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Concept: Diabetic foot

100

Significance: Chronic wounds include, but are not limited, to diabetic foot ulcers, venous leg ulcers, and pressure ulcers. They are a challenge to wound care professionals and consume a great deal of healthcare resources around the globe. This review discusses the pathophysiology of complex chronic wounds and the means and modalities currently available to achieve healing in such patients. Recent Advances: Although often difficult to treat, an understanding of the underlying pathophysiology and specific attention toward managing these perturbations can often lead to successful healing. Critical Issues: Overcoming the factors that contribute to delayed healing are key components of a comprehensive approach to wound care and present the primary challenges to the treatment of chronic wounds. When wounds fail to achieve sufficient healing after 4 weeks of standard care, reassessment of underlying pathology and consideration of the need for advanced therapeutic agents should be undertaken. However, selection of an appropriate therapy is often not evidence based. Future Directions: Basic tenets of care need to be routinely followed, and a systematic evaluation of patients and their wounds will also facilitate appropriate care. Underlying pathologies, which result in the failure of these wounds to heal, differ among various types of chronic wounds. A better understanding of the differences between various types of chronic wounds at the molecular and cellular levels should improve our treatment approaches, leading to better healing rates, and facilitate the development of new more effective therapies. More evidence for the efficacy of current and future advanced wound therapies is required for their appropriate use.

Concepts: Medicine, Wound healing, Healing, Evaluation, Wound, Chronic wound, Venous ulcer, Diabetic foot

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To evaluate the magnitude and impact of diabetic foot ulcers (DFUs) in emergency department (ED) settings from 2006-2010 in the United States (US).

Concepts: Myocardial infarction, United States, Diabetic foot

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An adult with ulcerative colitis and diabetes presented with a painful, swollen, edematous left foot. Diagnostic images and laboratory tests were inconclusive. Antibiotics were started immediately but aggravated his symptoms, and the laboratory results worsened. His foot was debrided twice per protocol for treating diabetic foot ulcers or cellulitis. After debridement, his condition worsened rapidly. Pyoderma gangrenosum was correctly diagnosed on the basis of massive neutrophilic infiltration detected in the biopsy tissue and because the lesion was well-defined and colored deep red to violet, unlike the bullosis diabeticorum blisters observed in the diabetic foot. His foot improved with systemic corticosteroids and topical wound care, and a skin defect was treated with a skin graft. After 9 months, his foot was well healed. Pyoderma gangrenosum can be diagnosed by careful examination and must be distinguished from an ulcerated diabetic foot lesion.

Concepts: Insulin resistance, Ulcerative colitis, Crohn's disease, Corticosteroid, Systemic lupus erythematosus, Cushing's syndrome, Pyoderma gangrenosum, Diabetic foot

28

The purpose of this study is to evaluate the efficacy of negative pressure wound therapy (NPWT) as compared to standard of care on wound healing in high-risk patients with multiple significant co-morbidities and chronic lower extremity ulcers (LEUs) across a continuum of care settings. A retrospective cohort study of ‘real world’ high-risk patients was conducted using Boston University Medical Center electronic medical records, along with chart abstraction to capture detailed medical history, co-morbidities, healing outcomes and ulcer characteristics. A total of 342 patients, 171 NPWT patients with LEUs were matched with 171 non NPWT patients by age and gender, are included in this cohort from 2002 to 2010. The hazard ratios (HRs) were estimated in COX proportional hazard models after adjusted for potential confounders. NPWT patients were 2·63 times (95% CI = 1·87-3·70) more likely to achieve wound closure compared to non NPWT patients. Moreover, incidence of wound closure in NPWT patients were increased in diabetic ulcers (HR = 3·26, 95% CI = 2·21-4·83), arterial ulcers (HR = 2·27, CI = 1·56-3·78) and venous ulcers (HR = 6·31, 95% CI = 1·49-26·6) compared to non NPWT patients. Additionally, wound healing appears to be positively affected by timing of NPWT application. Compared to later NPWT users (1 year or later after ulcer onset), early NPWT users (within 3 months after ulcer onset) and intermediate NPWT users (4-12 months after ulcer onset) were 3·38 and 2·18 times more likely to achieve wound healing, respectively. Our study showed that despite the greater significant co-morbidities, patients with NPWT treatment healed faster. Early use of NPWT demonstrated better healing. The longer the interval before intervention is with NPWT, the higher the correlation is with poor outcome.

Concepts: Cohort study, Proportional hazards models, Scar, Wound healing, Healing, Chronic wound, Diabetic foot, Negative pressure wound therapy

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Human adipocytes may have significant functions in wound healing and the development of diabetes through production of pro-inflammatory cytokines after stimulation by gram-negative bacterial endotoxin. Diabetic foot ulcers are most often associated with staphylococcal infections. Adipocyte responses in the area of the wound may play a role in persistence and pathology. We studied the effect of staphylococcal superantigens (SAgs) on immortalized human adipocytes, alone and in the presence of bacterial endotoxin or staphylococcal α-toxin.

Concepts: Immune system, Bacteria, Staphylococcus aureus, Wound healing, Staphylococcus, Gram-negative bacteria, Endotoxin, Diabetic foot

26

Diabetic foot ulcers represent a significant health issue. Currently, clinicians and nurses mainly base their wound assessment on visual examination of wound size and healing status, while the patients themselves seldom have an opportunity to play an active role. Hence, a more quantitative and cost-effective examination method that enables the patients and their caregivers to take a more active role in daily wound care potentially can accelerate wound healing, save travel cost and reduce healthcare expenses. Considering the prevalence of smartphones with a high resolution digital camera, assessing wounds by analyzing images of chronic foot ulcers is an attractive option. In this paper, we propose a novel wound image analysis system implemented solely on the Android smartphone. The wound image is captured by the camera on the smartphone with the assistance of an image capture box. After that, the smartphone performs wound segmentation by applying the accelerated mean shift algorithm. Specifically, the outline of the foot is determined based on skin color, and the wound boundary is found using a simple connected region detection method. Within the wound boundary, the healing status is next assessed based on red-yellow-black color evaluation model. Moreover, the healing status is quantitatively assessed, based on trend analysis of time records for a given patient. Experimental results on wound images collected in UMASS -Memorial Health Center Wound Clinic (Worcester, MA) following an IRB (Institutional Review Board) approved protocol show that our system can be efficiently used to analyze the wound healing status with promising accuracy.

Concepts: Wound healing, Sociology, Wound, Institutional review board, Camera, Windows Mobile, Diabetic foot, Digital cameras

26

Diabetic foot ulcers are the consequence of multiple factors including peripheral neuropathy, decreased blood supply, high plantar pressures, etc., and pose a significant risk for morbidity, limb loss and mortality. The critical aspects of the wound healing mechanism and host physiological status in patients with diabetes necessitate the selection of an appropriate treatment strategy based on the complexity and type of wound. In addition to systemic antibiotics and surgical intervention, wound care is considered to be an important component of diabetic foot ulcer management. This article will focus on the use of different wound care materials in diabetic foot. From a clinical perspective, it is important to decide on the wound care material depending on the type and grade of the ulcer. This article will also provide clinicians with a simple approach to the choice of wound care materials in diabetic foot ulcer.

Concepts: Medicine, Wound healing, Heart, The Canon of Medicine, Surgery, Diabetes, Diabetic neuropathy, Diabetic foot

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Microbial burden of chronic wounds is believed to play an important role in impaired healing and development of infection-related complications. However, clinical cultures have little predictive value of wound outcomes, and culture-independent studies have been limited by cross-sectional design and small cohort size. We systematically evaluated the temporal dynamics of the microbiota colonizing diabetic foot ulcers (DFU), a common and costly complication of diabetes, and its association with healing and clinical complications. Dirichlet multinomial mixture modeling, Markov chain analysis, and mixed-effect models were used to investigate shifts in the microbiota over time and its associations with healing. Here we show to our knowledge previously unreported temporal dynamics of the chronic wound microbiome. Microbiota community instability was associated with faster healing and improved outcomes. DFU microbiota were found to exist in one of four community types that experienced frequent and non-random transitions. Transition patterns and frequencies associated with healing time. Exposure to systemic antibiotics destabilized the wound microbiota, rather than altering overall diversity or relative abundance of specific taxa. This study provides to our knowledge previously unreported evidence that the dynamic wound microbiome is indicative of clinical outcomes and may be a valuable guide for personalized management and treatment of chronic wounds.

Concepts: Medicine, Bacteria, Wound healing, Infection, Wound, Chronic wound, Diabetic foot, Negative pressure wound therapy

24

Patients' illness beliefs have been associated with glycaemic control in diabetes and survival in other conditions.

Concepts: Diabetes mellitus, Diabetes, Illness, Glycemic index, Diabetic foot

22

The amniotic membrane has biological properties that are beneficial to the wound healing process of diabetic foot ulcers (DFU). Our aim is to analyse the scientific evidence found in literature on the use of the amniotic membrane to stimulate DFU healing.

Concepts: Scar, Wound healing, Healing, Physiology, Wound, Traumatology, Chronic wound, Diabetic foot