The International Journal of Lower Extremity Wounds

Bibliometric analysis represents a new tool for classifying and quantitatively assessing bibliographic material (publications, citations, authors, institutions, etc) of a scientific discipline. Is a computer-assisted review and, therefore, it should follow the methodology of a systematic review. These analyses download bibliographic data from electronic databases analyzing them and extracting several indicators (such as the h-index). Analysis can be enhanced by adding scientific maps using specific software. These analyses are increasingly accepted in the medical literature to identify the most influential papers/authors/institutions on a given topic. During the last decade, there is a remarkable increase in the number of published bibliometric analysis articles.

Randomized controlled trials represent the cornerstone for the regulatory approval of drugs and evidence-based medicine and policy. Compared with observational studies random assignment of participants to each study arm guarantees an equal distribution of potential confounders thus achieving impartiality in the evaluation of between group differences and allowing for causal inferences to be drawn. These complex and costly medical experiments are tightly regulated and require substantial planning with great attention to several methodological aspects ranging from allocation concealment and blinding to sample size estimation, statistical analysis, and handling of protocol deviations. This brief guide offers useful insights into the design, conduct, and interpretation of clinical trial findings for beginners.

Diabetic foot ulcers (DFUs) are common complications of diabetes mellitus that affect patients’ quality of life and pose a burden on the healthcare system. Although malnutrition and specific nutritional deficiencies can seriously impact wound healing in patients with chronic nonhealing wounds, the role of nutrition in the prevention and management of DFUs is still not clear. This review discusses the significance of frequent diet assessment and nutritional education of patients with DFUs with individualized correction of deficiencies and emphasis on adequate protein intake along with correction of vitamins D, C, E, and selenium status. Future research should clarify the impact of nutritional interventions, potentially involving the use of probiotics, zinc, and omega-3 fatty acids, and successfully translating the findings into practical guidelines for use in everyday clinical practice.

Few studies to date have investigated the role of adipose derived stem cells (ADSCs) in patients with diabetic foot ulcers (DFU). We aimed to conduct a systematic search of the literature to explore the available evidence behind ADSCs application in patients with DFU to establish if it has any added benefit regarding healing rate and healing time in this cohort of patients. The PubMed and Embase databases were searched for eligible studies. Only randomised controlled trials which investigated the impact of ADSCs alone on the healing of DFU were considered eligible and were included for the review. Reported healing rates, time to healing and procedure related complications were collected and analysed. The initial search resulted in 160 papers. Following duplicate removal, 131 papers were screened for eligibility. Only four trials met the study criteria and were included for the final review and analysis. 97 out of 189 patients who were included in the four studies received ADSCs for treatment of DFU whereas the remaining 92 patients received standard measures (control). The median participant age was 62, predominantly male (72.5%). Complete healing was achieved in 83.5% (n  =  81) of patients in the ADSC group compared to 52% (n  =  48) for patients in the control group at 12 months (OR = 4.8, 95%CI  =  2.25 to 10.24, P < 0.0001). Mean healing time in the ADSC group ranged from 31 to 85 days whereas mean healing time in the control group ranged from 42 to 85 days (Pooled weighted mean difference  =  -10.832856, 95%CI  =  -22.44 to 0.77, P  =  0.0673). No significant procedure related complications were reported in either group. The use of ADSCs in patients with DFU appears to demonstrate improved healing rates. The procedure of ADSC harvest and administration appears to be safe based on the initial reports. Large, randomised trials are needed to establish its role in patients with diabetic foot wounds.

The present descriptive study investigates the general and foot-care self-efficacy and the level of foot-care knowledge of 151 participants who presented to the internal medicine ward and diabetes nursing unit of a training and research hospital in Türkiye. The mean Diabetes Management Self-Efficacy Scale score of the participants was 69.0 ± 15.0 (min: 20, max: 100), the mean Diabetic Foot Care Self-Efficacy Scale score was 56.2 ± 23.1 (min: 9, max: 90) and the mean Diabetes Foot Self-Care Behavior Scale score was 51.5 ± 13.6 (min: 15, max: 75). The total Diabetes Management Self-Efficacy Scale, Diabetic Foot Care Self-Efficacy Scale and Diabetes Foot Self-Care Behavior Scale scores were noted to be higher in the participants who underwent regular health check-ups and used their medication regularly than in those who did not (p < 0.05). People with diabetes should be provided with counseling on the benefits of developing positive behaviors related to self-efficacy and foot self-care, and the prevention of wound development through education, support and the effective self-management of their condition.

Pythiosis is an infectious disease in humans and animals caused by an aquatic fungus-like micro-organism, Pythium insidiosum. Vascular pythiosis is a difficult condition to treat and can lead to loss of limb in addition to being a potentially life-threatening infection. The condition is furthermore unfamiliar among healthcare workers, which often results in delayed treatment or even misdiagnosis. In this study, we report our findings, which have been gathered over a 20-year period in caring for vascular pythiosis in Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand. We made a retrospective medical review of 32 patients presented with arterial occlusion who have serum anti-Pythium insidiosum antibodies. All patients underwent computed tomography angiography to confirm the level of arterial occlusion and decided on a treatment plan. Twelve out of 22 patients with infrainguinal disease, femoropopliteal or below-knee vascular occlusion, survived. The mean survival time is 6.58 years. Eight in 10 patients presented with suprainguinal disease died during the follow-up with a mean survival time of 31.6 months. The suprainguinal extension of the disease influenced the outcome, resulting in a higher mortality rate. However, patients presented with chronic limb ischemia had a much greater rate of survival compared to other clinical presentations. Extensive surgical resection combined with antifungal treatment and immunotherapy have proven to be effective in patients with vascular pythiosis in our findings.

The optimal method for assessing residual osteomyelitis after conservative surgery for diabetic foot infection remains controversial. Microbiological cultures are frequently used due to their rapid turnaround and utility in guiding antibiotic therapy, but their diagnostic reliability is uncertain. This study compared microbiological cultures and histopathology in evaluating bone resection margins, using histopathology as the gold standard. We included 93 patients undergoing conservative surgery for diabetic foot osteomyelitis. Bone samples were obtained from the proximal resection margin for both microbiology and histopathology. A microbiological result was considered contamination when cultures were positive but histopathology was negative. Microbiological cultures at bone resection margins yielded 52 true positives, 23 false positives (contamination), 10 false negatives, and 8 true negatives when compared to histopathology. This resulted in a sensitivity of 83.9%, specificity of 25.8%, positive predictive value of 69.3%, and negative predictive value of 44.4%. Contamination was not associated with the severity of infection, presence of soft tissue involvement, inflammatory markers, or glycemic control. No association was found between contamination and polymicrobial flora in the primary surgical specimen. However, Pseudomonas aeruginosa was the only species significantly associated with contamination (p = .008), suggesting species-specific factors may contribute to microbiological false positives. These findings emphasize that microbiology, while sensitive, is not a specific method for assessing residual bone infection and should not be used in isolation. Histopathology remains the more reliable diagnostic tool. Future research should explore biofilm-targeted strategies and intraoperative antiseptic protocols to reduce contamination of bone biopsy specimens obtained from resection margins.

Diabetic foot (DF) is a significant complication with high morbidity and mortality, often resulting from neuropathy and ischemia. In our study, we aimed to evaluate the relationship between serum Gremlin-1 levels and disease severity based on the Wagner classification in DF patients, and to determine its prognostic value in predicting the need for amputation.

Eighty-five patients with DF ulcers or considered at high risk for DF were included in the study. The patients’ complications were evaluated, and laboratory results were obtained from their records. The Wagner classification was applied, and serum Gremlin-1 levels were analyzed using the ELISA method.

It was found that as the Wagner stage of the DF increased, Gremlin-1 levels decreased significantly at the statistical borderline (p = 0.05). In the group of patients who underwent amputation, Gremlin-1 levels decreased significantly (p < 0.05). The sensitivity of Gremlin-1 in predicting amputation, with a cut-off value of 2.47 ng/ml, was 67%, and its specificity was 46%. Additionally, a positive correlation was found between total cholesterol, LDL, fasting glucose, and Gremlin-1 (p < 0.05). In the group of patients with an HbA1c value >7.5%, Gremlin-1 levels increased significantly (p < 0.05). In patients with albuminuria, serum Gremlin-1 levels decreased significantly (p < 0.05).

It was determined that Gremlin-1 plays a role through an unknown mechanism in DF patients, and its levels decrease as the Wagner stage increases. Gremlin-1 levels were significantly decreased in the amputation group (p < 0.05). It was shown that Gremlin-1 could be a prognostic marker for predicting amputation.

The current study aimed to evaluate the clinical outcomes of patients admitted for diabetic foot ulcers (DFUs) located in the heel. The study is a retrospective observational study including a population of patients admitted for DFUs from April 2024 to September 2024. According to the wound location, patients were divided in two groups: those with heel ulcers and those with forefoot/midfoot ulcers without calcaneal involvement. All patients have been managed through a limb salvage protocol in the respect of international guidelines. The following hospital outcomes were evaluated: minor and major amputation, mortality, length of stay, need for regenerative surgery by using dermal-epidermal graft. Overall, 150 patients were included. The mean age was 70.2 ± 12.2 years, most patients were male (76.0%), had type 2 diabetes (92.7%) with a mean duration of 22.1±13.2 years; 27 (18%) patients had heel ulcers, while 123 (82%) had forefoot/midfoot lesions. Outcomes for patients with heel location and without were: minor amputation (18.5 vs 32.5%, p = 0.1), major amputation (7.4 vs 0.8%, p = 0.02), mortality (0 vs 0.8%, p = 0.5), length of hospital stay (17.5 ± 8.5 vs 14.4 ± 8.7 days, p = 0.08), need for regenerative therapy using dermal-epidermal substitutes (48.1 vs 19.5%, p = 0.003) respectively. In addition, heel ulcer was found to be an independent predictor for major amputation [OR 5.06, CI95% (3.1–11.4), p = 0.02] and length of stay [OR 6 CI95% (3.6–10.9), p = 0.003]. In patients admitted for DFUs, wounds located in the heel were associated to an increased risk of major amputation, need for regenerative therapy and length of stay (even though in the limit of statistical difference) than wounds not located in the heel. These data underline the need for tailored management strategies in this high-risk subgroup of patients.

Diabetic foot ulcer (DFU) is a common complication of diabetes. It is often accompanied by infection and, in severe cases, necessitates amputation. Early diagnosis and monitoring are crucial for improving prognosis. Novel inflammatory biomarkers, such as the systemic inflammatory response index (SIRI), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) are useful for the diagnosis and predicting prognosis of some diseases. This study aimed to clarify the association between SIRI, NLR, PLR and DFU and assess their utility for early diagnosis and monitoring of DFU. Cross-sectional data were extracted on individuals with diabetes who participated in the National Health and Nutrition Examination Survey (NHANES) between 1999 to 2004. DFU was diagnosed based on the presence of foot ulcers that had not healed within 4 weeks. Weighted multivariable regression, subgroup analysis, and smooth curve fitting were used to evaluate the relationships between the SIRI, NLR, and PLR with DFU.A total of 1204 participants were included in the analysis, of whom 112 had DFUs. Participants with DFUs had higher NLR, PLR, and SIRI values than those without DFUs. For each unit increase in SIRI, the prevalence of DFU increased by 27% . Subgroup analyses showed a consistent association between an elevated SIRI and the prevalence of DFUs.SIRI is a low-cost, readily accessible biomarker that can be used in conjunction with NLR and PLR to assess the severity and predict the prognosis of DFU. Continuous monitoring of these indicators could assist with early diagnosis and management of DFU.

The aim of study was to confirm the hypothesis that advanced medial arterial calcification (MAC)/ small artery disease (SAD), much like the progression of peripheral arterial disease (PAD) stages can adversely impact the outcomes in DFU patients, even after successful endovascular procedures. In retrospective study, we enrolled 54 patients with DFUs who underwent percutaneous transluminal angioplasty (PTA). MAC was quantified using a three-level scoring system based on radiographs. Patients were categorized based on their MAC score into three groups. Study groups were compared in terms of primary DFU outcomes (healing, amputations) and secondary DFU outcomes (mortality, changes in transcutaneous oxygen pressure (TcPO2)) three and six months after PTA. The MAC/SAD score increased significantly with age (p = 0.014). The MAC/SAD score was't associated with the risk of amputation or the healing of DFUs up to three months after revascularization. However, a significant association was observed after six months (p = 0.043). The MAC/SAD score correlated significantly with severity of PAD, as classified by the Global Limb Anatomic Staging System (p = 0.042) and the Graziani system (p = 0.019). We found a negative correlation between the MAC/SAD score and absolute levels of TcPO2 after PTA. MAC/SAD score was significantly associated with long-term unhealed DFUs and the risk of lower limb amputations.

Venous leg ulcers (VLUs) cause a significant health care burden due to high health care costs, prolonged treatment, and high recurrence. Our study aims to compare between retrograde venous perfusion (RVP) combined with conventional therapy versus conventional therapy for treatment of chronic VLUs with regard to safety and efficacy. Drugs used for RVP were prostaglandin E1 (alprostadil), calcium heparin, hydrocortisone, pheniramine maleate, and lidocaine. This was a randomized controlled study conducted on 60 patients with chronic VLUs from June 2023 to June 2024. Patients were divided into two groups: RVP with conventional therapy versus conventional therapy only. Outcomes included the rate of complete ulcer closure and the percentage of healing at 6 months, ulcer-related complications, and recurrence rates. At 6 months, the RVP with conventional therapy group had a significantly higher ulcer surface area reduction, 83.7% versus 61%, p = 0.001, and a higher percentage of complete healing, 86.2% versus 44.8%, p = 0.005, as compared to the conventional therapy alone group. Similarly, time to complete healing was shorter in the RVP group at 7.8 ± 2.61 weeks versus 10.7 ± 4.31 weeks, p < 0.001. There was no significant difference in rates of wound infection between the two groups. Lower, though statistically non-significant, recurrence rates were seen within the RVP group: 8% versus 15.4%. RVP should be considered one of the adjunctive treatments for chronic VLUs. It offered positive results with regard to improved healing outcomes and reduced ulcer size. More researches are needed to confirm these conclusions.

Lower extremity arteriovenous (AV) access serves as a crucial alternative for hemodialysis when upper extremity options are no longer viable. While there are numerous reports on functional patency, limited information exists regarding complications related to venous insufficiency and postoperative quality of life. This study aims to assess the actual incidence of such complications and provide evidence-based insights for clinical decision-making. We retrospectively analyzed 121 end-stage renal disease patients who underwent lower extremity AV access at Maharaj Nakorn Chiang Mai Hospital from 2006 to 2023. Among them, 105 patients (86.8%) had lower extremity AV grafts, while 16 patients (13.2%) had lower extremity AVF. Primary and secondary patency rate were 69.4% and 81.8% at one year, respectively. The mortality probability was 50.4% with a mean follow-up of 58 months. Mortality predictors included age (P = .001), aspirin use (P = .022) and statin use (P = .005). Primary failure occurred in 8 patients (6.6%) and vascular graft infection is the primary cause. There were no occurrences of venous leg ulcers developed, suggesting that the risk of this complication may be lower than previously thought in the short to medium term. However, 13.3% of patients experienced leg swelling and 21.7% had hyperpigmentation. The mean revised venous clinical severity score was 1.22 and the average EQ-5D-5L quality of life score was 0.99. Our findings suggest that the risk of venous leg ulcers in patients with lower extremity AV access may be lower than previously thought, at least in the short to medium term. This should encourage surgeons to consider this technique when upper extremity options are exhausted, while maintaining vigilance for early signs of venous insufficiency. Continued research into the detrimental effects of the hyper-dynamic blood flow rate on AV access and preventive strategies will enhance the benefit of lower extremity AV access in the future.

Intermittent claudication is a primary symptom of peripheral artery disease (PAD). a chronic progressive disease caused primarily by atherosclerosis. It is usually characterized by leg pain, aches, cramps, or fatigue when walking, which improves with rest. Physical therapy, including a supervised exercise program, is often recommended as the first treatment for sprains. This study aims to evaluate the short-term effects of incorporating heel raise and calf stretch exercises with standard medical therapy compared to medical therapy alone in managing intermittent claudication. From May 2022 to November 2023, 160 patients with Stage II Fontaine PAD were randomly assigned to two equal groups. Group A (80 patients) received heel raise and calf stretch exercises in addition to medical treatment, while Group B (80 patients) received only medical treatment. Both groups underwent treadmill walking tests before and after three months to measure absolute walking distance (ACD), peak walking time (PWT), and Walking Impairment Questionnaire (WIQ) scores, including distance, speed, and symptom severity. At baseline, there were no significant differences between the groups in terms of ACD, peak walking time, ankle-brachial index, distance, speed, and symptoms. At follow-up, Group A showed significantly greater improvements in ACD (312.00 ± 45.43 m), peak walking time (8.54 ± 1.55 min), distance (29.46 ± 4.63 km), speed (20.01 ± 3.13 kph), and WIQ symptoms (22.10 ± 1.02) compared to Group B, which had ACD (276.55 ± 29.07 m), peak walking time (6.72 ± 1.70 min), distance (23.68 ± 3.89 km), speed (15.71 ± 2.71 kph), and WIQ symptoms (20.80 ± 1.47) (P < .001). The ankle-brachial index remained similar between the groups (P > .05). We concluded that integrating standard physical therapy exercises, such as calf raises and leg stretches, with medical therapy significantly enhances walking function in patients with ischemic intermittent claudication.

This study aimed to evaluate the effectiveness of prevention strategies and detect the risk level of recurrence. A randomized controlled trial (RCT) was conducted. Sixty participants were split into two groups: an intervention group consisting of 30 individuals and a control group also with 30 participants. For the intervention group, education and guidance on foot examination, foot care, dietary habits, exercise, and stress management were provided for 1 to 1.5 h each month. However, the control group only received standard care and education through a pamphlet at baseline. The both groups, the baseline risk level of ulcer recurrence score was assessed using INDIFURUTO (Indonesian Diabetic Foot Ulcer Recurrence Assessment Tool). The follow-up period was three months. A General Linear Model (GLM) repeated measures (ANCOVA) analysis was employed to compare the quality of life and risk level between the two groups at baseline and third follow-up. Risk factors for recurrence score in the intervention group significantly decreased after 3 months. These included improvements in mobility (P = .04), anxiety/depression (P < .001), EuroQol Visual Analogue Scale score (P = .004), and INDIFURUTO score (P = .004). The combination of preventive strategies could reduce the risk of recurrence ulcer and improve the quality of life.

This study explored the clinical effectiveness of antibiotic-loaded bone cement (ALBC) combined with vacuum-assisted closure (VAC) on the treatment of Wagner 3-4 diabetic foot ulcers (DFUs). This is a retrospective study, including 32 patients with Wagner 3-4 DFUs who had undergone treatment between August 2019 and June 2021. Patient age, sex, Hemoglobin A1c (HbA1c), body mass index (BMI), ankle brachial index (ABI), white blood cells (WBC), C-reactive protein (CRP) levels, comorbidities and wound closure methods were recorded. Patients were divided into the study group and control group according to the treatment modality. Patients in the study group received the combination treatment of ALBC and VAC, while patients in the control group received single VAC treatment. Clinical endpoints were assessed and compared between the two groups, including wound complete healing time and complications after operation. All patients were followed-up 6 months postoperation. Results showed that the mean healing time of the study group (44.20 ± 16.72 days) was shorter than that of the control group (64.00 ± 29.85 days) (P < .05). The infection rate of the study group on the 10th day postoperation was lower than that of the control group (6.67%, 47.06%, P < .05). And there were no significant statistical differences between the two groups in terms of bleeding and necrosis complications postoperation (P = .603, P = .603). Based on the findings, we conclude that the application of ALBC combined with VAC can facilitate wound healing in Wagner 3-4 DFUs patients. It can help to control wound infections and shorten wound healing time.

The objective of this study was to ascertain the foot self-care behaviour and its associated factors among people with type 2 diabetes mellitus (T2DM) living in the rural resource-constrained health setting of Punjab, North India. A community based cross sectional study was undertaken in the randomly selected underserved rural area of District Fatehgarh Sahib, Punjab, North India. A pre-validated Nottingham Assessment of Functional Footcare (NAFF) scale was administered to assess foot self-care behaviour, and participants were classified based on the percentage of a maximum possible score of 84 on the scale, as poor, if the score was <50%, satisfactory if score 50%-70% and >70% good foot self-care behaviour. A total of 700 participants’ responses were recorded. The study results revealed that 84% (588) of the respondents had poor, 16% (112) had satisfactory, and none were following good foot self-care behaviour. An outcome of multivariable logistics regression suggested satisfactory foot self-care behaviour was significantly associated with foot self-care education, with an adjusted odds ratio (aOR) of 2.83 (95%, CI:1.62 - 4.93; p <0.01) among respondents who had received foot self-care education, literate than illiterate (aOR 2.50 95%, CI:1.31- 4.74; p <0.01) and women compared to men (aOR 1.69 95%, CI: 1.06 −2.70; p −0.26). This study revealed that foot self-care behaviours were alarmingly low among people with T2DM living in rural resource-constrained health settings of Punjab, North India, suggesting an urgent need to disseminate foot self-care education to prevent diabetes foot related complications.

We aimed to investigate adherence to at-home monitoring of foot temperature and its association with patient-, disease- and behavior-related factors, in people with diabetes at high risk of ulceration. We analyzed 151 participants in the enhanced therapy arm of the DIATEMP trial (all at high diabetes-related foot ulcer risk) who aimed to perform and log foot temperatures daily for 18 months or until ulceration. Adherence was the proportion of measurement days covered (PDC), with being adherent defined as PDC≥70%. If a hotspot was recorded, adherence to subsequently reducing ambulatory activity was assessed. Multivariate logistic regression analysis was performed to investigate associations with adherence. We found ninety-four participants (62.3%) adherent to measuring foot temperatures. This was higher in months 1-3 versus months 4-18: 118 (78.1%) versus 78 (57.4%; P < .001). Of 83 participants with a hotspot, 24 (28.9%) reduced ambulatory activity. Increasing age (P = .021, OR = 1.045) and better self-care (P = .007, OR = 1.513) were positively associated with adherence to measuring foot temperature. In conclusion, in people at high diabetes-related foot ulcer risk, adherence to measuring foot temperature was high in the first months after study commencing, but dropped over time. Adherence to reducing ambulatory activity when a hotspot was found was low over the entire study period.

In recent years, nanotechnology and the subsequent production of nanoparticles have developed excellent methods for medical applications, including wound healing. One of these nanoparticles is bentonite nanoparticles (BNPs) which show high ability in tissue engineering. But our knowledge of its effectiveness in wound healing is based on little data. Therefore, the main purpose of this study was to evaluate the wound healing ability of BNPs and in the next step the suitability of honey as a solvent for these nanoparticles. Methods: In this experimental study, an excisional wound injury model was developed in adult male BALB/c mice (n = 60) by creative two equal-sized wounds (5 mm) on either side of their back midline. The animals were allocated into five groups (n = 12 each) as untreated control (U), honey (H), polyethylene glycol (P), and (BNPs) dissolved in honey or polyethylene glycol (H + BNPs, P + BNPs). Animals have received their relative topical treatments twice per day for 14 consecutive days. Tissue sampling was carried out on days 4, 7, 10, and 14. The tissue sections were stained with hematoxylin and eosin and Trichrome-Masson staining methods. The histomorphological parameters including inflammatory cells infiltration, fibroblasts, re-epithelialization, granulation formation, and collagenases were evaluated in all tissue sections. Data were analyzed by SPSS 16 software. Comparison between the groups was performed by one-way analysis of variance following Tukey's post-hoc test. Compared to the control group, BNPs showed significant wound healing activities with lower inflammatory cells infiltration, higher fibroblastosis and new epithelium thickness, and greater granulation area and collagen fibers density in the ulcer bed. In addition, honey as a solvent synergistically increased the wound healing activity of the studied nanoparticle. These results for the first time are clearly showing that BNPs have a promising wound healing activity, especially when applied with honey concurrently.

Diabetic foot osteomyelitis (DFO) is a clinical problem with high risk of amputation. The treatment of DFO is still an unsolved challenge. Surgical therapy, antibiotic therapy or conservative treatment are still debated for the timing and the consequences. Long antibiotic therapies expose the selection of multidrug-resistant bacteria. Nowadays the use of new bone substitutes aims to support the load of the bone segments and to ensure the eradication of the infectious process after surgical treatment. A case report of digital osteomyelitis due to a multidrug resistant bacteria was treated with a conservative treatment and use of bioglass (Bonalive) that has the ability to inhibit bacterial growth. A long follow-up shows the resolution of infectious process, no ulcer recurrence and persistent recovery of its ability to walk. Our results agree with literature data and suggest that bioglass may be considered a useful option to manage DFO and achieve healing with a very conservative approach.

Primary cutaneous mucormycosis is a consequence of environmental Mucorales spores inoculation at the abraded skin. In a diabetic patient, these spores germinate quickly and disseminate hematogenously to the surroundings. Cutaneous mucormycosis is a rare but aggressive, invasive, and life-threatening fungal infection. Its presentation is nonspecific, but it rapidly results in necrosis of underneath tissues. Diagnosis can be readily made by KOH wet mount of excise tissue. However, a prompt diagnosis with multidisciplinary management is a prerequisite for a better outcome. We present a case of fatal cutaneous mucormycosis caused by Apophysomyces elegans, in a diabetic patient who succumbed to death despite extensive debridement and antifungal treatment.

Background: Intravenous drug users (IVDUs) represent a very small group of patients affected by chronic wounds (CWs). Objectives: To assess the risk factors for CWs in IVDUs, to improve their treatment. Methods: A retrospective review of 7 IVDUs with CWs was performed at the Dermatology of the University of Bologna. Results: A history of 10 years of the most frequent injection was heroin in the gaiter area. The most observed comorbidities were HIV, HCV and HBV. They were treated most with an alginate with silver dressing with an average follow-up of 2.8 years. Conclusions: We would like to highlight the importance of clinical history in this type of patients and that in our experience specialized skin wounds risk assessment and management could be useful, aside from traditional compression therapy.

Several associations have been made between COVID-19 and vasculitis. Recent data also shows the prevalence and association of de novo vasculitis with either COVID-19 infection or COVID-19 post vaccination. In this article, we present the case of new-onset leukocytoclastic vasculitis, secondary to COVID-19 vaccination, that was complicated by severe infected and nonhealing ulcers in the lower extremities.

Nearly a decade ago, the Society for Vascular Surgery (SVS)'s wound, ischemia, and foot Infection (WIfI) classification was first developed to help assess overall limb threat. However, managing conditions such as diabetic foot ulcer and chronic limb-threatening ischemia can be complex. For instance, certain investigative findings might initially be pending such as the level of ischemia or extent of infection before the final classification is established. In addition, wounds evolve rapidly, and the current classification does not allow for tracking their progression over time during treatment. Therefore, we propose a supplemental consistent notation for scoring WifI re-assessment during treatment of a threatened limb inspired by the cancer staging before and after neoadjuvant treatment classification system. Thus, we describe the re-scoring system and how to use it. Our suggestion supports a coherent method to longitudinally communicate characteristics of a threatened limb. This has potential to support high quality interdisciplinary, patient-centered care and enhance the use of this classification in research. Further work is required to validate this modification of a common language of risk.

This communication provides a new insight into the unexplained physiology of beneficial effects of negative pressure wound therapy (NPWT). Possible mechanisms of beneficial effects of NPWT in failing replantation and free tissue transfer are discussed. Positive pressure generated by NPWT as well as its draining action creates exudate-free tight tissue-to-tissue interface, which may enhance neovascularization.