Prescribing Home Digital Thermometry Coupled with Activity Dosing and Optimized Offloading to Prolong Diabetic Foot Remission: A Case Report.

People with a history of diabetic foot ulcers (DFUs) experience diminished health-related quality of life and are at a 40% annual risk of DFU recurrence. Due to a fear of DFU recurrence, people in DFU remission participate less in physical activity and moderate-intensity exercise when compared to people with diabetes who have not had wounds. There is novel evidence to suggest that too little activity during DFU remission contributes to only low magnitudes of repetitive tissue loading creating a higher susceptibility to skin trauma during inadvertent high-activity bouts. Conversely, a hasty return to too much activity could lead to rapid recurrence. There is now high-level evidence from multiple meta-analyses to indicate that home-based foot temperature monitoring, coupled with activity modification and daily inspection of the feet for impending signs of ulceration, could reduce the risk of ulcer recurrence by 50%. There is little evidence, however, to guide the decision-making regarding the appropriate quantity and frequency of physical activity during DFU remission and the acceptability from the patient perspective. This has resulted in limited uptake of this novel intervention in clinical practice. Earlier, we proposed that activity can be dosed for people in foot ulcer remission, just like insulin or medication is dosed. Here, we describe a patient-centered approach to implementing home foot temperature monitoring coupled with daily foot checks and dosage-based return to physical activity in a patient in DFU remission, including his perspective. We believe using such an approach could maximize ulcer-free days in remission, thereby improving quality of life.

Dosing Activity and Return to Preulcer Function in Diabetes-Related Foot Ulcer Remission.

Diabetes-related foot ulcers are a leading cause of global morbidity, mortality, and health-care costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year after healing, and most occur in the first 3 months after wound healing. Hence, this period after ulceration is called "remission" due to this risk of reulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health-related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate off-loading and monitoring in people with a recently healed foot ulcer, foot reconstruction, or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring, which can identify dangerous "hotspots" prone to recurrence. By understanding areas at risk, patients are empowered to maximize ulcer-free days and to enable an improved quality of life. This perspective outlines a unified strategy to treat patients in the remission period after ulceration and aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patients to ensure a safe transition to footwear and return to activity.

What to put on (and what to take off) a wound: treating a chronic neuropathic ulcer with an autologous homologous skin construct, offloading and common sense.

Closure of chronic lower extremity wounds is important for minimizing the risk of infection and amputation in a very high-risk population. Developments in tissue cultures and matrix therapies have shown promise in enhancing healing. The use of autologous homologous skin constructs in wound treatment may enable the regeneration of functional dermal structures. We present the case of a chronic medial heel ulcer that dehisced following intraoperative debridement, which was subsequently treated using a combination of an autologous homologous skin construct and total contact casting. This case emphasizes the importance of proper offloading for healing and preventing recurrence of lower extremity wounds.

Functional ambulatory status as a potential adjunctive decision-making tool following wound, level of ischemia, and severity of foot infection assessment.

The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System has been developed to stratify amputation risk on the basis of extent of the wound, level of ischemia, and severity of foot infection (WIfI). However, there are no currently validated metrics to assess, grade, and consider functional status, especially ambulatory status, as a major consideration during limb salvage efforts. Therefore, we propose an adjunct to the current WIfI system to include the patient's ambulatory functional status after initial assessment of limb threat. We propose a functional ambulatory score divided into grade 0, ambulation outside the home with or without an assistive device; grade 1, ambulation within the home with or without an assistive device; grade 2, minimal ambulation, limbs used for transfers; and grade 3, a person who is bed-bound. Adding ambulatory function as a supplementary assessment tool can guide clinical decision making to achieve optimal future functional ambulatory outcome, a patient-centered goal as critical as limb preservation. This adjunct may aid limb preservation teams in rapid, effective communication and clinical decision making after initial WIfI assessment. It may also improve efforts toward patient-centered care and functional ambulatory outcome as a primary objective. We suggest a score of functional ambulatory status should be included in future trials of patients with chronic limb-threatening ischemia.

Negative Pressure Wound Therapy With Instillation and Dwell Time Used to Treat Pyoderma Gangrenosum: A Case Report.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare, ulcerative dermatosis that is part of a systemic auto-inflammatory process. The overall incidence of PG is 5.8 per 100 000 individuals and it is associated with an increased mortality rate compared with the general population. Due to the pathergy phenomenon-present in 20% to 30% of cases-traumatic events, such as debridement or surgery, are often avoided in these patients. This report is on the use of negative pressure wound therapy with instillation and dwell time (NPWTi-d) combined with a reticulated open cell foam dressing with through holes (ROCF-CC) to achieve debridement and granulation in a lower extremity PG wound. CASE REPORT: A known patient with history of neuropathic arthritis, systemic lupus erythematosus, and cryoglobulinemic vasculitis presented with worsening of his lower extremity wound including new onset pain, odor, and purulent discharge. Negative pressure wound therapy with instillation and dwell time using a hypochlorous acid solution and a ROCF-CC was initiated. Significant decrease in necrotic tissue was noted by day 4, with improved granulation tissue growth by day 25. No pathergy occurred in this case. CONCLUSIONS: The use of NPWTi-d with ROCF-CC demonstrated positive debridement effects on this PG wound.