Ischemic Ulcers Research Articles

The Controlling Nutritional Status Score is Significantly Associated with Complete Ulcer Healing in Patients with Critical Limb Ischemia

It has been reported that the Controlling Nutritional Status (CONUT) score, calculated using the serum albumin concentration, total peripheral lymphocyte count, and total cholesterol concentration, is a valuable nutritional status index. In the present study, we assessed whether the CONUT score was a significant predictor of complete ulcer healing in patients with critical limb ischemia (CLI). In this retrospective, single center, cohort study, conducted from January 2013 to June 2018, we treated 112 limbs of 89 patients with Fontaine 4 CLI at the Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan. The primary endpoint of the study was complete ulcer healing after revascularization, and the secondary endpoint was amputation-free survival (AFS). The mean follow-up time was 17.8months. Complete ulcer healing was achieved during the follow-up period in 91 (81.2%) limbs. The median ulcer healing time was 104days (range, 16-574days). In multivariate analysis, improvement of lower skin perfusion pressure ratio of <1, end-stage renal disease, and high CONUT score (>4) were predictive of incomplete ulcer healing in patients with Fontaine 4 CLI. In addition, the AFS rate was significantly better in patients with a CONUT score ≤4 than in those with a CONUT score >4. The CONUT score was associated with postprocedure ulcer healing and long-term limb retention in patients who underwent revascularization. The management of CLI involving ischemic foot ulcers may require ongoing consideration of nutritional status.

Martorell hypertensive ischemic leg ulcer: A case report

Introduction. Hypertensive ischemic leg ulcer, also known as Martorell ulcer, is not very rare, but an under-recognized type of leg ulcer. It has specific clinical and histopathological characteristics. It occurs almost exclusively in patients with arterial hypertension. It is more common in women and in patients with type 2 diabetes. It is localized particularly in the laterodorsal distal third of the lower leg. This ulcer is extremely painful. Its clinical features may very much resemble pyoderma gangrenosum. Case Report. We are presenting a case of a 40-year-old obese male, who suffered from arterial hypertension during the past 26 years. His ulcer appeared spontaneously on the lateral aspect of the right lower leg and progressed gradually. From the very onset, the ulcer was extremely painful. At first, it was diagnosed as pyoderma gangrenosum and treated with systemic corticosteroids and immunosuppressants. Since the response to therapy was not satisfactory, the histopathology was revised and the diagnosis of hypertensive ischemic leg ulcer was made. After initial wound debridement and local negative pressure therapy, split-thickness skin grafting was performed. The pain disappeared right away almost completely and complete epithelization was achieved two weeks after skin grafting. Conclusion. It is important to consider Martorell ulcer in hypertensive patients with extremely painful ulcers of the lower leg. In order to establish the appropriate diagnosis, it is essential to take a deep skin biopsy and correlate the finding with a specific histopathological picture. It is the only way not to confuse hypertensive ischemic leg ulcer with pyoderma gangrenosum, since the management of the two conditions is completely different.

Topical NATROX® oxygen wound therapy on patients with ischemic foot ulcers – A case series

Background: The essential role of oxygen in wound healing is well documented, and recent developments in the delivery of topical oxygen therapy have made this a more viable treatment in practice. This article examines the role of topical oxygen – the NATROX® Oxygen Wound Therapy System in wound healing and looks at the impact of increased oxygenation on ulcer healing through a case series where the NATROX system was used in patients with ischemic foot ulcers. Materials and Methods: Topical oxygen therapy was evaluated in patients with ischemic foot ulcers in a tertiary referral specialist center. Results: During this case series of six patients, four patients had a complete healing before the study completion and two patients wounds were on a healing trajectory (average reduction in wound size of 60 %) during the follow-up, which eventually healed. Conclusion: NATROX® is an innovative topical oxygen delivery system that warranty further research to assess its potential impact on wound healing.

Ischemic diabetic foot ulcer when treated in association with photobiomodulation: Case report

Introduction: Because ischemic diabetic foot has arterial lesions with micro and macroangiopathies, it is challenging successfully treat ulcers even now. This becomes especially true if limb revascularization is impossible due to the particularities of systemic pathology and/or local arterial disease. Case Report: A 61-year-old male patient with type II Diabetes mellitus, arterial hypertension, chronic arterial insufficiency, single limb, with ischemic calcaneal ulcer and posterior tibial artery occlusion that irrigates the angiosome of the lesion, but unfavorable to revascularization. Defined by conventional treatment with platelet antiaggregant, statin and vasodilator associated with laser photobiomodulation (PBM). Red laser, 660 nm, 108 mW, 2.7 W/cm2, was used to irradiate the ulcer point by point, since the area of the laser beam was smaller than the area of the ulcer (laser beam = 0.04 cm2), in contact mode, 108 J/cm2, 4.32 J, and 10 s per point once a week for 33 weeks. Arterial Doppler ultrasound examinations were performed twice, i.e., after three and six months of treatment. Results: Gradual improvement of blood flow in the ulcer bed with postocclusive flow after three months, and after six months, triphasic flow toward the calcaneus. Conclusion: Photobiomodulation proved to be effective for the formation of collateral circulation in the occluded vascular bed studied here, despite only partial ulcer healing. Randomized controlled trials should be performed to better understand the effects of PBM.

Thromboangiitis obliterans: Aggressive angioplasty provides a potential solution (randomized pilot study).

Background:Thromboangiitis obliterans is an inflammatory disease affecting both medium- and small-sized vessels. Vasodilators, antiplatelets were proposed for treatment but the effect was minimal.Objective:This study was conducted to investigate the effect of balloon angioplasty on patients with Buerger’s disease compared to medical treatment.Methods:Between January 2006 and December 2016, 82 patients with Buerger’s disease were enrolled in the study, of whom 52 were randomized to the aggressive endovascular intervention and 30 were randomized medically by cilostazol and aspirin as a control group. In all, 23% of the patients presented with severe claudication, 50% with ischemic rest pain and 27% with ischemic ulcers. Randomization was done using the opaque envelope method. Allocation concealment was maintained to ensure no selection bias. Patient groups were compared for the duration of ulcer healing, ankle–brachial index, peak systolic velocity changes and transcutaneous oximetry (TcPO2) level for 30 months.Results:No major procedural complications occurred in the endovascular group. Angiographic success was achieved in 100% of supragenicular lesions but in 90% of infrapopliteal lesions. The endovascular group showed a statistically significant improvement in the ulcer healing size and duration at 6 months after the procedure with a mean time of 3 ± 0.9 months compared to 5.8 ± 1.69 months for the medical treatment group (p < 0.001), the mean TcPO2 from 27.23 ± 16.75 mm Hg (range: 0–56 mm Hg) before the procedure to 71.32 ± 12.94 mm Hg (range: 52–92 mm Hg) following revascularization (p < 0.01). The mean ankle–brachial index significantly improved from 0.54 ± 0.14 preoperatively to 0.82 ± 0.08 at final follow-up (p < 0.01).Conclusion:The endovascular therapy should be considered as an effective, safe, minimally invasive method in the light of the promising results after a modification of the standard technique.

Hyperbaric oxygen therapy in patients suffering from wounds in calciphylaxis: a narrative review

Calcific uremic arteriolopathy (calciphylaxis) is a rare and highly lethal vascular disease. Vascular calcification with calcium depositions lead to ischemic ulcers associated with gangrene, severe pain and poor healing. Although hyperbaric oxygen (HBO2) therapy has been used in the treatment of calciphylaxis, evidence of its effectiveness is limited. To determine whether HBO2 therapy has a beneficial effect in the healing of calciphylaxis ulcers. A search was made in PubMed using a comprehensive strategy to identify the effect of HBO2 on calciphylaxis wounds. Included in the analysis were studies published up to October 2018 involving a minimum of four patients receiving HBO2 therapy. Ten retrospective (case) series were included. This review included a total of 131 patients with calciphylaxis who were treated with HBO2 therapy; of these, 58 patients (45%) had full response on HBO2 with complete wound closure. Regarding partial response, 17 of the patients (13%) experienced substantial wound improvement on different wound scale scores. Patients with calcific uremic arteriolopathy can benefit from HBO2. More research is needed using standardized wound scores. Outcomes related to quality of life and pain relief should also be assessed.

Martorell’s hypertensive ischemic leg ulcer: a case report

Martorell’s hypertensive leg ulcer is a unique form of lower extremity ischemic ulcers that is associated with underlying hypertensive state. In this case report, we present a 61-year-old hypertensive patient with the characteristic ulcer, which was totally cured with treatment, along with a concise review of the condition to renew the appreciation of the existence of this clinical entity.

Limb Preservation Using Edetate Disodium-based Chelation in Patients with Diabetes and Critical Limb Ischemia: An Open-label Pilot Study.

BackgroundIn 2015, there were 30.3 million patients with diabetes in the US, including 25.2% of people ages 65 or older and 108,000 hospitalizations for non-traumatic amputations. Severe diabetic limb disease includes critical limb ischemia (CLI ) due to an infrapopliteal disease with foot pain and ischemic ulcerations including gangrene. Environmentally acquired toxic metals, such as lead and cadmium, have been associated with cardiovascular disease. Thus, we designed the present unblinded pilot study to determine whether there was a signal of benefit for edetate disodium-based infusions in patients with critical limb ischemia.MethodsThis was an open-label pilot study in 10 patients with diabetes and critical limb ischemia. Each patient received up to 50 edetate disodium-based infusions and was assessed for safety, clinical efficacy, metal excretion, and quality of life. The primary endpoint was to assess the effect of edetate disodium-based therapy plus vitamins in patients with diabetes and infra-popliteal peripheral artery disease presenting with severe CLI and determine if there were improvements in vascular flow parameters.ResultsWe enrolled 10 (60% male) predominantly Caucasian (90%) subjects. The mean age was 75.3 (8.0) years. Smoking was reported by 30%. There were 70% with coronary artery disease (30% had prior coronary artery bypass grafting) and 50% had a prior lower-extremity amputation, three having previous minor amputations and two major amputations. There were no major adverse cardiovascular events during the infusion phase through the one-year follow-up. Patients completing 40 infusions demonstrated complete wound healing and improvement in the quality of life.ConclusionPatients with diabetes and CLI treated with a regimen of edetate disodium-based infusions demonstrated a potential signal of benefit and preliminary evidence of safety. The Trial to Assess Chelation Therapy in Critical Limb Ischemia (TACT3a), a randomized double-blind, placebo-controlled clinical trial now in progress, will further test these findings.

Limb Revascularization in Patients with Diabetes Mellitus

The review describes morbidity, mortality and possible complication rates for diabetic patients with peripheral arteries disease. The article demonstrates the modern tendency in the surgical treatment of peripheral arteries atherosclerosis, shows and compares worldwide results of endovascular and open revascularization. The authors have assessed the risk of amputation for patients with diffuse peripheral arteries disease and described basic treatment principals for better chronic ischemic ulcer healing.

Elastic compression after ultrasound-guided foam sclerotherapy in overweight patients does not improve primary venous hemodynamics outcomes

ObjectiveLower extremity varicose veins have a high prevalence and can be associated with significant morbidity in their more advanced presentations; overweight patients tend to present with more severe clinical symptoms and conventional surgical treatment remains challenging. Although the advent of ultrasound-guided foam sclerotherapy (UGFS) increased the treatment options for these patients, the need for elastic compression after UGFS remains controversial. MethodsOverweight patients with lower extremity varicose veins secondary to great saphenous vein reflux were treated with UGFS and then randomized to use or no use of a 3-week treatment of elastic compression stockings. Follow-up was performed by clinical evaluation and duplex ultrasound examination. The primary outcome measure was the absence of venous reflux in the great saphenous vein. ResultsOne hundred thirty-five lower limbs were treated; 72 limbs were randomized to elastic compression and 63 limbs to the control group. There were no statistically significant differences in the number of procedures (P = .64) or the mean foam volume per procedure (P = .27) between groups. There was no difference in the reflux rate at either 3 weeks (26% vs 35%; P = .16) or 3 months (25% vs 21%; P = .85). Major complications were venous deep thrombosis (n = 2), neurologic event (n = 1), and ischemic ulceration (n = 1); the overall rate was 3% in both groups—2 of 62 in control patients and 2 of 69 in compression patients (P = .45). Venous diameter reduction was noted in both groups during treatment (P < .05) but with greater decrease in greater saphenous vein diameter in patients treated with compression. ConclusionsElastic compression stockings for 3 consecutive weeks after UGFS in overweight patients did not decrease great saphenous vein reflux, need for repeat procedures, or the volume of foam injected. However, UGFS was associated with a greater and uniform reduction in saphenous vein diameter at all times after the procedure.

Surgical Wound Healing After Below the Knee Bypass Surgery for Critical Limb Ischemia

Introduction - Lower limb infrainguinal revascularization, especially with converted vein include a major surgical trauma on initially ischemic tissue. Vein harvesting wound healing has been studied in patients undergoing coronary surgery. However, wound healing hasn’t been well characterized in patients undergoing lower limb revascularization. Aim of this study was to assess the vein harvesting wound healing in ischemic limb. Methods - This was a retrospective single centre study. All consecutive patients (195) with critical limb ischemia undergoing below the knee bypass surgery with converted great saphenous vein graft during 2015-2017 in Turku University Hospital, department of Vascular Surgery were included. Follow up data was collected until February 28th 2018. The patients were divided into two categories, those who initially had ischemic ulcers and those who didn’t. Wound dehiscence was recorded as well as the wound healing times and whether a major amputation was needed after the revascularization. Results - The mean follow-up after revascularization was 535 days (SD 345.1). Amputation free survival was 505 days (SD 355.5). In 65 patients with no ischemic ulcers, the wounds healed faster, the mean estimated healing time 69.0 days (95%CI 56.0-82.0). Respectively, in 130 patients with ischemic ulcers the mean estimated healing time was 85.3 days (95%CI 71.4-99.2), P = 0.227. Conclusion - Vein harvesting wound in the revascularized limb heal considerably slow. Although a revascularization procedure has been done to restore the blood flow.

Hyperbaric Oxygen Therapy in the Treatment of Ischaemic Lower Extremity Ulcers in Patients with Diabetes: Results of the Damocles Multicentre Randomised Clinical Trial

Introduction - Conflicting evidence exists on the effects of hyperbaric oxygen therapy (HBOT) in the treatment of chronic ischaemic leg ulcers. The aim of this multicentre trial was to investigate whether HBOT, as an adjunct to revascularisation and standard wound care, can improve wound healing and reduce major amputation rates in patients with diabetes and ischaemic lower extremity ulcers. Methods - The DAMOCLES study was designed as a multicentre, randomised, parallel-group, superiority trial. In total, 120 patients were randomised to standard care without (SC) or with HBOT (SC+HBOT). Eligible diabetic patients had a Wagner grade 2-4 ulcer present for at least 4 weeks and concomitant limb ischaemia with or without revascularisation options. Primary outcomes were limb salvage and complete wound healing after 12 months of follow-up, as well as time to wound healing. Other endpoints were amputation-free survival (AFS) and mortality. Results - Both groups contained 60 patients. Limb salvage was achieved in 47 patients (78%) in the SC group vs. 53 (88%) patients in the SC+HBOT group (risk difference [RD] 0.10, 95% CI -0.04 to 0.23). After 12 months, 28 index wounds were healed in the SC group vs. 30 in the SC+HBOT group (RD 0.03, 95% CI -0.14 to 0.21). AFS was achieved in 41 patients in the SC group and 49 patients in the SC+HBOT group (RD 0.13, 95% CI -0.02 to 0.28). In the SC+HBOT group 21 patients (35%) were unable to complete the HBOT-protocol as initially planned. Those who did had significantly less major amputations and higher AFS (RD 0.26, 95% CI 0.10 to 0.38). Conclusion - Additional HBOT did not significantly improve complete wound healing and limb salvage in patients with diabetes and lower limb ischaemia. However, a trend was seen towards a better amputation-free survival among HBOT-treated patients. The potential efficacy of HBOT may not be realised because a considerable number of patients is unable to complete a full HBOT-regimen.

Effects of simultaneous pancreas-kidney transplantation and kidney transplantation alone on the outcome of peripheral vascular diseases

BackgroundThe effects of Simultaneous Pancreas Kidney Transplantation (SPKT) on Peripheral Vascular Disease (PVD) warrants additional study and more target focus, since little is known about the mid- and long-term effects on the progression of PVD after transplantation.Methods101 SPKT and 26 Kidney Transplantation Alone (KTA) recipients with insulin-dependent diabetes mellitus (IDDM) were retrospectively evaluated with regard to graft and metabolic outcome. Special subgroup analysis was directed towards the development and progression of peripheral vascular complications (PVC) (amputation, ischemic ulceration, lower extremity angioplasty/ bypass surgery) after transplantation.ResultsThe 10-year patient survival was significantly higher in the SPKT group (SPKT: 82% versus KTA 40%; P < 0.001). KTA recipients had a higher prevalence of atherosclerotic risk factors, including coronary artery disease (P < 0.001), higher serum triglyceride levels (P = 0.049), higher systolic (P = 0.03) and diastolic (P = 0.02) blood pressure levels. The incidence of PVD before transplantation was comparable between both groups (P = 0.114). Risk factor adjusted multivariate analysis revealed that patients with SPKT had a significant lower amount (32%) of PVCs (32 PVCs in 21 out of 101 SPKT; P < 0.001) when compared to the KTA patients who developed a significant increase in PVCs to 69% of cases (18 PVCs in 11 out of 26 KTA; P < 0.001). In line mean values of HbA1c (P < 0.01) and serum triglycerides (P < 0.01) were significantly lower in patients with SPKT > 8 years after transplantation.ConclusionSPKT favorably slows down development and progression of PVD by maintaining a superior metabolic vascular risk profile in patients with IDDM1.

Outcomes of Infrainguinal Bypass Procedures in Diabetic Patients with Ischaemic Foot Ulcers: A Sri Lankan Experience in Limb Salvage

Outcomes of Infrainguinal Bypass Procedures in Diabetic Patients with Ischaemic Foot Ulcers: A Sri Lankan Experience in Limb Salvage

Limb Salvage in Diabetic Patients With Ischemic Heel Ulcers.

The purpose of this study is to investigate the outcomes of diabetic individuals with ischemic heel ulcers. The study group was composed of a consecutive sample of persons with diabetic ischemic foot ulcers managed by a preset multidisciplinary limb salvage protocol, including revascularization through endovascular technique. The outcome measures were healing, major amputation (above the ankle), and death at 1-year of follow-up. The outcomes between patients with heel ulcers (HUs) and without (NHUs) were compared. A total of 254 patients were recruited. There were 50/254 (19.7%) HUs and 204/254 (79.3%) NHUs. Overall, 190/254 (74.8%) patients healed. The rate of healing for HUs and NHUs was 30/50 (60%) and 160/204 (78.4%); P = .03, respectively. Major amputation occurred in 24/254 (9.4%) patients. The rates of major amputation for HUs and NHUs were 10/50 (20%) and 14/204 (6.9%; P = .002), respectively; 40/254 (15.7%) patients died, unhealed. The rates of mortality for HUs and NHUs were 10/50 (20%) and 30/204 (14.7%; P = .07), respectively. In HUs patients, absence of infection [95% CI = 3.1 (1.6-5.5); P = .002] and superficial ulcers [95% CI = 4.4 (2.2-9.3); P = .0001] were independent predictors of healing, whereas revascularization failure [95% CI = 8.1 (1.5.0-19.4); P = .0001], involvement of the plantar arch [95% CI = 6.3 (2.0-15.4); P = .0001], and dialysis [95% CI = 2.2 (1.3-4.5); P = .006] were independent predictors of major amputation. A multidisciplinary approach achieves good rate of limb salvage in people with diabetic ischemic heel ulcers.

Study on the mechanism of low-frequency electromagnetic field promoting the healing of ischemic foot ulcer in experimental rabbits

Objective By modeling ischemic foot ulcers in experimental rabbits, the mechanism of healing in animal models was investigated. Methods Sixty healthy male clean grade New Zealand rabbits were 3 months. The weight range was 2.1-2.5 kg. Randomly draw auording to the number, the experimental rabbits were randomly divided into 4 groups, namely, no ischemia-no ulcer-no intervention group (group A), no ischemia-no ulcer-no intervention group (group B), no ischemia-no ulcer-no intervention group (group C) and no ischemia-ulcer-intervention group (group D), with 15 rabbits in each group. Ischemic foot ulcers experimental rabbit building complete after 24 h, will naturally exposed ischemic foot ulcers in the low frequency electromagnetic field on experimental rabbit 7 d feeding experiment, the experimental rabbits ischemia crus muscle and the ulcer base were collected, and plasma by enzyme-linked immunosorbent assay (ELISA) verification tests in experimental rabbit plasma hypoxia-inducible factor 1 alpha subunit (HIF-1α), matrix metalloproteinases 9 (MMP-9) and soluble leukocyte differentiation antigen 40 ligand 1 (sCD40L1) expression level, while detecting ulcer healing area change, hematoxylin-eosin staining was used to detect and analyzed the pathological changes of ulcerated skin. Measurement data were expressed as mean±standard deviation (Mean±SD), one-way analysis of variance was used for comparison between groups, and LSD method was used for pairwise comparison. Results The concentration of MMP-9 and sCD40L1 in group D were (40.510±10.155) ng/ml and (44.580±19.138) ng/ml, respectively. Concentrations in group C were (93.210±17.838) ng/ml and (318.500±52.680) ng/ml, respectively. Group D was significantly lower than group C, and the difference was statistically significant (P< 0.000 1). The concentrations of HIF-1α in group D was (249.700±71.824) ng/ml, and that in group C was (124.830±20.110) ng/ml. The concentration in group D was significantly higher than that in group C, and the difference was statistically significant (P< 0.000 1). The concentrations of HIF-1α, MMP-9 and sCD40L1 in group B were (181.590±31.927), (78.950±16.652) and (173.670±43.048) ng/ml, respectively. The concentrations of group A were (35.420±9.916), (32.700±6.449) and (47.440±11.831) ng/ml, respectively. The concentration in group B was significantly higher than that in group A, the difference was statistically significant(P<0.000 1). The concentration of HIF-1α in group D was (249.700±71.824) ng/ml, and the concentration of group A was (35.420±9.916) ng/ml. The concentration of group D was significantly higher than that of group A, and the difference was statistically significant (P=0.000 1). The concentration of the MMP-9 in the group D was compared with the concentration of group A, and the difference was not statistically significant (P=0.207). The concentration of sCD40L1 in group D was (44.580±19.138) ng/ml, and that in group A was (47.440±11.831) ng/ml. The difference between group D and group A was not statistically significant(P=0.858). The healing area of ulcer was (1.855±0.394) cm2 in group D and (0.653±0.269) cm2 in group C. Group D was significantly higher than group C, and the difference was statistically significant (P<0.000 1). Hematoxylin-eosin staining results of ulcer skin showed that the epithelial of ischemic foot ulcer was significantly atrophied, hyperkeratinized, and the acinous cell layer was atrophied with a small amount of obvious inflammatory cell infiltration and hyperplasia of small vessels. After intervention, the symptoms were relieved. Conclusion Low frequency electromagnetic fields can promote the expression of HIF-1α in experimental rabbits, inhibit the expression of MMP-9 and sCD40L1, and promote the healing of ischemic foot ulcer. Key words: Foot ulcer; Matrix metalloproteinase 9; Electromagnetic fields; Hypoxia-inducible factor 1, alpha subunit; Rabbits

Thromboangiitis Obliterans Manifests As Rheumatic Symptoms

Thromboangiitis obliterans (TAO) is a non-atherosclerotic inflammatory arthritis mainly involving small arteries and veins. Although it is closely related to the tobacco exposure, the general pathophysiology of the disease remains unclear. TAO mainly affects young male patients with ischemic ulcer, pain during rest, limping, chills in limbs, and migratory thrombophlebitis. However, some patients present joints swelling and pain as the first manifestations before the clinical manifestations above. They are easy to be misdiagnosed as rheumatic diseases, which is a challenge to the diagnosis and treatment of rheumatologists. Here we report a case in which TAO was misdiagnosed as Seronegative Spondyloarthritis (SpA) and eventually amputated.

Diabetic Foot Infection, Biofilm &amp; New Management Strategy

The world is facing a major epidemic of diabetes mellitus (DM) &amp; available reports suggest that all these patients are at risk of developing diabetic foot ulcer (DFU). Approximately 50 – 60% of all DFUs can be classified as neuropathic. Signs or symptoms of vascular compromise are observed in 40 to 50% of all patients with the vast majority having neuro-ischemic ulcers, and only a minority of patients has purely ischemic ulcers. Diabetic foot infections are usually polymicrobial in nature, involving both aerobes and anaerobes, which can decay any part of the body especially the distal part of the lower leg. However, one of the hidden barriers to wound healing is the presence of biofilm in chronic DFUs. Biofilms are difficult to identify &amp; diagnose, recalcitrant to topical antibiotics &amp; can reoccur even after sharp debridement. More than 90% of chronic wounds are complicated with biofilms. Hence, early identification and management of diabetic foot infections becomes imperative in order to prevent complications &amp; amputation. Debridement is considered to be the gold standard treatment approach for managing DFU manifested with necrotic tissue. However, biofilm can reform even after sharp debridement and can delay healing &amp; recovery. Also, antibiotics &amp; few antiseptics have limited role in managing DFUs complicated with biofilm. Until recently, Cadexomer iodine, a new generation iodine formulation with microbead technology has taken a different profile in wound care. It can effectively manage biofilm along with exudate &amp; possesses superior desloughing action. Additionally, appropriate ways of offloading, dressings &amp; use of newer treatment strategies like negative pressure wound therapy (NPWT), hyperbaric oxygen therapy (HBOT) and / or use of growth factors can ensure faster healing &amp; early wound closure. Although, commendable efforts in recent years have been taken in the diagnosis and treatment of DFU, it still remains a major public health concern.

Assessment of the Risk Factors of Multidrug-Resistant Organism Infection in Adults With Type 1 or Type 2 Diabetes and Diabetic Foot Ulcer

ObjectivesTo our knowledge, this is the first review to analyze the literature identifying risk factors for multidrug-resistant organism (MDRO) infection in patients with diabetic foot ulcer. The purpose of this study was to collect the currently published data to determine the most commonly and consistently identified risk factors for MDRO infection. MethodsPubMed, MEDLINE, BIOSIS, Web of Science and the Cochrane Library electronic databases were searched. The last search updated was in September 2019. The evaluated outcomes included age, male sex, type of diabetes, diabetes duration, level of glycated hemoglobin, ulcer type, wound duration, ulcer size, ulcer grade, osteomyelitis, previous antibiotic therapy and previous hospitalization. The standard mean difference or the odds ratio (OR) was calculated for continuous or dichotomous data, respectively. The quality of the studies was assessed, and meta-analyses were performed with Cochrane Collaboration's RevMan 5.0 software. ResultsA total of 11 studies, including 1,229 patients provided evidence for 6 possible risk factors for MDRO infection. Ischemic ulcer (OR, 0.50; 95% confidence interval [CI], 0.35 to 0.71), ulcer size (standard mean difference, −0.27; 95% CI, −0.46 to −0.08), ulcer grade (OR, 0.36; 95% CI, 0.15 to 0.83), osteomyelitis (OR, 0.33; 95% CI, 0.25 to 0.45), previous antibiotic therapy (OR, 0.08; 95% CI, 0.04 to 0.14) and previous hospitalization (OR, 0.15; 95% CI, 0.08 to 0.28) were identified as risk factors for MDRO infection in patients with diabetic foot ulcer. ConclusionsOur meta-analysis indicated that ischemic ulcer, ulcer size, ulcer grade, osteomyelitis, previous antibiotic therapy and previous hospitalization were associated with MDRO infection in patients with diabetic foot ulcer.

Application of International Best Practice Guideline in Diabetic Ulcer Patients

Background: Diabetic ulcer is one of the complications of Diabetes mellitus. Assessment of diabetic ulcers is done as a basis in determining wound care and therapy provided so that it needs to know its characteristics.Purpose: This study was to determine the characteristics of wounds assessment tools diabetic ulcer International Best Practice Guideline (IBPG).Method: The study design was descriptive with a case study approach, the sampling technique was purposive sampling carried out in May 2019 with three respondents. The instrument used is the wound assessment tool International Best Practice Guideline which contains: sensation, callus, wound base, temperature and location.Results: Respondents 1 experienced neuroiskemic injuries. Respondent 2 suffered neuropathic injuries and Respondent 3 had ischemic injury.Conclusion: Characteristics of ulcers based on the International Best Practice Guidelines respectively, neuroiskemic, neuropathic and ischemic ulcers. Health workers are expected to apply a more detailed assessment of diabetic ulcers so that they can determine the appropriate treatment.