chondroitin-sulfates and Diabetic-Foot

Skin substitutes are frequently used to treat chronic diabetic foot ulcers (DFU), and many different options are available. While the clinical efficacy of many products has been evaluated, a comprehensive cost-effectiveness analysis comparing the most popular skin substitutes and using the most recent cost data has been lacking.. This study compared eight skin substitutes using published efficacy rates combined with the Centers for Medicare and Medicaid Services (CMS) 2018 cost data. The study criteria resulted in the inclusion of seven studies that described efficacy rates for treatment of DFUs using the skin substitutes.. The results revealed wide discrepancies between these skin substitutes for the costs of treatments and healing rates in hospital outpatient departments and physician office settings. Healing rates for 12 and 16 weeks ranged from 28% to 68%, while the average cost for treating one DFU varied from $2001 to $14,507 and $1207 to $8791 in the hospital outpatient department and physician's office setting, respectively. The estimated patient share of costs for treating a single DFU ranged from $400 to $2901 and $241 to $1758 in the hospital outpatient department and physician's office setting, respectively. Most importantly, the estimated number of wounds healed out of 100 DFUs per $1000 expenditure with each patient ranged from 3.9-26.5 DFUs in the hospital outpatient department, and 4.3-36.4 DFUs in the physicians' office setting.. This study revealed that the costs of a skin substitute itself did not necessarily correlate with its healing efficacy. These results provide a comprehensive cost-effectiveness analysis to enable integrated health-care systems, health professionals and reimbursement payers to make informed value decisions when treating DFUs.

Topics: Ambulatory Care; Ambulatory Care Facilities; Biological Dressings; Chondroitin Sulfates; Collagen; Cost-Benefit Analysis; Diabetic Foot; Health Expenditures; Humans; Outpatient Clinics, Hospital; Quality-Adjusted Life Years; Skin, Artificial; Wound Healing

Chronic wounds such as diabetic foot wounds are a tremendous burden to the health care system and often require a multidisciplinary approach to prevent amputations. Advanced technologies such as negative pressure wound therapy (NPWT) and bioengineered tissues have been successfully used in the treatment of these types of complex wounds. However, the introduction of NPWT with instillation (NPWTi) has provided an alternative treatment for treating complex and difficult-to-heal wounds. This article provides an overview of NPWT and the new NPWTi system and describes preliminary experience using NPWTi on patients with complicated infected diabetic foot wounds after surgical debridement and in a multidisciplinary setting.

Topics: Anti-Bacterial Agents; Biguanides; Chondroitin Sulfates; Collagen; Debridement; Diabetic Foot; Granulation Tissue; Humans; Negative-Pressure Wound Therapy; Skin, Artificial; Therapeutic Irrigation; Wound Healing; Wound Infection

In diabetic patients, wound healing is impaired. We studied the pathogenesis behind this clinical observation by characterizing the pattern of deposition of extracellular matrix (ECM) molecules and the cellular infiltrate in chronic (>8 wk) diabetic wounds, compared with chronic venous ulcers and an acute wound healing model. Punch biopsies were obtained from the chronic ulcer margins and control samples were collected from upper leg skin 5, 19, 28 d and 12 and 18 mo postwounding (p.w.). T cells, B cells, plasma cells, granulocytes and macrophages, and the ECM molecules fibronectin (FN), chondroitin sulfate (CS), and tenascin (TN) were visualized using immunohistochemical techniques. Expression of FN, CS, and TN was detected in dermal tissue early in normal wound healing (5-19 d p.w.). Abundant staining was seen 3 mo p.w., returning to prewounding levels after 12-18 mo p.w. In the dermis of chronic diabetic and venous ulcers with a duration of 12 mo or more, a prolonged presence of these ECM molecules was noted. Compared with normal wound healing: (i) the CD4/CD8 ratio in chronic wounds was significantly lower (p < 0.0027) due to a relatively lower number of CD4+ T cells; (ii) a significantly higher number of macrophages was present in the edge of both type of chronic ulcers (p < 0.001 versus day 29 p.w.); and (iii) more B cells and plasma cells were detected in both type of chronic wounds compared with any day in the acute wound healing model (p < 0.04 for CD20+ and p < 0.01 for CD79a+ cells). These data indicate that important differences exist in the cellular infiltrate and ECM expression patterns of acute, healing versus chronic wounds, which may be related to the nonhealing status of chronic wounds.

Topics: Acute Disease; Adult; Aged; Basement Membrane; CD4-CD8 Ratio; CD8-Positive T-Lymphocytes; Cell Count; Chondroitin Sulfates; Chronic Disease; Diabetes Mellitus, Type 1; Diabetic Foot; Extracellular Matrix; Female; Fibronectins; Granulocytes; Humans; Lymphocytes; Macrophages; Male; Middle Aged; Tenascin; Varicose Ulcer; Wound Healing; Wounds and Injuries

Diabetic foot ulcers may lead to nontraumatic amputations of the foot, leading to a decrease in patient quality of life. Transmetatarsal amputations (TMAs) represent an effective surgical procedure in cases of severe foot infection, but the tissue reconstruction is complicated and additional procedures should be considered. The present case report evaluates the wound closure of an open TMA in a patient with diabetes treated with a new aerogel composed of chitosan (ChS) and chondroitin sulphate (CS), without needing a skin graft.. A 72-year-old man with diabetes and a history of successive amputations was admitted to a hospital in Valdivia, Chile, due to a severe infection of toes 2 and 4 of the right foot. After the diagnosis of gangrene and osteomyelitis, the patient underwent a TMA of his right forefoot. The surgeon proposed the incorporation of ChS and CS aerogels to accelerate wound healing to avoid another surgical procedure. The TMA surgical wound area closed 50% after day 28 from starting treatment with aerogels. Complete closure was achieved at day 94 of treatment with aerogels, with good epithelial tissue and favorable cosmetic results and without residual limb deformities. The patient experienced minimal physical and psychological impairment from the procedure. Other surgical procedures were not necessary.. Due to the results of this patient, use of ChS and CS aerogels could represent an alternative treatment for forefoot TMA wound closure and prevent further surgical procedures, such as skin grafting. Future works should consider a larger number of cases.

Topics: Aged; Amputation, Surgical; Chitosan; Chondroitin Sulfates; Diabetes Mellitus, Type 2; Diabetic Foot; Gangrene; Gels; Humans; Male; Metatarsus; Osteomyelitis; Wound Healing

Topics: Accidents, Traffic; Adult; Aged, 80 and over; Burns; Cellulitis; Chondroitin Sulfates; Collagen; Debridement; Diabetic Foot; Elastin; Female; Foot Injuries; Humans; Leg Injuries; Male; Middle Aged; Necrosis; Skin, Artificial

Creative surgical strategies are often warranted for long-term closure of diabetic foot wounds. This article provides a case report describing the successive use of negative pressure wound therapy, advanced biologics, and split thickness skin grafting for healing an extensive surgical wound. Although the success of these therapies is enticing, their use should be based on careful patient selection in a multidisciplinary setting.

Topics: Biological Dressings; Chondroitin Sulfates; Collagen; Combined Modality Therapy; Diabetic Foot; Humans; Male; Middle Aged; Negative-Pressure Wound Therapy; Skin Transplantation; Soft Tissue Infections; Wound Closure Techniques; Wound Healing

The diabetic foot ulcer presents a therapeutic challenge with a high rate of limb infection and extremity amputation. Adequate debridement and stable coverage of exposed structures are paramount to preserving limb length. The authors reviewed their use of a collagen bilayer matrix in the diabetic population for the preservation of functional limb length. Salvage rates were stratified with patient comorbidities of severe peripheral arterial disease and/or persistent infection.. A retrospective review was performed of all consecutive patients who underwent application of Integra by the senior authors (J.S.S., C.E.A.) for lower extremity salvage between January of 2004 and December of 2008.. A total of 105 patients with 121 separate wounds were analyzed. Patient age ranged from 22 to 80 years (mean, 58 years). The average wound size was 25.9 cm2 in the diabetic population. Average follow-up was 325 days, and average number of operations before closure was 1.28. In the diabetic population, of the 59 patients identified as low risk for amputation, 10 (17 percent) progressed to amputation. Of the 28 patients identified as high risk for amputation, 15 (54 percent) progressed to amputation. In the nondiabetics, 31 patients were classified as low risk for amputation, and one (3 percent) went on to an amputation.. Use of a collagen bilayer matrix appears to be a viable option for reconstruction and stable closure in the diabetic patient at low risk for amputation, with risk based on available blood supply and evidence of infection. In the diabetic patient at high risk for amputation, however, the rate of salvage may not be improved with the use of Integra.

Topics: Adult; Aged; Aged, 80 and over; Amputation, Surgical; Chondroitin Sulfates; Collagen; Debridement; Diabetic Foot; Humans; Infections; Limb Salvage; Male; Middle Aged; Peripheral Arterial Disease; Retrospective Studies; Risk Factors; Young Adult

Topics: Amputation, Surgical; Burns; Chondroitin Sulfates; Collagen; Dermatologic Surgical Procedures; Diabetic Foot; Female; Humans; Limb Salvage; Male; Plastic Surgery Procedures; Skin; Skin, Artificial

In this study, we evaluated the utility of a dermal substitute for preserving maximal foot length after urgent surgical debridement. Patients referred to our Diabetic Foot Center with foot lesions were assessed for sensory-motor neuropathy, infection and critical limb ischaemia. The presence of acute foot infection indicated the need for immediate surgical debridement. The degree of amputation, if necessary, was based on the amount of apparently non infected vital tissue. When vital tendon/bone tissue remained exposed, the lesion was covered with a dermal substitute. From January to December 2008, 393 patients underwent surgical treatment for diabetic foot syndrome; 30 patients underwent immediate surgical debridement resulting in exposed tendon and/or bone tissues. An average of 4.4 +/- 2.1 days following surgical debridement, all 30 patients underwent dermal regeneration template grafting to cover-exposed healthy tendon and bone tissues, instead of achieving primary wound closure with a proximal amputation. After 21 days, a skin graft was performed. Complete wound healing occurred in 26 patients (86.7%). In these patients, the amputation level was significantly more distal (P < 0.003) with respect to that potentially required for immediate wound closure. The average healing time was 74.1 +/- 28.9 days. Four patients underwent a more proximal amputation. No patients underwent major amputation. The use of the dermal substitute for treating exposed tendon and bone tissues allowed timely wound healing and preserved maximal foot length. Continued follow-up will allow assessment of long-term relapse and complication rates. Such treatment could constitute part of the comprehensive management of diabetic wounds.

Topics: Acute Disease; Aged; Amputation, Surgical; Bacterial Infections; Chi-Square Distribution; Chondroitin Sulfates; Collagen; Debridement; Diabetic Foot; Emergencies; Female; Humans; Male; Retrospective Studies; Shoes; Skin Transplantation; Time Factors; Treatment Outcome; Wound Healing; Wound Infection

We have studied the growth kinetics of fibroblasts derived from uninjured skin and chronic wounds in non-diabetic and diabetic (IDDM) patients. DNA measurements during the first 24 h after cell starvation showed that fibroblasts derived from chronic wounds, both non-diabetic and diabetic, display a decreased adhesion and proliferation. When determining the rate of proliferation after another 48, 72 and 96 h, a significant decrease in the proliferation rate was found in the chronic wound fibroblasts compared to those from uninjured skin. Furthermore, we have investigated the effects of heparin, hyaluronic acid and other heparin-like substances on the proliferation of non-diabetic and diabetic fibroblasts. We found that these substances stimulated the proliferation of human fibroblasts derived from both normal skin and chronic wounds measured as DNA content. Stimulation with heparin normalized the proliferation of the diabetic chronic wound fibroblasts. This effect was independent of the presence of serum. The effect of heparin was dose-dependent and most pronounced during the first 24 h of stimulation. These results suggest that heparin may be of importance in the treatment of chronic diabetic wounds.

Topics: Anticoagulants; Cell Count; Cell Division; Chondroitin Sulfates; Diabetes Mellitus, Type 1; Diabetic Foot; DNA; Fibroblasts; Heparin; Humans; Hyaluronic Acid; Skin; Time Factors