[DIABETIC FOOT IN ISRAEL - CURRENT STATUS AND FUTURE PERSPECTIVES].

INTRODUCTION: Diabetic foot ulcers and amputations are the most dreaded diabetes complications. The annual incidence of diabetic foot ulcers in Israel is estimated at 1.8% of all patients with diabetes. The number of patients with diabetes undergoing major amputation in the recent decade has been relatively stable in Israel, and in 2018, 887 patients with diabetes had undergone a major amputation. The proportion of patients undergoing a vascular intervention in the year prior to a major amputation has remained steady over the recent decade, and ranges between 20-40% depending on the patient's age. Aiming to reduce amputation rate, efforts should be made at three levels: 1) Primary care - increasing awareness of patients and health care teams to diabetic foot complications, the means to avoid them, and the delivery of preliminary care. Efforts to further increase awareness should be undertaken. Identification of the foot at-risk and incorporation of professional teams in the care of these patients, as well as provision of appropriate preventive offloading footwear should be sought. 2) Secondary clinics - these multidisciplinary clinics tend to all complications which cannot be adequately addressed in primary care. The professional standard of these clinics should be determined, and the access to these clinics improved. Adequate equipment in these clinics is mandatory as well. 3) Tertiary hospitals - care for the patients who require hospitalization. A national standard for inpatient diabetic foot care should be implemented and multi-disciplinary departments incorporating internists, orthopedists and vascular surgeons should be established aiming to address the medical and surgical complexity of these patients. Qualified nursing staff as well as additional health care professionals including physiotherapists, dieticians, clinical pharmacists, social workers, occupational therapists and others should also be included. Documentation of diabetic foot ulcers is lacking, both in the community and in hospitals. Use of uniform diagnostic codes should be implemented to enable close monitoring of disease trends.

Diabetic Foot Ulcers and Epidermal Growth Factor: Revisiting the Local Delivery Route for a Successful Outcome.

Soon after epidermal growth factor (EGF) discovery, some in vivo models appeared demonstrating its property to enhance cutaneous wound healing. EGF was the first growth factor (GF) introduced in the clinical arena as a healing enhancer, exerting its mitogenic effects on epithelial, fibroblastoid, and endothelial cells via a tyrosine kinase membrane receptor. Compelling evidences from the 90s documented that, for EGF, locally prolonged bioavailability and hourly interaction with the receptor were necessary for a successful tissue response. Eventually, the enthusiasm on the clinical use of EGF to steer the healing process was wiped out as the topical route to deliver proteins started to be questioned. The simultaneous in vivo experiments, emphasizing the impact of the parenterally administered EGF on epithelial and nonepithelial organs in terms of mitogenesis and cytoprotection, rendered the theoretical fundamentals for the injectable use of EGF and shaped the hypothesis that locally infiltrating the diabetic ulcers would lead to an effective healing. Although the diabetic chronic wounds microenvironment is hostile for local GFs bioavailability, EGF local infiltration circumvented the limitations of its topical application, thus expanding its therapeutic prospect. Our clinical pharmacovigilance and basic studies attest the significance of the GF local infiltration for chronic wounds healing.