Point-of-care ultrasonography for gas gangrene detection in a closed diabetic foot ulcer

Introduction: Diabetes is one of the most prevalent metabolic chronic diseases due to the imbalance production of insulin. One of the studies reported that in 2010 worldwide 285 million adults had diabetes and this figure may be increase to 439 million by the year 2030. Globally Diabetic foot ulcers (DFUs) constitute major health problem in people that significantly contribute to morbidity and mortality in diabetes patients. Approximate 1.0% to 4.1% of the annual population-based incidences of a diabetic foot ulcer (DFU) were reported. Due to this the lifetime may be as high as 25%. In Asian countries diabetic foot ulcer are major problems which are different from European countries or developing countries. From many studies reported diabetic foot problems in India are infectious and neuropathic in nature as compared to developed countries. According to World Health Organization (WHO) diabetic foot is defined as lower limb of a diabetic patient characterized by infection, potential risk of pathologic consequences ulceration or destruction of deep tissues associated with neurological abnormalities, various changes in peripheral neuropathy vasculopathy and superimposed infection that are mainly responsible foot ulceration. Ulcers are one kind of abscess which is difficult to treat because of poor wound healing that result from a combination of neuropathy, ischemia and hyperglycemia. 
 Aim: The main objective was to study the outcome of treatment modalities and it’s relating factors to complication in diabetic foot ulcer. Material and method: Total 60 diabetic foot ulcer patients with the age range from 20 to 70 years were included. From all the patients’ detailed past and present history were recorded. For all the patients, general, physical and local and systemic examinations were also done. Detail laboratory examination like Fasting and Post Prandial Blood sugar levels, blood count, ECG, ESR, complete urine examination for the presence of ketone bodies and sugar, x-ray as well as culture and sensitivity of the discharge from ulcer were also done. Patients were treated with various treatment methods like conservative treatment, split skin grafting and amputation.
 Result: In this study male patients were more in proportion as compared to female. This study showed that maximum with the age group 14 -50 (43.3%) years old followed by 18.3% in 31-40 years old, 16.7% in 61-70 years old. 6.7% showed the least age group as 20 -30 years old. Out of total 60 patients, 38.3% of the patients showed diabetic ulcer foot which was more whereas 15% showed diabetic gangrene foot which was least. 25% showed diabetic cellulites foot and 21.7% showed as diabetic abscess foot. 
 Conclusion: Globally as diabetes mellitus cases are increasing and it became rapidly the public health problem. This may be due to burden on economy, health system and on society to manage the diabetic foot problems. Diabetic foot management guidelines must be made into our practice protocols which may preventing limb loss, and decrease mortality and increase the quality of life of the patient. Hence for this it is only possible with the help of foot care education and health care workers. Hence, foot infection is to put first and care for it like hands.
 Keywords: Diabetes, foot ulcers, infections, amputations.

Chronic wounds, including pressure sores, leg ulcers, diabetic foot ulcers and other kinds of wounds, healing by secondary intention are common in both acute and community settings. The prevention and treatment of chronic wounds includes many strategies, including the use of various wound dressings, bandages, antimicrobial agents, footwear, physical therapies and educational strategies. This review is one of a series of reviews, and focuses on the prevention and treatment of diabetic foot ulcers and the role of antimicrobial agents in chronic wounds in general. To assess the clinical- and cost-effectiveness of (1) prevention and treatment strategies for diabetic foot ulcers and (2) systemic and topical antimicrobial agents in the prevention and healing of chronic wounds. METHODS - DATA SOURCES: Nineteen electronic databases were searched, including MEDLINE, CINAHL, Embase and the Cochrane Library. Relevant journals, conference proceedings and bibliographies of retrieved papers were hand-searched. An expert panel was consulted. Randomised and non-randomised trials with a concurrent control group, which evaluated any intervention for the prevention or treatment of diabetic foot ulcers, or systemic or topical antimicrobials for chronic wounds (diabetic foot ulcers, pressure ulcers, leg ulcers of various aetiologies, pilonidal sinuses, non-healing surgical wounds, and cavity wounds) and used objective measures of outcome such as: (1) development or resolution of callus; (2) incidence of ulceration (for diabetic foot ulcer prevention studies); (3) incidence of pressure sores (pressure sore prevention studies); (4) any objective measure of wound healing (frequency of complete healing, change in wound size, time to healing, rate of healing); (5) ulcer recurrence rates; (6) side-effects; (7) amputation rates (diabetic foot ulcer treatment studies); (8) healing rates and recurrence of disease, among others, for pilonidal sinuses. Studies reporting solely microbiological outcomes were excluded. Decisions on the inclusion of primary studies were made independently by two reviewers. Disagreements were resolved through discussion. Data were extracted by one reviewer into structured summary tables. Data extraction was checked independently by a second reviewer and discrepancies resolved by discussion. All included studies were assessed against a comprehensive checklist for methodological quality. INCLUDED STUDIES - DIABETIC FOOT ULCERS: Thirty-nine trials which evaluated various prevention and treatment modalities for diabetic foot ulcers: footwear (2), hosiery (1), education (5), screening and foot protection programme (1); podiatry (1) for the prevention of diabetic foot ulcers; and footwear (1), skin replacement (2), hyperbaric oxygen (2), ketanserin (3), prostaglandins (3), growth factors (5), dressings and topical applications (9), debridement (2) and antibiotics (2) for the treatment of diabetic foot ulcers. INCLUDED STUDIES - ANTIMICROBIALS: Thirty studies were included, 25 with a randomised design. There were nine evaluations of systemic antimicrobials and 21 of topical agents. The methodological and reporting quality was generally poor. Commonly encountered problems of reporting included lack of clarity about randomisation and outcome measurement procedures, and lack of baseline descriptive data. Common methodological weaknesses included: lack of blinded outcome assessment and lack of adjustment for baseline differences in important variables such as wound size; large loss to follow-up; and no intention-to-treat analysis. RESULTS - PREVENTION OF DIABETIC FOOT ULCERS: There is some evidence (1 large trial) that a screening and foot protection programme reduces the rate of major amputations. The evidence for special footwear (2 small trials) and educational programmes (5 trials) is equivocal. A single trial of podiatric care reported a significantly greater reduction in callus in patients receiving podiatric care. RESULTS - TREATMENT OF DIABETIC FOOT ULCERS: Total contact casting healed significantly more ulcers than did standard treatment in one study. There is evidence from 5 trials of topical growth factors to suggest that these, particularly platelet-derived growth factor, may increase the healing rate of diabetic foot ulcers. Although these studies were of relatively good quality, the sample sizes were far too small to make any definitive conclusions, and growth factors should be compared with current standard treatments in large, multicentre studies. Topical ketanserin increased ulcer healing rate in 2 studies, while systemic hyperbaric oxygen therapy reduced the rate of major amputations in 1 study. Preliminary research into the effects of iloprost and prostaglandin E1 (PGE1) on diabetic foot ulcer healing suggests possible benefits. However, good quality, large-scale confirmatory research is needed. (ABSTRACT TRUNCATED)

Background: Many types of infection can cause diabetic foot ulcers Infections involving the bacteria; E. coli, Acinetobacter spp (MDR) and K. pneumoniae, pseudomonas aeruginosa, so the assessment of Bacterial profile and patterns is needed to understand the source and management of these injuries.
 Objective: To determine Bacterial infections profile and patterns for diabetic foot ulcers in nongovernmental.
 Method: During a period of eleven months, 148 patients with diabetic mellitus foot syndrome (DMFS). Patients were involved, out of 130 which foot ulceration infections. data analysis was done using SPSS version 20. p value was set at <0.05.
 Results: Out of 607 Patients with diabetic foot ulceration (DFU) were 130 out of 148 with diabetic mellitus foot syndrome (DMFS). Diabetic foot ulceration (DFU) therefore contributed 20.3% of DMFS among these subjects. Microbiological culture pattern was total of 17 different pathogenic microorganisms were isolated from the participants, one yeast and 16 types of bacteria, from the diabetic foot swabs for ulcers. S. aureus was the most frequent pathogen followed by E.coli then Acinetobacter spp (MDR) and K. pneumonia, then pseudomonas aeruginosa , then p. mirabilis then Streptococcus agalactiae ( group b) then (Enitrobacteria spp and pseudomonas spp and Candida spp and P. vulgaris and K. oxytoca ESBL) then S. viridanse and Enterobacter spp ESBL and Staphylococcus coag. negative). The Enterobacter spp ESBL was the less frequent pathogen.
 Conclusion: Diabetic Foot Ulcerations (DFU), is forming about a quarter of the diabetic patient’s tissue infections, the causative agents were bacterial and fungal(yeast). Most of the causative pathogens were; Staphylococcus aureus, and Acinetobacter spp (MDR). The risk of development of High resistant drug isolates of diabetic foot ulcers to be multidrug resistance were high by 53% of total isolated pathogens specially with K. pneumonia (K. pneumoniae), Escherichia coli (E. coli) and Proteus mirabilis bacterial.

We aimed to evaluate the effects of ultrasound-assisted wound (UAW) debridement on cellular proliferation and dermal repair in complicated diabetic foot ulcers as compared to diabetic foot ulcers receiving surgical/sharp wound debridement. A randomized controlled trial was performed involving 51 outpatients with complicated diabetic foot ulcers that either received surgical debridement (n = 24) or UAW debridement (n = 27) every week during a six-week treatment period. Compared to patients receiving surgical debridement, patients treated with UAW debridement exhibited significantly improved cellular proliferation, as determined by CD31 staining, Masson’s trichrome staining, and actin staining. Bacterial loads were significantly reduced in the UAW debridement group compared to the surgical group (UAW group 4.27 ± 0.37 day 0 to 2.11 ± 0.8 versus surgical group 4.66 ± 1.21 day 0 to 4.39 ± 1.24 day 42; p = 0.01). Time to healing was also significantly lower (p = 0.04) in the UAW group (9.7 ± 3.8 weeks) compared to the surgical group (14.8 ± 12.3 weeks), but both groups had similar rates of patients that were healed after six months of follow-up (23 patients (85.1%) in the UAW group vs. 20 patients (83.3%) in the surgical group; p = 0.856). We propose that UAW debridement could be an effective alternative when surgical debridement is not available or is contraindicated for use on patients with complicated diabetic foot ulcers.

Diabetes is emerging as a significant health and societal concern globally, impacting both young and old populations. In individuals with diabetic foot ulcers (DFUs), the wound healing process is hindered due to abnormal glucose metabolism and chronic inflammation. Minor injuries, blisters, or pressure sores can develop into chronic ulcers, which, if left untreated, may lead to serious infections, tissue necrosis, and eventual amputation. Current management techniques include debridement, wound dressing, oxygen therapy, antibiotic therapy, topical application of antibiotics, and surgical skin grafting, which are used to manage diabetic wounds and foot ulcers. This review focuses on a hydrogel-based strategy for phase-wise targeting of DFUs, addressing sequential stages of diabetic wound healing: hemostasis, infection, inflammation, and proliferative/remodeling phases. Hydrogels have emerged as a promising wound care solution due to their unique properties in providing a suitable wound-healing microenvironment. We explore natural polymers, including hyaluronic acid, chitosan, cellulose derivatives, and synthetic polymers such as poly (ethylene glycol), poly (acrylic acid), poly (2-hydroxyethyl methacrylate, and poly (acrylamide), emphasizing their role in hydrogel fabrication to manage DFU through phase-dependent strategies. Recent innovations, including self-healing hydrogels, stimuli-responsive hydrogels, nanocomposite hydrogels, bioactive hydrogels, and 3D-printed hydrogels, demonstrate enhanced therapeutic potential, improving patient outcomes. This review further discusses the applicability of various hydrogels to each phase of wound healing in DFU treatment, highlighting their potential to advance diabetic wound care through targeted, phase-specific interventions.

Objective To evaluate the efficiency and safety of ultrasonic debridement therapy (UDT) and intelligence negative-pressure wound therapy(INPWT) for diabetic foot ulcers with Wagner 2-3degree.Methods Eighty patients with diabetic foot ulcers with Wagner 2-3 degree were divided into two groups according to the treatment method.The UDT and INPWT group (INPWT group) had 53 cases.Routine treatment group(routine group) had 27 cases.Both groups were given blood sugar and blood pressure control,anticoagulation,anti-infection and supportive treatment.The efficiency and complications were compared between two groups.Results In INPWT group,29 cases were healed,14 cases showed obvious effectiveness,7 cases were effective and 3 cases were inefficacy.The total effective rate was 94.34％(50/53).For routine group,they were 7,8,6,6 cases and 77.78％(21/27) respectively.The total effective rate between two groups had significant difference (P ＜0.05).Pain was found in 9 cases and hemoglobin decreased in 1 case in INPWT group.Conclusion INPWT after UDT for diabetic foot ulcers with Wagner 2-3 degree shows a good efficiency and safety. Key words: Diabetic foot; Blood gas monitoring,transcutaneous; Ultrasonic debridement; Intelligence negative-pressure wound therapy

The role of stitching in healing diabetic foot ulcers (DFUs) has little attention, with few reports published on the technique. This study aimed to report on the role of stitching in healing of neuropathic DFUs. This comparative study was between patients with diabetes with neuropathic foot ulcers who had undergone wound stitching and those on conventional wound care. The study was carried in Jabir Abu Eliz Diabetic Center Khartoum (JADC) during between January 1 2011 and January 1 2013. All patients presented with neuropathic diabetic septic foot on the plantar aspect or extending up the leg were included. Initial surgical sharp debridement under intravenous broad spectrum antibiotics was performed and oral antibiotics were given 3 days later after the results of the bacterial culture were received. Regular wound debridement was performed with the aim of pairing the wound edges for stitching. Primary closure was performed when the wound was clean from any necrotic tissues and partial closure when the wound was still oozy to secure drainage and avoid splaying of the wound edges. All patients were using either crutches or wheel chair initially until any sepsis cleared and then proper off-loading by shoes purpose made in our centre. A 160 patients with neuropathic DFUs that needed debridement and frequent dressing changes as outpatients were included. Both groups had the same tap water wound dressing either daily, every other day or every two days according to the wound progress. Absorbent dressings and negative pressure wound therapy (NPWT) were unavailable. Half of the patients (n=80) had debridement, frequent dressing change using tap water throughout the period of study (group 1) while the rest (n=80) in addition to wound debridement underwent stitching of their wounds (group 2). Complete healing was achieved in 46 patients in Group 1 (57.5%) compared with 19 patients (23%) in group 2 (p=0.001). The average number of dressings used was 19 in stitch group compared with 30 in the non-stitch group (p=0.000). The average duration of healing in stitch group was 2.9 months compared with 5.7 months in non-stitch group (p=0.000). Stitching of neuropathic DFUs reduced the duration of wound healing and the frequency of wound dressing change.

Diabetic foot ulcers (DFU) are chronic complications due to poor diabetic control. Diabetic foot ulcers can lead to lifelong disability and substantially diminish the quality of life. The aim of this study was to carry out a thorough evaluation of diabetic foot ulcer management, compare current scenario of DFUs care with the International guidelines and to identify the extended roles of clinical pharmacist to improve the conditions of diabetic patient with foot ulcers. It is a retrospective qualitative study carried out in two tertiary care hospitals of Tamil Nadu state. The patients were selected based on inclusion and exclusion criteria admitted in the hospitals with diabetic foot ulcers. The patient’s sociodemographic and clinical characteristics tools from the patient medication records (PMR) were collected and taken into considerations for the study. The study revealed that diabetic foot ulcer was more prevalent among male patients with type 2 diabetes since 11 to 25 yrs belongs to the age group between 51-60 years. It was found that 60.5% of the patients having at least one co-morbid condition and 90.6% of patients possess one or more risk factors to develop diabetic foot ulcers. Glycated hemoglobin (HbA1c) test were done only by 54.7% of the patients, which showed that it was not insisted as an important identification tool for diabetic foot ulcer. The PMR revealed numerous antibiotics switch-over for the wound treatment as well. From the study it was concluded that an immediate requirement and thorough evaluation of enhanced foot care management, patient centered care and diabetic foot surveillance etc is needed for diabetic foot ulcer management. A comparative current scenario of DFUs care with the International guidelines and its adaptation and modifications according to our need is to be emphasized. Amalgamation of clinical pharmacy services with the multidisciplinary diabetic foot care team services is to be made. The clinical pharmacist’s intervention is to be put forward to improve the conditions of diabetic patient with foot ulcers to decrease the alarming incidences in Indian hospital settings. Key Words: Diabetes, diabetic foot ulcer, wounds, guidelines, clinical pharmacy intervention

Introduction: Diabetic foot ulcers (DFU) are a devastating complication of diabetes. There are numerous challenges with preventing diabetic foot complications and barriers to achieving the care processes suggested in established foot care guidelines. Multi-faceted digital health solutions, which combine multimodal sensing, patient-facing biofeedback, and remote patient monitoring (RPM), show promise in improving our ability to understand, prevent, and manage DFUs. Methods: Patients with a history of diabetic plantar foot ulcers were enrolled in a prospective cohort study and equipped with custom sensory insoles to track plantar pressure, plantar temperature, step count, and adherence data. Sensory insole data enabled patient-facing biofeedback to cue active plantar offloading in response to sustained high plantar pressures, and RPM assessments in response to data trends of concern in plantar pressure, plantar temperature, or sensory insole adherence. Three non-consecutive case participants that ultimately presented with pre-ulcerative lesions (a callus and/or erythematous area on the plantar surface of the foot) during the study were selected for this case series. Results: Across three illustrative patients, continuous plantar pressure monitoring demonstrated promise for empowering both the patient and provider with information for data-driven management of pressure offloading treatments. Conclusion: Multi-faceted digital health solutions can naturally enable and reinforce the integrative foot care guidelines. Multi-modal sensing across multiple physiologic domains supports the monitoring of foot health at various stages along the DFU pathogenesis pathway. Furthermore, digital health solutions equipped with remote patient monitoring unlock new opportunities for personalizing treatments, providing periodic self-care reinforcement, and encouraging patient engagement—key tools for improving patient adherence to their diabetic foot care plan.

Background: Diabetic foot ulcer is one of the most common problems in diabetic patients. Its treatment is very complicated and needs to be carefully monitored, because inappropriate responses to various therapeutic and surgical treatments may occur. Case Presentation: In this study, 10 patients with second and third degree diabetic foot ulcers were evaluated based on the therapeutic protocols of Iranian Traditional Medicine in Bojnurd. All the patients were hospitalized in one of the hospitals of Bojnurd during 2015-2016 and were undergoing initial treatment. The wounds of patients did not respond to common treatments, and based on the advice of an orthopedic surgeon, amputation was ordered by the physician. Patients were referred to the traditional medicine clinic for advice. The patients had various wounds on the left or right leg with severe inflammation. In other words, the patients had infectious wounds with severe inflammation. After entering the traditional medicine clinic, patients were treated with health and nutrition measures. Drug therapy in these patients is associated with the condition of the disease, and includes medicinal herbs, combined medications and modern blood glucose control drugs. Manual treatments including full back cupping every night until the end of treatment, massage therapy and leech therapy inside and around the wound, were used once every 3 to 7 days with 10 to 12 small, medium and large leeches during 10 sessions for patients. In all the patients, after 40 to 60 days of treatment, the diabetic foot ulcer was cured completely, the physical and mental status of the patients improved and the patients' blood glucose was controlled. Conclusion: Effective medicine can have effective clinical findings in the treatment of certain diseases, such as diabetic foot ulcer disease. In the treatment of diabetic foot ulcers, the use of effective medicine leads to lower costs and reduces the use of antibiotics in diabetic patients. Therefore, according to the principles of modern and traditional medicine in Iran, it can be investigated and evaluated as a new non-invasive therapeutic method with the highest therapeutic effect in the shortest time.

ABSTRAKDiabetic Foot Ulcer (DFU) termasuk kedalam salah satu komplikasi dari penyakit Diabetes Melitus yang mana kondisi ini merupakan masalah yang serius juga dapat menyebabkan kecacatan. Dampak merugikan pada ulkus kaki diabetik ialah biologis, psikologis, sosial ekonomi dan spiritual. Dampak psikologis yang sering terjadi pada pasien DFU ialah depresi. Depresi merupakan gangguan psikologis yang sering dikaitkan dengan stressor jangka panjang seperti penyakit kronis diantaranya diabetes melitus. Penelitian dilakukan berjutuan untuk mengetahui hubungan antara derajat DFU terhadap tingkat depresi pada pasien diabetes melitus di RSUD Dr.H.Moch Ansari Saleh Banjarmasin. Penelitian ini menggunakan metode kuantitatif dan menggunakan kuesioner sebagai alat pengupulan data. dengan jumlah 40 responden dengan Non-probability dengan teknik pengambilan sampel menggunakan Sampling Jenuh dengan semua menjadi sampel dengan jumlah 40 responden yang sedang menjalani rawat jalan dipoli kaki diabetik. Untuk alat ukur derajat dfu menggunakan kuesioner Diabetic Foot Ulcer Wegner dan kuesioner Back Depresion Inventory (BDII) untuk mengukur tingkat depresi. Hasil penelitian menjunjukan bahwa terdapat hubungan antara derajat diabetic foot ulcer terhadap tingkat depresi dengan hasil Sig. (2-tailed) (<0,05), yang artinya adanya hubungan yang signifikan antara derajat diabetic foot ulcer terhadap tingkat depresi pada pasien diabetes melitus. Kata kunci: Diabetic Foot Ulcer, Tingkat Depresi ABSTRACTDiabetic Foot Ulcer (DFU) is one of the complications of Diabetes Mellitus, where this condition is a serious problem and can also cause disability. The detrimental impacts on diabetic foot ulcers are biological, psychological, socio-economic and spiritual. The psychological impact that often occurs in DFU patients is depression. Depression is a psychological disorder that is often associated with long-term stressors such as chronic diseases including diabetes mellitus. Several studies were conducted to determine the relationship between the degree of DFU and the level of depression in diabetes mellitus patients at Dr.H.Moch Ansari Saleh Hospital, Banjarmasin. This research uses quantitative methods and uses questionnaires as a data collection tool. with a total of 40 respondents with Non-probability with a sampling technique using Saturated Sampling with all being sampled with a total of 40 respondents who were undergoing outpatient treatment at the diabetic foot clinic. To measure the degree of dfu, Wegner's Diabetic Foot Ulcer questionnaire and the Back Depression Inventory (BDII) questionnaire are used to measure the level of depression. The results of the study showed that there was a relationship between the degree of diabetic foot ulcers and the level of depression and the Sig results. (2-tailed) (<0.05), which means there is a significant relationship between the degree of diabetic foot ulcers and the level of depression in diabetes mellitus patients.Keywords: Diabetic Foot Ulcer, Depression Rate

INTRODUCTION: In this study, we explore the intricate domain of Diabetic Foot Ulcers (DFU) through the development of a comprehensive framework that encompasses diverse operational scenarios. The focus lies on the identification and classification assessment of diabetic foot ulcers, the implementation of smart health management strategies, and the collection, analysis, and intelligent interpretation of data related to diabetic foot ulcers. The framework introduces an innovative approach to predicting diabetic foot ulcers and their key characteristics, offering a technical solution for forecasting. The exploration delves into various computational strategies designed for intelligent health analysis tailored to patients with diabetic foot ulcers. OBJECTIVES: The primary objective of this paper is to present a technical solution for forecasting diabetic foot ulcers, utilizing computational strategies for intelligent health analysis. METHODS: Techniques derived from social network analysis are employed to conduct this research, focusing on diverse computational strategies geared towards intelligent health analysis for patients with diabetic foot ulcers. The study highlights methodologies addressing the unique challenges posed by diabetic foot ulcers, with a central emphasis on the integration of Internet of Medical Things (IoMT) in prediction strategies. RESULTS: The main results of this paper include the proposal of IoMT-based computing strategies covering the entire spectrum of DFU analysis, such as localization, classification assessment, intelligent health management, and detection. The study also acknowledges the challenges faced by previous research, including low classification rates and elevated false alarm rates, and proposes automatic recognition approaches leveraging advanced machine learning techniques to enhance accuracy and efficacy. CONCLUSION: The proposed IoMT-based computing strategies present a significant advancement in addressing the challenges associated with predicting diabetic foot ulcers. The integration of advanced machine learning techniques demonstrates promise in improving accuracy and efficiency in diabetic foot ulcer localization, marking a positive stride towards overcoming existing limitations in previous research.

Background and Aim: Diabetes mellitus is an increase in blood glucose levels results in altered fat, protein metabolism, and carbohydrate which leads to cardiac, eye, nervous system dysfunction, and kidney. The major cause of hospitalizations in patients with diabetes mellitus (DM) is diabetic foot ulcers (DFU). The purpose of the present study was to evaluate the peripheral arterial disease in diabetic foot ulcer patients presented to endocrine clinic. Patients and Methods: This descriptive cross-sectional study was carried out on 206 diabetic foot ulcers patients presented to the endocrine clinic in Peshawar from January 2021 to December 2022. Patients were enrolled after taking written informed consent from each individual. Patient’s details such as gender, age, peripheral artery disease (PAD), diabetes types, heart failure, wound size, diabetes duration, end-stage renal disease, DFU history, prior history of amputation, and peripheral neuropathy were recorded. Angiography and revascularization may be required if arterial Doppler ultrasound confirmed PAD. Additionally, wound debridement and topical dressings were applied. In the treatment of wound ischemia, pentoxifylline, and calcium blockers were recommended along with diabetes control procedures and appropriate antibiotics. SPSS version 27 was used for data analysis. Results: Of the total 206 DFU patients, there were 142 (68.9%) male and 64 (31.1%) females. The prevalence of peripheral artery disease (PAD) was 58.3% (n=120). Age-wise distribution of patients were as follows: 31 (15%) in 25-45 years, 107 (52%) in 46-65 years, 60 (29.1%) in 66-85 years, and 8 (3.9%) >85 years. Out of 206 DFU patients, the prevalence of type-I diabetes mellitus and type-II diabetes mellitus was 8 (3.9%) and 198 (96.1%) respectively. PAD prevalence was significantly associated with Type 2 diabetes. The incidence of PAD in plantar foot, non-plantar foot, and heel was 66 (55%), 42 (35%), and 12 (10%) respectively among 120 cases. Out of 206 DFU cases, the incidence of peripheral neuropathy, DFU history, amputation history, heart failure, and chronic renal failure was 142 (68.9%), 104 (50.5%), 54 (26.2%), 46 (22.3%), and 42 (20.4%) respectively. Conclusion: The present study concluded that the prevalence of peripheral artery disease (PAD) was 58.3% among diabetic foot ulcers. Results indicate that DFU and PAD are significantly related. It has been found that male patients with DFU were more likely to suffer from PAD as compared to women with statistically insignificant association. Keywords: Peripheral artery disease, diabetic foot ulcers, type-II diabetes mellitus

Objectives: This study aims to evaluate the efficacy of a comprehensive management plan in the treatment of diabetic foot ulcers (DFUs). Evaluating the effects of wound debridement on the outcomes of diabetic foot ulcers, advanced dressings, blood sugar control, and offloading strategies are the main objectives. The study also intends to investigate the function of surgery in managing chronic ulcers and preventing recurrences. The goal is to offer advice for managing DFUs optimally and lowering related morbidity based on evidence. Methods: The intervention program includes techniques like wound debridement, advanced dressings, unloading modalities, blood sugar level control, and, where necessary, surgical treatments. Growth factors, electrical stimulation, negative pressure wound therapy, bio-engineered skin, and hyperbaric oxygen therapy are among the many treatments that are included. Regression models are among the statistical analyses used to assess the efficacy of the overall management strategy. Results: Significant findings are presented in the results section, which shows how the holistic management strategy improves DFU outcomes. Improved wound healing rates, reduced infection incidents, and enhanced patient-reported outcomes are highlighted. The results underscore the significance of maintaining blood sugar levels, wound debridement, and incorporating various therapeutic modalities in DFU management. Conclusion: This study concludes by recommending a thorough and interdisciplinary approach to DFU management. Maintaining blood sugar levels, debridement of the wound, sophisticated dressings, unloading techniques, and surgical procedures are among the effective strategies that help reduce morbidity and prevent serious complications related to diabetic foot ulcers. Additional investigation is necessary to enhance and broaden these results for ongoing progress in the management of diabetic foot ulcers.

INTRODUCTION For the 35th anniversary of Advances in Skin & Wound Care, a variety of thought leaders have been invited to share their insight into a range of topics of current interest to the field. In this special installment of Practice Reflections, Dr James McGuire describes the history of podiatry and wound care, Dr Bharat Kotru reflects on the present state of podiatry and wound care, and Dr Anthony R. Iorio ponders how future advances will impact the intersection between the two. Ancient Wound History There comes a time in one's life when you have to face your own mortality. For me, it was on a bus to the airport recently when a much younger man stood to offer me his seat. The second was when I was asked to write this history of wound care prior to 2000. I am sure it was because Advances wanted an eye-witness report as opposed to a mere recanting of writings from the annals of history. So, I will limit my review to the events within my lifetime and not a discussion of the use of poultices and potions, although during my time in Vermont it was not uncommon to encounter patients who had received advice from a "white witch" or backwoods healer. My earliest memory of wound care was my mother, who—after listening to the advice of her mother-in-law, who assured her that without pain there was no gain and that direct application of alcohol, peroxide, and or mercurochrome was the only way to prevent bugs from entering a wound—applied myriad painful solutions to help heal wounds. As she did, she was doubtless remembering the words of her grandmother quoting Dr Joseph Lister, who in 1865 recommended the use of carbolic acid, another pleasant antiseptic used to fight infection.1 This explains the toughness of the greatest generation and whatever remnants of it remain in the baby boomers of today. Bandages and dry gauze followed, with assurances that a nice dry scab was the way to go. By the time I went to physical therapy school in 1974, the concept of moist healing using Adaptic and saline-moistened gauze had taken hold to aid in dressing removal for patients with burns, as well as ease the pain and facilitate healing. The ghost of my German grandmother still pervaded society though in the form of the wet-to-dry dressing that ripped off slough and adherent tissues with each dressing change, assuring a nice clean, granular, painful surface and eventual healing. By the time I entered podiatry school in 1977, medicine had figured out that if saline wet-to-dry works well, then povidone iodine-soaked gauze had to work better. Besides, the new "safe" opioid pain relievers were much better at helping patients tolerate the dressing changes than the old "bite the bullet" technique. After my residency training, in 1985, I was fortunate to fall under the tutelage of an icon in wound care, Nancy Faller, RN, to whom I owe my interest in wound care. She introduced me to hydrocolloids and a new concept in wound care, "moist wound healing." Now, to be accurate, hydrocolloids were introduced in 1967, but took 18 years before their use began to influence clinicians in Vermont.2 This explains the continued use of wet-to-dry dressings, dry gauze, Betadine dressings, and even mercurochrome today. It also is a perfect example of the phrase "information travels quickly but acceptance lags behind"—way behind. When I left Vermont for Philadelphia in 1992, the local doctors still thought that hydrocolloids induced infection as evidenced by the "pus" that accumulated between dressing changes. The need to do daily dressing changes dies hard. Alginates followed in 1983, and foams were not introduced by Fleichman until 1995.3,4 Negative-pressure devices were added in the early 1990s5 and, after many years of study, topical platelet-derived growth factor was introduced in 1997.6 I do not want to list the introduction of every dressing here, but these are examples of "ancient history" in wound care that have all become the standard of care today. In fact, this "history" really is not that ancient, and points to the fact that we are in the infancy of modern wound innovations. I first entered full time wound care in 1999 when I became the Director of the Leonard Abrams Center for Advanced Wound Healing at Temple University's School of Podiatric Medicine, right after the introduction of the aforementioned topical platelet-derived growth factor. In 1995, Cook Biotech Inc introduced a new wound healing bioscaffold, porcine small intestinal submucosa, that we were privileged to study. It is now marketed as OASIS Matrix by Smith & Nephew (Fort Worth, Texas). First studied as a wound healing material in 1989, this bioscaffold was first used clinically in 2002.7 One of the first artificial "skin substitutes," this xenograft became the springboard for numerous other "slaughterhouse floor" wound products. Pigs, cows, horses, fish, and sheep all met their demise and contributed to the repair of human tissue. Vegans should not worry—there is still hope for vegetable proteins, just stay tuned. Needless to say, I entered wound care right at the birth of the modern era of wound healing; the ride has been fast and has not slowed down to this day. The Present Role of Podiatry in Wound Care Podiatry has become specialized in the past few decades to include everything from sports medicine and ankle surgery to wound care. The podiatry designation was introduced by MJ Lewi in 1917. In some countries, including Canada, practitioners are known both as chiropodists or podiatrists, depending on their training program and provincial regulatory authority. Podiatrists play major and impactful roles in wound care. Podiatrists manage diseases, disabilities, and deformities of the foot with procedures that include physiotherapy techniques, nail care, local wound care, and minor surgeries in addition to providing therapeutic footwear and orthotic devices. Podiatry skills include gait assessments to identify biomechanic anomalies and pressures. When these gait abnormalities are diagnosed and treated in a timely manner, further foot complications can be prevented. Foot specialists are often the first to recognize the presence of limb- and life-threatening wounds. The role of podiatry in wound healing is essential, and emphasizes lower extremity preservation and limb salvage. Currently, the majority of podiatrists are trained in advanced wound care. The prevalence of type 2 diabetes is increasing worldwide, resulting in foot complications that lead to poor quality of life and increased cost of living. In 2019, 463 million people worldwide were living with diabetes, a number that is estimated to increase to 700 million by 2045. Unfortunately, four out of five people with diabetes live in low- and middle-income countries, where podiatry services are usually lacking.8 There is a need to empower nursing or allied healthcare professionals with foot care and podiatry services in these countries because persons with diabetes can develop several foot problems, which can lead to serious complications. Up to 70% of all nontraumatic lower leg amputations occur in persons with diabetes.9 With the increase of diabetes and diabetic foot problems, many wound care programs now offer specialized lower extremity wound care by podiatrists. Podiatry plays a major role in the prevention of many lower extremity ulcers: with early assessments, treatments, and timely referrals, amputations can be avoided. Podiatrists are trained to recognize the signs and symptoms of peripheral arterial disease. This knowledge facilitates timely referrals to the appropriate vascular specialists, but also cardiologists and internists to prevent catastrophic medical events including heart attacks, strokes, and other medical complications.10 In India, podiatrists employed within the public health system provide conservative sharp wound debridement to all patients with nonischemic diabetic foot ulcers (DFUs) as the predominant modality to remove nonviable tissue and promote healing.11 Advanced wound care centers offer a specialized level of care that is typically not available in a local healthcare system. These centers offer state of the art specialized equipment, up-to-date techniques, an interprofessional team approach, and evidence-based practice to manage complex diabetic foot cases.12 This approach enables providers to collaborate with one another for immediate care and is optimal in patients with diabetic foot infections to increase limb salvage.13 In addition to an interprofessional approach, advanced wound care centers offer a plethora of skilled services and advanced technological resources that may not be available in local centers. These resources may include hyperbaric oxygen chambers, digital thermography, transcutaneous oximetry, foot Dopplers, negative-pressure wound therapy, biogenic skin graft substitutes, and various pressure-offloading devices. Increased plantar pressure is a causative factor in the development of diabetes-related plantar foot ulcers. Plantar pressure redistribution can heal plantar foot ulcers and prevent their recurrence.14 Because they are well equipped and have the latest technology, wound care centers offer the best possible outcome for patients. Specialized dressings are also impactful in the treatment of DFUs. With podiatric medical advancements, a paradigm shift away from conventional and traditional medical thinking is needed. The following are some recent innovations in podiatric wound care: Biomechanical analysis systems Walking and running gait analysis with a light illuminator podoscope Foot scans, computer-aided design and manufacturing Orthotic devices with different specifications as per patient need Customized footwear Various wound care solutions including regenerating bone with innovative grafts The podiatry profession proved its flexibility and adaptability during the pandemic, adjusting rapidly to ensure that patients could access treatment to reduce risk of infection, ulceration, and amputation. Many clinicians have offered virtual care supplemented with algorithms and enablers to ensure that patients are triaged appropriately. To support clinicians, the number of virtual continuing professional development webinars have increased. Podiatrists have also embraced remote technology to facilitate patient self-care.15 Although the fight against diabetes is an uphill battle, it is a battle worth fighting and winning. Healthcare providers must work as a team, communicate among all specialties, and know when and where to refer. Patients are the priority, and referring patients with diabetes to a podiatrist, especially individuals with a high-risk foot, is a good strategic move. Early referral can optimize foot care, wound care, and podiatry services in their settings. Podiatrists can be "gatekeepers" for the prevention and management of DFUs. Successful collaboration between podiatry services will implement change to standardize the clinical assessment and management of DFUs. The interprofessional approach has demonstrated a reduction in DFUs and lower extremity amputations, with a heterogeneity of team members and interventions.16,17 The clinical and economic burden of lower-limb tissue loss should not be tolerated and must be reduced across the entire population with the help of podiatry. The Future of Podiatry in Wound Care Despite considerable advances in the past 25 years, DFUs continue to present a considerable healthcare burden.18,19 For a DFU without surgery, the median time to healing is 12 weeks; DFUs result in considerable suffering, frequently recur, and are associated with high mortality, not to mention enormous healthcare costs. The 5-year survival following presentation with a new DFU is around 50% to 60%: worse than that of many common types of cancer. Although national and international guidance exists, the evidence base for much of the routine clinical care is thin. It follows that many aspects of the structure and delivery of care are susceptible to the beliefs and opinion of individual clinicians. It is probable that these differences contribute to the geographic variation in outcomes that has been documented in several countries. Clinical outcomes vary widely even within the same country, suggesting that some patients are managed considerably better than others. There is an urgent need to improve the design and conduct of clinical trials in this field. Specifically, the evidence base for clinical practice can be improved through randomized controlled trials. In addition, researchers should undertake systematic comparisons of the results of routine care in different health economies. Why is the current evidence base so poor? For one, diabetic foot care has traditionally been neglected. Also, there is a complexity to the pathogenesis that predisposes patients to ulceration. The care process is complex, in that caregiving and treatments are conducted by many different people, including physicians, surgeons, podiatrists, and other healthcare professionals. Some evidence suggests that appropriate changes in the relevant care pathways can result in a prompt improvement in clinical outcomes. The difficulties posed vary to some extent in each of the main areas of foot ulcer care; however, an attempt has been made to address them in a detailed summary written on behalf of the International Working Group on the Diabetic Foot and the European Wound Management Association. Other factors and pathways such as study design, study conduct, and study reporting all can be used as contributors to influence different outcomes. Much has been achieved in the past 2 decades with major amputations occurring much less frequently, at least in some countries, but there are more advances to come. There are wide variations in outcomes, even in industrialized countries and those with nationalized health care systems. If communities embrace these initiatives, it will be possible to trigger substantial improvement in outcomes relating to DFUs. Care of the foot needs to metamorphose from a subspeciality to a "superspecialist" of diabetes.