Severe Ulceration Research Articles

Adverse effects of anti-cancer biologics on the ocular surface.

Cancer immunotherapy is one of the most emerging and rapidly growing fields.Ocular side effects associated with these therapies are common and can be present in up to 70% of patients.The cornea may be involved in different pathogenic mechanisms triggered by different immunotherapeutic agents, and corneal disease varies from mild symptoms to severe corneal ulceration and melting with visual loss.We aimed to review the incidence, mechanism, and management of ocular surface side effects in cancer patients receiving immunotherapy. With the recent use of immunotherapeutic agents in cancer patients, in particular immune checkpoint inhibitors (ICIs) and epidermal growth factor receptor (EGFR) inhibitors, ocular surface and corneal involvement are common side effects.These patients can be at risk of sight threatening complications that warrant prompt diagnosis and careful monitoring and management. Immunotherapy- related corneal complications in cancer patients are associated with a decreased quality of life. Prompt recognition and an interdisciplinary approach between ophthalmologists and oncologists are crucial to handle immune related ocular adverse events in these patients, in order to maintain ocular surface integrity and avoid a vision threatening complication.

Comparative Study of Morphine, Fentanyl or Nalbuphine Patient Controlled Analgesia (PCA) for Mucositis Pain in Pediatric Patients Undergoing Cancer Therapy. A Prospective Randomized Clinical Trial

Abstract Background Cancer treatment may cause several side effects, including severe oral mucositis (SOM). Oral mucositis is an inflammation of the oral mucosa that causes severe pain and ulceration. Children and adolescents are more prone to develop chemotherapy-induced SOM. Opiates have been the cornerstone of pain management for moderate to severe oral mucositis. The effective use of opiates requires balancing the desired effects of pain relief with undesired adverse effects Aim of the Work We evaluated the efficacy and safety of Nalbuphine (agonist – antagonist) in comparison with the pure agonist opioids (Morphine and Fentanyl) when used for oral mucositis pain in pediatric patients undergoing cancer therapy. Primary outcomes measures were Pain intensity self- assessment by using VAS, Number of active and total pushes of PCA buttons, Total opioid consumptions for each patient, and Patient satisfaction at the end of the 7 days using Patient Satisfaction Score PSS were assessed using a linear scale where 0 = very satisfied; 10 = very dissatisfied. Secondary outcomes measures were Adverse events including Respiratory depression, Bradycardia, Hypotension, Over sedation, Nausea and vomiting, Pruritus, Urinary retention. Patients and Methods This was a Randomized Clinical Trial conducted on 90 Pediatric patients who were diagnosed with cancer, admitted to Children Cancer Hospital -Egypt (CCHE-57357) and underwent cancer therapy that was complicated with Mucositis grade 3 and 4 (severe oral mucositis) according to the WHO scale for oral mucositis. Patients were randomly allocated into 3 equal groups each included 30 patients using of: PCA Morphine (Group M), PCA Nalbuphine (Group N) and PCA Fentanyl (Group F). Using equipotent doses of the three medications. Results Highly significant decrease in VAS score (7th day) and total opioid consumption (7th day), in Nalbuphine and Morphine groups; compared to Fentanyl group (p < 0.01 respectively). Significant increase in patient satisfaction score PSS in Nalbuphine drug group; compared to other drug groups (p = 0.032). Highly significant decrease in serious side effects (especially respiratory depression and sedation problems), in Nalbuphine and Morphine groups; compared to Fentanyl group (p = 0.0004). Conclusion Nalbuphine proven to be adequately effective, not inferior to Morphine in terms of improving pain relief, decreasing opioid consumptions in pediatric PCA users. However patients reported less satisfaction with Nalbuphine than Fentanyl or Morphine. In terms of safety profile, Nalbuphine had less adverse effects in pediatric patients with oral mucositis related to cancer therapy in comparison to Fentanyl or morphine.

Tibial cortex transverse transport surgery improves wound healing in patients with severe type 2 DFUs by activating a systemic immune response: a cross-sectional study.

Tibial cortex transverse transport (TTT) surgery has become an ideal treatment for patients with type 2 severe diabetic foot ulcerations (DFUs) while conventional treatments are ineffective. Based on our clinical practice experience, the protective immune response from TTT surgery may play a role against infections to promote wound healing in patients with DFUs. Therefore, this research aimed to systematically study the specific clinical efficacy and the mechanism of TTT surgery. Between June 2022 and September 2023, 68 patients with type 2 severe DFUs were enrolled and therapized by TTT surgery in this cross-sectional and experimental study. Major clinical outcomes including limb salvage rate and antibiotics usage rate were investigated. Ten clinical characteristics and laboratory features of glucose metabolism and kidney function were statistically analyzed. Blood samples from 6 key time points of TTT surgery were collected for label-free proteomics and clinical immune biomarker analysis. Besides, tissue samples from 3 key time points were for spatially resolved metabolomics and transcriptomics analysis, as well as applied to validate the key TTT-regulated molecules by RT-qPCR. Notably, 64.7% of patients did not use antibiotics during the entire TTT surgery. TTT surgery can achieve a high limb salvage rate of 92.6% in patients with unilateral or bilateral DFUs. Pathway analysis of a total of 252 differentially expressed proteins (DEPs) from the proteomic revealed that the immune response induced by TTT surgery at different stages was first comprehensively verified through multi-omics combined with immune biomarker analysis. The function of upward transport was activating the systemic immune response, and wound healing occurs with downward transport. The spatial metabolic characteristics of skin tissue from patients with DFUs indicated downregulated levels of stearoylcarnitine and the glycerophospholipid metabolism pathway in skin tissue from patients with severe DFUs. Finally, the expressions of PRNP (prion protein) to activate the immune response, PLCB3 (PLCB3, phospholipase C beta 3) and VE-cadherin to play roles in neovascularization, and PPDPF (pancreatic progenitor cell differentiation and proliferation factor), LAMC2 (laminin subunit gamma 2) and SPRR2G (small proline rich protein 2G) to facilitate the developmental process mainly keratinocyte differentiation were statistically significant in skin tissues through transcriptomic and RT-qPCR analysis. Tibial cortex transverse transport (TTT) surgery demonstrates favorable outcomes for patients with severe type 2 DFUs by activating a systemic immune response, contributing to anti-infection, ulcer recurrence, and the limb salvage rate for unilateral or bilateral DFUs. The specific clinical immune responses, candidate proteins, genes, and metabolic characteristics provide directions for in-depth mechanistic research on TTT surgery. Further research and public awareness are needed to optimize TTT surgery in patients with severe type 2 DFUs.

Association of Race With Referral Disparities for Patients With Diabetic Foot Ulcers at an Institution Serving Rural and Urban Populations.

Racial minorities are more likely to develop type 2 diabetes and experience associated microvascular complications. Non-Hispanic Blacks and Hispanics initially present with more severe diabetic foot ulcers (DFUs) and peripheral artery disease (PAD), with an associated 10-fold increase in risk for lower extremity amputation within the first year after diagnosis. This study was designed to determine if race is associated with a failure to refer to specialists for DFU treatment, and the severity of DFU at the time of initial presentation. Patients were identified from the medical record based on a diagnosis related to diabetic foot complications between January 1, 2018, and June 1, 2023, in the family medicine, endocrinology, orthopaedic, or emergency clinics at a Midwest Academic Hospital serving rural and urban populations. Patients self-reported race, demographics, severity of ulcer based on Wagner ulcer scale at time of referral, eventual amputation status, and measures of social determinants of health including the national Area Deprivation Index (ADI) and Rural-Urban Commuting Area (RUCA) codes were manually extracted and analyzed for correlations with referral status. A total of 597 patients were eligible for inclusion. Race was not associated with lower referral rates (P > .99) or source of referral (P = .58) to specialty clinic and ulcer severity at initial examination (P = .34). Patients who initially presented to the emergency department had more severe ulcers (P = .016), and higher severity was significantly associated with lower limb amputation vs mild ulcers (odds ratio = 38.8, P = .02). No significant differences in referral source or severity of ulcer at presentation were seen for sex, age, marital status, insurance type, rural status, ADI, time from referral to appointment, or eventual amputation. In this study, we found that patient race was not associated with severity of DFU at presentation or subsequent referral to a Midwest academic specialty orthopaedic clinic for care.Level of Evidence: Level III, retrospective review.

Comparison of Severity in Diabetic Ulcer Patients with and Without Sepsis

Diabetes mellitus patients in Central Java grow yearly. According to data provided by the Central Java Health Department in 2019, Diabetes mellitus ranks second as the largest non-communicable disease (NCD), covering 13,4% of the total NCD patients. The prevalence of diabetic ulcers is 15-25% of all diabetes mellitus patients in Indonesia, which concerns the author regarding the possible increase of the diabetic ulcer population in Central Java. The severity of diabetic ulcers depends on various factors, including infection and complications. The most common complication is sepsis, a systemic infection often arising from local infections that are not appropriately treated, causing progressive damage and increasing mortality rates. This study aims to examine the comparison of ulcer severity in diabetic ulcer patients with sepsis and non-sepsis complications using Meggitt Wagner's criteria. This study utilizes an analytic observational study using a cross-sectional approach. The author sampled 126 patients diagnosed with Diabetic Ulcers in 2022 at Dr. Moewardi General Hospital for this study, using a purposive sampling method. The research was conducted by looking at the patient's medical record data, and data analysis using SPSS software. The test used in this research includes a Parametric T-independent test and a Pearson bivariate relationship test. This study shows that the comparison of ulcer severity in diabetic ulcer patients with sepsis and without sepsis was statistically significant (p-value = 0.000002). The mean of the group with sepsis (3.4127) was greater than the group without sepsis (2.5238). In conclusion, the comparison of ulcer severity in diabetic ulcer patients with sepsis and without sepsis is significant. We recommend future researchers include patients’ comorbidities, total hospitalization time, and detailed information on drug use and patient adherence to treatment in their research for more nuanced findings.

Comprehensive nursing model for diabetic foot ulcers: A strategy to improve prognosis and quality of life.

Diabetic foot (DF) ulcer is one of the common complications of diabetic patients, with high incidence and amputation rate, which seriously affects the quality of life and health of patients. Therefore, how to effectively prevent and treat DF ulcers and reduce amputation rate has become an urgent problem in the medical field. As a comprehensive nursing model for patients with DF ulcers, comprehensive nursing intervention is designed to improve the therapeutic effect and prognosis and reduce the rate of amputation. Convenient sampling method was used to select 360 patients with DF who received routine care for DF ulcers from July 2013 to July 2023 for retrospective cohort analysis. According to the existence of exposure factors (comprehensive nursing intervention), 180 cases were divided into observation group and comparison group. The basic demographic data, amputation rate, severity of foot ulcer, neuropathy and vascular disease, and blood glucose control were compared between the 2 groups. The data was analyzed using SPSS26.0. Harman single factor test was used to check whether there was common method bias in the study data. Descriptive analysis, Spearman rank correlation analysis and multiple linear regression analysis were used to analyze the current situation of amputation rate of DF patients and the influence of comprehensive nursing intervention on the amputation rate of DF patients. The amputation rate was 2.8% in the Observation group compared to 8.3% in the Comparison group. The amputation rate of the observation group was generally higher in the age group, and the amputation rate of the observation group was higher in the middle school education level and below and the economic status of <5000 yuan. The difference was statistically significant (P < .05). Age (odds ratio [OR] = 1.96; 95% confidence interval [CI]: 0.88-4.38), education level (OR = 1.30; 95% CI: 1.69-6.46), economic status (OR = 2.28; 95% CI: 1.69-10.85) was an independent risk factor for amputation rate (P < .05). Comprehensive nursing interventions have played a positive role in reducing the rate of amputation in patients with DF.

Canakinumab is effective for refractory Entero-Behçet’s disease with compound heterozygous variants of the MEFV gene: A case report

Rationale: Behçet’s disease (BD) is characterized by recurrent oral ulcers, skin lesions, genital ulcers, and ocular inflammation, with uncontrolled gastrointestinal manifestations potentially leading to fatal complications. Human leukocyte antigen (HLA) class I alleles such as HLA-B51 and HLA-A26 are genetic risk factors for BD, and interleukin-1β activation plays a key role in BD pathogenesis. Familial Mediterranean fever, another autoinflammatory disease caused by MEFV gene mutations, shares similarities with BD, including enhanced interleukin-1β production. Patient concerns: We present a case of BD with severe gastrointestinal ulcers and MEFV variants treated with canakinumab. Diagnoses: A 69-year-old Japanese woman with a history of malignant lymphomas and nontuberculous mycobacterial arthritis developed BD symptoms, including oral and gastrointestinal ulcers. Interventions: Despite after treatments with 2 tumor necrosis factor inhibitors, her oral and gastrointestinal ulcers persisted. Genetic analysis revealed L110P/E148Q MEFV variants, prompting the administration of canakinumab and granulocyte and monocyte adsorption apheresis. Outcomes: Continuous treatment with canakinumab improved the oral and gastrointestinal ulcers. Lessons: This case highlights the potential efficacy of canakinumab in treating severe gastrointestinal ulcers in BD patients with MEFV variants.

Role of traditional healers in the management of microbial keratitis in eastern Nepal

Background Microbial Keratitis (MK) is a leading cause of corneal blindness due to infection and its consequences, with a higher incidence in resource-limited nations. Hospital-based patient records from different parts of Nepal suggest patients often use traditional eye medicine to treat MK. Traditional healers (TH) within the community are often the first point of care for MK management. Little is known of their practice, perceptions, and knowledge around MK management. We aimed to understand the role of traditional healers in the management of MK in south-eastern Nepal. Methods A cross-sectional, mixed method, descriptive study was conducted in the Siraha district of Nepal. A total of 109 traditional healers consented to participate in a survey of knowledge, attitude, and practices. Some participants were also invited to participate in in-depth interviews and focus group discussions. Interviews and focus groups were conducted and recorded in the Maithili language by a native speaking interviewer and transcribed into English. Descriptive analysis was performed for the survey. Data saturation was considered the endpoint for qualitative data collection, and a thematic was analysis applied. Results Traditional healers believe that infection of the eye can be caused by trauma, conjunctivitis, or evil spirits. They were unclear about differentiating MK from other eye conditions. They provided various types of treatment. Some were confident that they could treat severe ulcers that had not responded to medical therapy, while others thought treating larger diameter ulcers would be difficult. Although there were mixed responses in referring patients with MK, the majority of TH were willing to refer. Conclusion In a weak health system, traditional healers may help address barriers to healthcare access and reduce delays to definitive care, upon integration into the formal health system and referral pathway.

Therapeutic Effectiveness of Leukocyte- and Platelet-rich Fibrin for Diabetic Foot Ulcers: A Retrospective Study.

Diabetic foot ulcer (DFU) is one of the most serious complications of diabetes. Leukocyte- and platelet-rich fibrin (L-PRF) is a second-generation autologous platelet-rich plasma. This study aims to investigate the clinical effects of L-PRF in patients with diabetes in real clinical practice. Patients with DFU who received L-PRF treatment and standard of care (SOC) from 2018 to 2019 in Tongji Hospital were enrolled. The clinical information including patient characteristics, wound evaluation (area, severity, infection, blood supply), SOC of DFU, and images of ulcers was retrospectively extracted and analyzed. L-PRF treatment was performed every 7±2 days until the ulcer exhibited complete epithelialization or an overall percent volume reduction (PVR) greater than 80%. Therapeutic effectiveness, including overall PVR and the overall and weekly healing rates, was evaluated. Totally, 26 patients with DFU were enrolled, and they had an ulcer duration of 47.0 (35.0, 72.3) days. The severity and infection of ulcers varied, as indicated by the Site, Ischemia, Neuropathy, Bacterial Infection, and Depth (SINBAD) scores of 2-6, Wagner grades of 1-4, and the Perfusion, Extent, Depth, Infection and Sensation (PEDIS) scores of 2-4. The initial ulcer volume before L-PRF treatment was 4.94 (1.50, 13.83) cm3, and the final ulcer volume was 0.35 (0.03, 1.76) cm3. The median number of L-PRF doses was 3 (2, 5). A total of 11 patients achieved complete epithelialization after the fifth week of treatment, and 19 patients achieved at least an 80% volume reduction after the seventh week. The overall wound-healing rate was 1.47 (0.63, 3.29) cm3/week, and the healing rate was faster in the first 2 weeks than in the remaining weeks. Concurrent treatment did not change the percentage of complete epithelialization or healing rate. Adding L-PRF to SOC significantly improved wound healing in patients with DFU independent of the ankle brachial index, SINBAD score, or Wagner grade, indicating that this method is appropriate for DFU treatment under different clinical conditions.

Evaluation of Serum Vitamin D Levels and its Association with Increased Risk of Pressure Ulcer among Non-Ambulatory Patients

Background: Pressure ulcers are a significant health concern for non-ambulatory patients, often resulting from prolonged immobility. Vitamin D, recognized for its role in skin health and wound healing, may influence the development of these ulcers. This study examines the relationship between serum vitamin D levels and the prevalence of pressure ulcers in individuals unable to walk or move independently. Objective: To explore the association between serum Vitamin D levels and the risk of pressure ulcers, aiming to contribute to the literature and improve patient outcomes through evidence-based healthcare practices. Methods: A cross-sectional study was conducted at Sheikh Zayed Hospital and Bahria International Hospital, Lahore, from August 2023 to January 2024. Seventy non-ambulatory patients were recruited using a non-probability convenient sampling method. The Braden scale was employed to assess pressure ulcer severity, and serum vitamin D levels were measured through blood samples. Results: Participants had a mean age of 38.5 years (SD = 6.27) and a mean non-ambulatory duration of 13.72 days (SD = 5.22). Gender distribution was 55.7% female and 44.3% male. Historical pressure ulcer incidence was 10%. The leading reasons for hospitalization were stroke (28.6%), neuromuscular conditions (31.4%), and road traffic accidents (38.6%). A significant positive correlation was found between Braden scale scores and vitamin D levels (11.91 ± 3.40 and 11.40 ± 3.40 respectively, Pearson correlation coefficient = 0.71, p &lt; 0.01). Conclusion: There is a significant association between low serum vitamin D levels and an increased risk of developing pressure ulcers in non-ambulatory patients, supporting the need for vigilant monitoring and management of vitamin D levels.

Onychomycosis: Prevalence, Fungal Pathogens, Risk Factors, and Antifungal Susceptibility Profile among People Living with Diabetes Mellitus in Kano, Northwestern Nigeria

Abstract Context: Onychomycosis is a fungal infection of the nail unit that over time results in dystrophy and disfigurement. It affects the quality of life and increases the prevalence and severity of foot ulcers in patients with diabetes. Aim: The study investigated the prevalence of onychomycosis, the associated fungal pathogens, and their antifungal susceptibility profile in a cohort of people living with diabetes (PLWDM) in Kano, Nigeria. Settings and Designs: This cross-sectional hospital-based study recruited and enrolled 300 PLWDM from two major diabetes treatment centers in Kano. Materials and Methods: Participants were screened for thickened, brittle, crumbly, or ragged nails, and 30 met the inclusion criteria. Sociodemographic data, clinical history, and other risk factors for onychomycosis were also evaluated. Toenail and fingernail, nail clippings, and scrapings were collected and cultured on Sabouraud dextrose agar (SDA). The identification of yeasts and mold isolates was performed using gram stain, germ tube test, CHROMagar, lactophenol cotton blue (LPCB) mount, and slide cultures. Antifungal susceptibility testing was achieved by the agar well-diffusion method. Statistical Analysis Used: The data generated were analyzed using descriptive statistics and associations between variables checked by the chi-square test or Fisher’s exact test. Results: The prevalence of onychomycosis was 63.3% (19/30), and fingernails were mostly affected. Fungal pathogens recovered include dermatophytes, yeasts, and non-dermatophyte molds, with a predominance of Aspergillus spps. (7/19 (36.8%)), Trichophytonmentagrophytes (4/19 (21.1%)), Trichophytonrubrum (4/19 (21.1%)), and Candidaalbicans (2/19 (10.5%)). A preponderance of the isolates shows a good susceptibility profile to itraconazole, ketoconazole, and clotrimazole, but demonstrated high resistance to fluconazole. Age and use of oral hypoglycemic agents were some of the risk factors identified. Conclusion: The study shows a high prevalence of onychomycosis among PLWDM in Kano and calls for routine screening to minimize or eliminate all possible complications.

Bone transport induces the release of factors with multi-tissue regenerative potential for diabetic wound healing in rats and patients

Tibial cortex transverse distraction is a surgical method for treating severe diabetic foot ulcers (DFUs), but the underlying mechanism is unclear. We show that antioxidant proteins and small extracellular vesicles (sEVs) with multiple-tissue regenerative potential are released during bone transport (BT) in humans and rats. These vesicles accumulate in diabetic wounds and are enriched with microRNAs (miRNAs) (e.g., miR-494-3p) that have high regenerative activities that improve the circulation of ischemic lower limbs while also promoting neovascularization, fibroblast migration, and nerve fiber regeneration. Deletion of miR-494-3p in rats reduces the beneficial effects of BT on diabetic wounds, while hydrogels containing miR-494-3p and reduced glutathione (GSH) effectively repair them. Importantly, the ginsenoside Rg1 can upregulate miR-494-3p, and a randomized controlled trial verifies that the regimen of oral Rg1 and GSH accelerates wound healing in refractory DFU patients. These findings identify potential functional factors for tissue regeneration and suggest a potential therapy for DFUs.

Synergies of co-infecting pathogens, sea lice (Lepeophetheirus salmonis) and Moritella viscosa, are impacted by exposure order, and host response to initial infection

Sea lice infestations and winter ulcer disease caused by Moritella viscosa are two major challenges for the Atlantic salmon (Salmo salar) aquaculture industry. Despite their common tropisms for the skin/muscle, we know very little about the interaction between these two significant pathogens. The objective of this study was to elucidate the transcriptomic response of Atlantic salmon to sea louse (Lepeophtheirus salmonis) and M. viscosa under single infection and different scenarios of co-infection (i.e., first, L. salmonis and then, M. viscosa and vice versa). After exposure, sampling was performed from the infestation site as well as the adjacent area on fish skin, followed by transcriptome analysis. RNA-seq analysis revealed that infection with either L.salmonis or M. viscosa induced a significant immune response from the skin and resulted in extensive transcriptomic changes. More differentially expressed genes (DEGs) were detected at M. viscosa lesion sites compared to L. salmonis attachment sites. In addition, the effect of the infection order was evaluated. Interestingly, we found that primary infection with lice was associated with a significantly higher number of DEGs during the co-infection process on fish skin compared to the fish first infected with M. viscosa (721 and 5336 DEGs from lice attachment and M. viscosa lesion sites, respectively, vs 291 and 3601 DEGs from lice attachment and M. viscosa lesion sites, respectively). We also found that lice infection caused localized effects on the skin of Atlantic salmon, while single infection with M. viscosa caused a moderate systemic impact and inhibited the tissue repair function of the skin, leading to severe ulceration. In addition, the C-type lectin receptor signaling pathway was drastically activated at the lice attachment sites during both lice alone- and co-infections, regardless of the order of infections, and similar results were observed in M. viscosa infection at both lesion and adjacent sites, indicating that this pathway played an essential role for immunity in Atlantic salmon. A more intense inflammatory and immune response was also observed at M. viscosa lesion sites. These results will promote our understanding of the immune interactions between L. salmonis and M. viscosa during the co-infection process and provide insights for the development of preventive and treatment strategies for these pathogens in salmonid aquaculture.

Prevalence of Peripheral Arterial Disease and Principal Associated Risk Factors in Patients with Type 2 Diabetes Mellitus: The IDON-Peripheral Arterial Disease Study

The principal purpose of this study is to determine the prevalence of peripheral arterial disease (PAD), as well as the principal associated risk factors, in patients registered in the IDON-PAD database. PAD is a condition characterized by the narrowing or blockage of arteries in the body’s extremities due to plaque buildup, leading to reduced blood flow and tissue ischemia. While PAD primarily affects the lower extremities, it can lead to symptoms such as intermittent claudication and, in severe cases, ulcers and amputations. Risk factors for PAD are numerous and cumulative, including smoking, age over 50, type 2 diabetes mellitus, and hypertension. The prevalence of PAD increases with age, with rates ranging from 2.5% in those over 50 to 60% in those over 85, varying by ethnicity and study population. Diabetic patients face a higher risk of PAD-related complications and have lower success rates with revascularization procedures. The diagnosis of PAD traditionally relied on physical examination and symptoms, but the Ankle–Brachial Index is now a standard diagnostic tool due to its non-invasive nature and reliability. In Mexico, the prevalence of PAD is estimated at 10%, with significant risk factors being the duration of diabetes, hypertension, hypertriglyceridemia, and smoking. Notably, 70% of PAD cases are asymptomatic, emphasizing the importance of proactive screening. This study aimed to determine the prevalence of PAD and associated risk factors in diabetic patients aged 40 and above. The prevalence was found to be 11.2%, with high-risk waist circumference, elevated triglycerides, positive Edinburgh questionnaire, and weak pulses as significant predictors. The detection and management of PAD in diabetic patients require a comprehensive approach, including lifestyle modifications and regular screenings. Prevention strategies should focus on controlling risk factors, including obesity, hypertension, and dyslipidemia. In conclusion, PAD is a prevalent yet underdiagnosed condition in diabetic patients, necessitating proactive screening and comprehensive management to mitigate associated risks and improve patient outcomes. The principal limitation of this study is that, as it uses a cross-sectional methodology and is not an experimental study, although we can establish the prevalence of PAD as well as the associated risk factors, we cannot define causality or determine the hazard ratio for each of these factors. Special thanks to Dr. Leobardo Sauque Reyna and all participants for their contribution to this research.

Challenging the angiosome concept: Delineating peripheral arterial disease patterns in diabetic foot ulcers.

The angiosome concept has significantly impacted diabetic foot ulcer management by highlighting the vascular anatomy's role in wound healing. However, its clinical applicability and validity remain debated due to complexities in foot blood supply and ulcer location determination. A cross-sectional study was conducted on 84 individuals with diabetic foot ulcers undergoing lower limb angiography. Demographics, ulcer characteristics, and angiographic data were collected and analyzed using descriptive statistics and relevant tests. Digital subtraction angiography assessed 89 limbs with diabetic foot ulcers; males comprised 54.8%, primarily type 2 diabetes (96.4%), averaging 64.36 ± 10.09 years. Of 129 angiosomes, angiosome 2 (40.3%) had the highest ulcer incidence. Posterior tibial artery (PTA) involvement was predominant (72.9%), while external iliac artery (EIA) and profunda femoris artery (PFA) were least affected (2.4% each). Posterior tibial artery showed 46.5% complete occlusion. Angiosome 2 correlated notably with anterior tibial artery (ATA), peroneal artery (CPA), and PTA, but categorizing angiosomes by supply patterns showed no significant artery correlation (p > .05). The research indicates inconsistent support for below-the-knee artery involvement correlating with foot ulcer locations in angiosomes. While aiding vascular comprehension, the angiosome concept may not fully elucidate lower limb vascular complexities and ulcer genesis. Factors like collateral circulation should be noticed to understanding ulcer localization and severity, extending beyond angiosomal arterial supply.

Management of Dushtavrana (Non-Healing Ulcer) through Ayurveda - A Case Report

Shalyatantra is one among the Astang Ayurveda, the branch of Shalyatantra refers to surgical and parasurgical procedures in Ayurveda. Dusthavrana (non healing ulcer) are a frequently encountered problem in present era produced commonly as a complication of trauma or pathologic insult and it causes long term agony to the patient. The issue of non-healing ulcers management with Ayurvedic remedy is one of the major areas of the research and has come under increased study. This is a case report of 40-year-old female, who had an episode of Dushtavrana (non healing ulcer) and presented to the outpatient department with complaints of severe pain, itching and ulcer over right ankle region. The first line of management for Dushtavrana is Shodhana. Kalka is the specific treatment for Dusthavrana which is mentioned under Shodhana and Ropana Kriya of Saptopakrama. Yavadi Kalka is one of the formulations mentioned in Dwivraniya Chikitsa Adhyaya. Yavadi Kalka is simple, very cost-effective procedure. In the present case, Yavadi Kalka after Jaloukavacharana has shown assuring results in the management of Dushtavrana.

Impact of foot ulcer-related factors on quality of life in patients with diabetes: Prospective observational study.

Quality of life (QOL) may be impacted by foot ulcer-related factors, with prevention of diabetes-related foot ulcers or more effective early healing helping to improve overall patient QOL. This study, which examined the relationship between foot ulcer-related factors and QOL in patients with diabetes, was conducted as a secondary analysis of a prospective observational study entitled: "Factors associated with the discontinuation of wound care specialist clinic visits in patients with diabetic foot ulcers". We investigated EQ-5D-5L, patient characteristics and foot ulcer-related factors of 73 patients with diabetes-related foot ulcers who visited one wound clinic in Indonesia between August 2020 and February 2021. Results showed that the mean health utility was 0.294 ± 0.371. Factors selected for the multiple regression analysis included inflammation/infection of DMIST, first-ever foot ulcer, and size of DMIST. First-ever foot ulcer (β = 0.309, p = 0.003) and size of DMIST (β = -0.316, p = 0.015) were significantly associated with the health utility (p < 0.001). Significant improvement in the health utility of 15 patients was observed when the ulcer healed (Wilcoxon signed-rank sum test, p = 0.001). In conclusion, not only ulcer severity but also the first-ever foot ulcer itself affected the QOL in patients with diabetes. These results suggest there will be a greater impact on the QOL of patients who develop diabetes-related foot ulcers for the first time, along with the importance of prevention and early healing, through early infection control and wound size reduction.

Tibial Cortex Transverse Transport Facilitates Severe Diabetic Foot Wound Healing via HIF-1α-Induced Angiogenesis.

Management of severe diabetic foot ulcers (DFUs) remains challenging. Tibial cortex transverse transport (TTT) facilitates healing and limb salvage in patients with recalcitrant DFUs. However, the underlying mechanism is largely unknown, necessitating the establishment of an animal model and mechanism exploration. Severe DFUs were induced in rats, then assigned to TTT, sham, or control groups (n=16/group). The TTT group underwent a tibial corticotomy, with 6 days each of medial and lateral transport; the sham group had a corticotomy without transport. Ulcer healing was assessed through Laser Doppler, CT angiography, histology, and immunohistochemistry. Serum HIF-1α, PDGF-BB, SDF-1, and VEGF levels were measured by ELISA. The TTT group showed lower percentages of wound area, higher dermis thickness (all p < 0.001 expect for p = 0.001 for TTT vs Sham at day 6) and percentage of collagen content (all p < 0.001) than the other two groups. The TTT group had higher perfusion and vessel volume in the hindlimb (all p < 0.001). The number of CD31+ cells (all p < 0.001) and VEGFR2+ cells (at day 6, TTT vs Control, p = 0.001, TTT vs Sham, p = 0.006; at day 12, TTT vs Control, p = 0.003, TTT vs Sham, p = 0.01) were higher in the TTT group. The activity of HIF-1α, PDGF-BB, and SDF-1 was increased in the TTT group (all p < 0.001 except for SDF-1 at day 12, TTT vs Sham, p = 0.005). The TTT group had higher levels of HIF-1α, PDGF-BB, SDF-1, and VEGF in serum than the other groups (all p < 0.001). TTT enhanced neovascularization and perfusion at the hindlimb and accelerated healing of the severe DFUs. The underlying mechanism is related to HIF-1α-induced angiogenesis.

Oral bacteria may affect conjunctival microorganisms in brachycephalic dogs: a preliminary study.

To evaluate the prevalence of oral bacteria in the conjunctiva of brachycephalic and nonbrachycephalic dogs. 12 brachycephalic (9.58 ± 3.55 years) and 12 nonbrachycephalic (8.33 ± 4.92 years) dogs without systemic disease, regardless of breed and sex, were included in the study, and half of the dogs in each group had periodontitis. This prospective study investigated clinical data including craniofacial ratio, ophthalmic examination results, and periodontal status of the included dogs. Bacterial samples were collected by swabbing the oral mucosa and conjunctival surfaces. The presence and quantity of bacteria were analyzed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, 16S rRNA sequencing analysis, and the 10-fold dilution method. Statistical analyses were performed to assess correlations and factors influencing the presence of oral bacteria in the conjunctiva. The most common bacteria in the conjunctival flora in both groups were Micrococcus luteus, Corynebacterium spp, and Staphylococcus spp. The prevalence of oral bacteria on the conjunctival surface was 33%, with a significantly higher incidence in brachycephalic dogs (P = .027). Oral bacteria detected in the conjunctiva were predominantly Frederiksenia canicola, Neisseria spp, and Moraxella spp. Multiple regression analysis identified age, craniofacial ratio, and gingival index as factors influencing the presence of oral bacteria in the conjunctival flora. Oral resident bacteria have often been isolated from severe infectious corneal ulcers. This study provided evidence that brachycephalic dogs may require dental prophylaxis to reduce their oral bacterial load and that the association of oral bacteria in ocular diseases should be considered.

Laparoscopic management of benign gastric outlet obstruction: a case series with review of literature

Surgery for peptic ulcer disease has since long become a thing of the past, in the era of proton pump inhibitors. Today, it is difficult to believe that these were common operations about 6-7 decades ago. Such has been the impact of proton pump inhibitors (PPI), that, surgery for peptic ulcer has been relegated to the realms of history. However, even in present day, in some rare clinical situations, surgeons may have to resort to surgery for patients suffering from peptic ulcer disease. Herein, we present our experience of laparoscopic surgical management of one of those rare clinical scenarios related to severe peptic ulcer disease. The clinical condition in discussion is gastric outlet obstruction caused by severe peptic ulcer disease in the first part of duodenum. We identified 8 patients (7 males and 1 female) who underwent laparoscopic vagotomy with gastrojejunostomy for benign gastric outlet obstruction, at our institution, operated upon by a single surgeon, between 2004 to 2023. All patients had undergone oesophago-gastro-duodenoscopy (OGD scopy), and contrast enhanced computerised tomography (CECT) of the abdomen. The patients were analysed for age, sex, symptoms, pre-operative evaluation, morbidity/mortality and functional outcomes. They were also reviewed to examine the length of stay, length of procedure, complications and recurrent symptoms on follow-up.