected studies fell into the following ten categories: sharp debridement and wound bed preparation with larvae or hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; oxygen and other gases, compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, electromagnetic, lasers, shockwaves and ultrasound and other systemic therapies, which did not fit in the aforementioned categories. Heterogeneity of studies prevented pooled analysis of results. Of the 2161 papers identified, 30 were selected for grading following full text review. The present report is an update of the earlier IWGDF systematic reviews, and the conclusion is similar: that with the possible exception of negative pressure wound therapy in post-operative wounds, there is little published evidence to justify the use of newer therapies. Analysis of the evidence continues to present difficulties in this field as controlled studies remain few and the majority continue to be of poor methodological quality.

Physical Therapy in Wound Care: A Cost-Effectiveness Analysis

Management of chronic wounds remains unsatisfactory in terms of treatment cost and time required for complete wound closure (CWC).This study aimed to calculate the healing rates, estimated cost, and time required for CWC in wounds; compare estimated wound care costs between healing and nonhealing wounds; and compare cost effectiveness between venous leg ulcer (VLU) and non-VLU.This was a retrospective cohort study performed at a physical therapy (PT) wound care clinic. Deidentified patient data in the electronic medical database from September 10, 2012 to January 23, 2015 were extracted.Among 159 included patients with wounds, 119 (74.84%) patients were healed with CWC. The included patients were treated for 109.70 ± 95.70 days, 29.71 ± 25.66 visits, and at the costs per treatment episode of $1629.65 ± 1378.82 per reimbursement rate and $2711.42 ± 2356.81 per breakeven rate. For patients with CWC (healing group), the treatment duration was 98.01 ± 76.12 days with the time for CWC as 72.45 ± 64.21 days; the cost per treatment episode was $1327.24 ± 1143.53 for reimbursement rate and $2492.58 ± 2106.88 for breakeven cost. For patients with nonhealing wounds, treatment duration was found to be longer with costs significantly higher (P < 0.01 for all). In the healing group, no differences were found between VLU and non-VLU in treatment duration (95.46 days vs. 100.88 days, P = 0.698), time for CWC (68.06 days vs. 77.38 days, P = 0.431), and cost ($2756.78 vs. 2397.84 for breakeven rate, P = 0.640) with the exception of wound dressing costs ($329.19 vs. 146.47, P = 0.001).Healing rates may be affected with patient exclusions. Costs at physicians' offices were not included.Incorporation of PT in wound care appeared to be cost effective. PT may thus be a good referral option for patients with wounds. However, the results should be interpreted cautiously and further studies are warranted.

Topical application of Acheflan on rat skin injury accelerates wound healing: a histopathological, immunohistochemical and biochemical study

Background

Dermal wound healing involves a cascade of complex events including angiogenesis and extracellular matrix remodeling. Several groups have focused in the study of the skin wound healing activity of natural products. The phytomedicine Acheflan®, and its main active constituent is the oil from Cordia verbenacea which has known anti-inflammatory, analgesic and antimicrobial activities. To our knowledge, no investigation has evaluated the effect of Acheflan® in an experimental model of skin wound healing.

The present study has explored the wound healing property of Acheflan® and has compared it with topical effectiveness of collagenase and fibrinolysin by using Wistar rat cutaneous excision wound model.

Methods

Animals were divided into four groups: untreated animals are negative control (NC), wounds were treated topically every day with Collagenase ointment (TC), with Fibrinolysin ointment (TF) and with cream Acheflan (TAc). Skin samples were collected on zero, 8th and 15th days after wounding. The healing was assessed by hematoxylin-eosin (HE), picrosirius red, hydoxyproline content and immunohistochemical analysis of the vascular endothelial growth factor (VEGF) and matrix metalloprotease-9 (MMP-9). Statistical analysis was done by ANOVA and Student t-test (p < 0.05).

Results

The histological analysis HE of wound in the TAc group was more efficient because it was possible to observe the complete remodeling of the epidermis indicating the regression of lesions compared with the NC. The evaluation of picrosirius staining has demonstrated a significant increase of collagen distribution in the TC and TAc treatments compared with NC and TF groups. These results are corroborated with hydroxyproline content. Skin TC and TAc treated rats have showed an increase of VEGF and MMP-9 compared with NC and TF groups. All parameters were significant (P < 0.05).

Conclusion

The phytomedicine Acheflan® (oil of Cordia verbenacea) and TC possess higher therapeutic properties for wound healing compared with TF. These ointments seem to accelerate wound healing, probably due to their involvement with the increase of angiogenesis and dermal remodeling.