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By Temple University School of Podiatric Medicine Journal Review Club

Hard-to-heal wounds, such as diabetic foot ulcers, pressure injuries, and venous leg ulcers, comprise a significant portion of health care visits, and these wounds place a physical and economic burden on many patients. These hard-to-heal wounds are defined as wounds with stagnant or delayed stages of healing that fail to resolve within eight weeks. Finding ways to accelerate this healing process is of great importance because it can reduce the physical and economic burden on patients, as well as decreasing costs for health care facilities. Matrix metalloproteinases (MMPs) are endopeptidases, which are involved in many healing processes, including the cell signaling processes, migration processes, angiogenesis, and the degradation of extracellular proteins. These mechanisms are necessary for the wound healing process by breaking down damaged tissue. In the late stages of healing, when breaking down of tissue is no longer necessary, tissue inhibitors of metalloproteinases down-regulate MMPs. In hard-to-heal wounds, this process is thrown off balance, with delays in the subsequent stages of healing. In an attempt to restore this balance, MMPs have been investigated for their role in wound healing through MMP-inhibiting wound dressings. There have been a number of consequential reviews done using current market wound dressings, such as oxidized regenerated cellulose/collagen and Technology Lipido-Colloid with nano-oligosaccharide factor (TLC-NOSF).

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By Temple University School of Podiatric Medicine Journal Review Club

Chronic wounds require an increased amount of oxygen to help with cellular function and growth. They often manifest with biofilm, slough, and necrotic tissue, all of which deprive cells of the oxygen they need to perform vital functions. Various forms of debridement are commonly employed to rid wounds of pathological tissues that negatively affect cellular communication and growth. Sharp surgical debridement is most frequently performed by physicians. Continuous diffusion of oxygen (CDO) involves the use of humidified, purified air at 3mL/hour in conjunction with moist wound therapy (MWT) dressing. A previous paper by Niederauer et al. published in 2018 in the Journal of Wound Care, described using CDO for healing DFUs. This study showed that CDO improved the healing rate of DFUs in terms of time, chronicity, and weight-bearing ability when compared to a placebo. Additionally, the previous paper described wound size, chronicity, and adverse events.

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By Temple University School of Podiatric Medicine Journal Review Club

One of the most severe complications of the diabetic foot is diabetic osteomyelitis. The diagnosis of diabetic foot osteomyelitis requires clinical suspicion of infection, and an associated soft tissue infection only increases the likelihood of confirming diabetic foot osteomyelitis. That said, there are still challenges in the diagnosis of osteomyelitis, such as a bone infection without the clinical manifestations of infection. This occurs in approximately half of all hard-to-heal osteomyelitis cases. Currently, the tests used to confirm a diagnosis of diabetic foot osteomyelitis include a probe-to-bone test, radiography, magnetic resonance imaging (MRI), and bone biopsy. Laboratory tests are also used to confirm the diagnosis of diabetic foot osteomyelitis, with the most important biomarker being erythrocyte sedimentation rate (ESR).

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By Temple University School of Podiatric Medicine Journal Review Club

Chronic diabetic foot ulcers affect approximately 13% of the United States population. Chronic diabetic foot ulcers, or DFU, are defined by the authors as, “nonhealing ulcers of the foot lasting more than 3 months’ duration in patients with diabetes”. It is critical to treat DFUs effectively and timely, as ulcers may progress to the point of requiring an amputation. Patients suffering from a DFU may have an amputation rate of 21.5% to 28.4%.

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By Temple University School of Podiatric Medicine Journal Review Club

An appropriate timeline to initiate biofilm-based wound care (BBWC) has been a topic of question since the incorporation of biofilm therapy was introduced. In hard-to-heal delayed wounds, it is largely agreed upon that biofilms are a significant barrier to healing, and that removal is essential. By definition, hard-to-heal wounds are wounds that have failed to respond to evidence-based standard of care and contain biofilm. Biofilms are polymicrobial communities residing in an extracellular matrix produced by bacteria, which is well-hydrated and resistant against antimicrobial agents and host defenses. Biofilm can form within hours, can reach maturity within 48-72 hours, and has the ability to regrow within 24-48 hours. A first critical step to BBWC is debridement, though it requires additional suppression methods, as well as considerations of a patient’s risk factors. Risk factors include peripheral vascular disease, infection, diabetes, and pressure off-loading, which encourage biofilm development by delaying wound healing. Risks and costs with early BBWC are most likely less than those associated with biofilm-related wound complications. Thus, in March 2019, a panel of nine experts met in London for an Advisory Board Meeting, where they developed solutions to barriers preventing early BBWC and methods of appropriate “wound hygiene” for all health professionals. They reconvened in the summer of 2019 to create a clinical consensus document published in the Journal of Wound Care supported by ConvaTec Limited.

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By Temple University School of Podiatric Medicine Journal Review Club

Venous leg ulcerations (VLUs) are a common and often chronic pathology, and these wounds diminish the quality of life and increase the financial burden for affected patients. A recent article estimates that up to 3% of the U.S. population suffer from VLUs. A venous leg ulcer can be severely painful and may decrease a patient’s quality of life by affecting sleep, mobility, activities of daily living, and even result in social isolation. A 1994 paper proposed that approximately 65% of patients felt financially affected by a VLU, and this number is likely to have increased as a result of rising healthcare costs. The prevalence and chronic nature of the venous leg ulceration has motivated physicians to research novel techniques to heal ulcers successfully and in a timely manner.
Acellular dermal matrices have been utilized to treat diabetic foot ulcers with favorable outcomes.4 This study investigated the efficacy of a specific acellular dermal matrix for VLUs.

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By Temple University School of Podiatric Medicine Journal Review Club

The advancement of technology and the introduction of the World Wide Web have allowed information to be a click of a button away for health care providers as well as patients. This advancement led to the demand and production of portal devices such as smartphones, which transformed many aspects of society today, including health care. Today, smartphone applications may aid health care providers in drug reference, diagnosis, treatment, literature search, and even medical training. In 2009, an estimated 6.5 million patients had chronic wounds and spent more than $25 billion dollars on wound care. In addition, rising costs of wound management have suggested the need for the use of mobile applications in treatment of wound care patients.

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Mesenchymal stem cells to heal diabetic foot ulcers

By Temple University School of Podiatric Medicine Journal Review Club

Article Title: Mesenchymal Stem Cells Improve Healing of Diabetic Foot Ulcer
Authors: Cao Y, Gang X, Wang G
Journal: J Diabetes Res. 2017;2017:9328347.
Reviewed by: Sai Vemula, class of 2020, Temple University School of Podiatric Medicine

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Temple University School of Podiatric Medicine Journal Review Club

Delayed healing in diabetic foot ulcers (DFUs) is the result of the polymicrobial structures of DFUs and the buildup of biofilms. Wound debridement is an essential part of wound bed preparation (WBP) that helps to remove bacteria and allow the body to continue the healing process. Although sharp debridement is the most common technique used for DFUs, it has many limitations, including contraindications in patients with poor vascular status, the need for an operating room, and the requirement for specific surgeon skills. There is also the potential for extensive damage to the wound bed with exposed bone because of obstruction of the view from biofilm formation. The use of an ultrasound-assisted wound (UAW) debridement device aims to disrupt the formation of biofilms and stimulate wound granulation, thus allowing for the wound to have a healthy environment in which to heal. This study evaluated the clinical and microbiological impact of using UAW debridement devices in individuals with neuroischemic DFUs.

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Temple University School of Podiatric Medicine Journal Review Club

Article Title: Efficacy of Cadexomer Iodine in the Treatment of Chronic Ulcers: A Randomized, Multicenter, Controlled Trial
Authors: Radhakkrishnan R, Kethavath SN, Sangavarapu SM, Kanjarla P, Dexadine Study Group
Journal: Wounds. 2019;31(3):85-90
Reviewed by: Elizabeth Connolly, class of 2021, Temple University School of Podiatric Medicine

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