A Wolf in Sheep's Clothing: An Unusual Presentation of Diabetic Myonecrosis.

GENERAL PURPOSE: To provide information about the diagnosis and treatment of diabetic myonecrosis (DMN).This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.After participating in this educational activity, the participant should be better able to:1. Cite the incidence and symptomatology of diabetic myonecrosis.2. Identify the diagnostic tests associated with DMN.3. Summarize the evidence-based treatments for DMN.Diabetic myonecrosis is a rare complication of poorly controlled diabetes mellitus that presents similarly to many common conditions such as cellulitis, abscess, and fasciitis. Therefore, a high index of suspicion is required for diagnosis. Magnetic resonance imaging is the investigative test of choice. Treatment includes antiplatelet therapy, nonsteroidal anti-inflammatory agents, and glycemic control.

Wound Care Center of Excellence: A Process for Continuous Monitoring and Improvement of Wound Care Quality.

GENERAL PURPOSE: To provide information about a study using a new process for continuous monitoring to improve chronic wound care quality.This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.After completing this continuing education activity, you should be better able to:1. Recognize problems associated with chronic wound care.2. Identify methods used in this project to improve care.3. Illustrate the findings from this and similar projects and implications for providing improved wound care.Patients with chronic wounds require complex care because of comorbidities that can affect healing. Therefore, the goal of this project was to develop a system of reviewing all hospitalized patients seen by the study authors' wound care service on a weekly basis to decrease readmissions, morbidity, and mortality. Weekly multidisciplinary conferences were conducted to evaluate patient data and systematically assess for adherence to wound care protocols, as well as to create and modify patient care plans. This review of pathology and the performance of root-cause analyses often led to improved patient care.

A Framework to Assist Providers in the Management of Patients with Chronic, Nonhealing Wounds.

GENERAL PURPOSE: To describe the development of an evidence-based wound electronic medical record (WEMR) framework for providers to execute timely, protocol-based, best-practice care for patients with chronic, nonhealing wounds. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be better able to: ABSTRACT: The care of patients with nonhealing wounds involves a host of treatment modalities. The authors developed a wound-specific framework to enhance provider management of these wounds and a summary sheet to involve patients and caregivers in their own healthcare to improve treatment adherence and outcomes. Implementing evidence-based practice for chronic wounds enables corrective actions to optimize care.

Development of a Method for Clinical Evaluation of Artificial Intelligence-Based Digital Wound Assessment Tools.

Importance: Accurate assessment of wound area and percentage of granulation tissue (PGT) are important for optimizing wound care and healing outcomes. Artificial intelligence (AI)-based wound assessment tools have the potential to improve the accuracy and consistency of wound area and PGT measurement, while improving efficiency of wound care workflows. Objective: To develop a quantitative and qualitative method to evaluate AI-based wound assessment tools compared with expert human assessments. Design, Setting, and Participants: This diagnostic study was performed across 2 independent wound centers using deidentified wound photographs collected for routine care (site 1, 110 photographs taken between May 1 and 31, 2018; site 2, 89 photographs taken between January 1 and December 31, 2019). Digital wound photographs of patients were selected chronologically from the electronic medical records from the general population of patients visiting the wound centers. For inclusion in the study, the complete wound edge and a ruler were required to be visible; circumferential ulcers were specifically excluded. Four wound specialists (2 per site) and an AI-based wound assessment service independently traced wound area and granulation tissue. Main Outcomes and Measures: The quantitative performance of AI tracings was evaluated by statistically comparing error measure distributions between test AI traces and reference human traces (AI vs human) with error distributions between independent traces by 2 humans (human vs human). Quantitative outcomes included statistically significant differences in error measures of false-negative area (FNA), false-positive area (FPA), and absolute relative error (ARE) between AI vs human and human vs human comparisons of wound area and granulation tissue tracings. Six masked attending physician reviewers (3 per site) viewed randomized area tracings for AI and human annotators and qualitatively assessed them. Qualitative outcomes included statistically significant difference in the absolute difference between AI-based PGT measurements and mean reviewer visual PGT estimates compared with PGT estimate variability measures (ie, range, standard deviation) across reviewers. Results: A total of 199 photographs were selected for the study across both sites; mean (SD) patient age was 64 (18) years (range, 17-95 years) and 127 (63.8%) were women. The comparisons of AI vs human with human vs human for FPA and ARE were not statistically significant. AI vs human FNA was slightly elevated compared with human vs human FNA (median [IQR], 7.7% [2.7%-21.2%] vs 5.7% [1.6%-14.9%]; P < .001), indicating that AI traces tended to slightly underestimate the human reference wound boundaries compared with human test traces. Two of 6 reviewers had a statistically higher frequency in agreement that human tracings met the standard area definition, but overall agreement was moderate (352 yes responses of 583 total responses [60.4%] for AI and 793 yes responses of 1166 total responses [68.0%] for human tracings). AI PGT measurements fell in the typical range of variation in interreviewer visual PGT estimates; however, visual PGT estimates varied considerably (mean range, 34.8%; mean SD, 19.6%). Conclusions and Relevance: This study provides a framework for evaluating AI-based digital wound assessment tools that can be extended to automated measurements of other wound features or adapted to evaluate other AI-based digital image diagnostic tools. As AI-based wound assessment tools become more common across wound care settings, it will be important to rigorously validate their performance in helping clinicians obtain accurate wound assessments to guide clinical care.

Injectable Therapeutic Organoids Using Sacrificial Hydrogels.

Organoids are becoming widespread in drug-screening technologies but have been used sparingly for cell therapy as current approaches for producing self-organized cell clusters lack scalability or reproducibility in size and cellular organization. We introduce a method of using hydrogels as sacrificial scaffolds, which allow cells to form self-organized clusters followed by gentle release, resulting in highly reproducible multicellular structures on a large scale. We demonstrated this strategy for endothelial cells and mesenchymal stem cells to self-organize into blood-vessel units, which were injected into mice, and rapidly formed perfusing vasculature. Moreover, in a mouse model of peripheral artery disease, intramuscular injections of blood-vessel units resulted in rapid restoration of vascular perfusion within seven days. As cell therapy transforms into a new class of therapeutic modality, this simple method-by making use of the dynamic nature of hydrogels-could offer high yields of self-organized multicellular aggregates with reproducible sizes and cellular architectures.

In situ collagen assembly for integrating microfabricated three-dimensional cell-seeded matrices.

Microscale fabrication of three-dimensional (3D) extracellular matrices (ECMs) can be used to mimic the often inhomogeneous and anisotropic properties of native tissues and to construct in vitro cellular microenvironments. Cellular contraction of fibrous natural ECMs (such as fibrin and collagen I) can detach matrices from their surroundings and destroy intended geometry. Here, we demonstrate in situ collagen fibre assembly (the nucleation and growth of new collagen fibres from preformed collagen fibres at an interface) to anchor together multiple phases of cell-seeded 3D hydrogel-based matrices against cellular contractile forces. We apply this technique to stably interface multiple microfabricated 3D natural matrices (containing collagen I, Matrigel, fibrin or alginate); each phase can be seeded with cells and designed to permit cell spreading. With collagen-fibre-mediated interfacing, microfabricated 3D matrices maintain stable interfaces (the individual phases do not separate from each other) over long-term culture (at least 3 weeks) and support spatially restricted development of multicellular structures within designed patterns. The technique enables construction of well-defined and stable patterns of a variety of 3D ECMs formed by diverse mechanisms (including temperature-, ion- and enzyme-mediated crosslinking), and presents a simple approach to interface multiple 3D matrices for biological studies and tissue engineering.

A Perioperative Approach to Increase Limb Salvage When Treating Foot Ulcers in Patients With Diabetes.

Foot ulceration in patients with diabetes increases the risk of lower extremity amputation. Major amputations produce substantial adverse consequences, increase length of hospital stay, diminish quality of life, and increase mortality. In this article, we describe approaches that decrease amputations and improve the quality of life for patients with diabetes and foot ulcers. We highlight the role of the perioperative nurse, who is essential to providing optimal patient care in the perioperative period. Perioperative care of patients with diabetes involves providing optimal surveillance for a break in the skin of the foot, screening for neuropathy, following guidelines for foot ulcer infections, preparing for pathophysiology-based debridement, using adjuvant therapies, and offloading the patient's affected foot. Nurses should understand the disease process and pathophysiology and how to use these approaches in the perioperative setting to assist in curtailing the morbidity and mortality associated with foot ulcers in patients with diabetes.

A direct tissue-grafting approach to increasing endogenous brown fat.

There is widespread evidence that increasing functional mass of brown adipose tissue (BAT) via browning of white adipose tissue (WAT) could potentially counter obesity and diabetes. However, most current approaches focus on administration of pharmacological compounds which expose patients to highly undesirable side effects. Here, we describe a simple and direct tissue-grafting approach to increase BAT mass through ex vivo browning of subcutaneous WAT, followed by re-implantation into the host; this cell-therapy approach could potentially act synergistically with existing pharmacological approaches. With this process, entitled "exBAT", we identified conditions, in both mouse and human tissue, that convert whole fragments of WAT to BAT via a single step and without unwanted off-target pharmacological effects. We show that ex vivo, exBAT exhibited UCP1 immunostaining, lipid droplet formation, and mitochondrial metabolic activity consistent with native BAT. In mice, exBAT exhibited a highly durable phenotype for at least 8 weeks. Overall, these results enable a simple and scalable tissue-grafting strategy, rather than pharmacological approaches, for increasing endogenous BAT and studying its effect on host weight and metabolism.

Synthetic tissue biology: tissue engineering meets synthetic biology.

We propose the term "synthetic tissue biology" to describe the use of engineered tissues to form biological systems with metazoan-like complexity. The increasing maturity of tissue engineering is beginning to render this goal attainable. As in other synthetic biology approaches, the perspective is bottom-up; here, the premise is that complex functional phenotypes (on par with those in whole metazoan organisms) can be effected by engineering biology at the tissue level. To be successful, current efforts to understand and engineer multicellular systems must continue, and new efforts to integrate different tissues into a coherent structure will need to emerge. The fruits of this research may include improved understanding of how tissue systems can be integrated, as well as useful biomedical technologies not traditionally considered in tissue engineering, such as autonomous devices, sensors, and manufacturing.

Direct patterning of composite biocompatible microstructures using microfluidics.

This study demonstrates a versatile and fast method for patterning three-dimensional (3D) monolithic microstructures made of multiple (up to 24 demonstrated) types of materials, all spatially aligned, inside a microchannel. This technique uses confocal scanning or conventional fluorescence microscopy to polymerize selected regions of a photocurable material, and microfluidics to automate the delivery of a series of washes and photocurable reagents. Upon completion of lithographic cycles, the aligned 3D microstructures are suitable for microfluidic manipulation and analysis. We demonstrated the fabrication of composite 3D microstructures with various geometries, size scales (up to 1 mm2), spatial resolution (down to 3 microm), and materials. For a typical multi-cycle process, the total fabrication time was tens of minutes, compared to tens of hours for conventional methods. In the case of 3D hydrogels, a potential use is the direct patterning of inhomogeneous 3D microenvironments for studying cell behavior.

Building a microphysiological skin model from induced pluripotent stem cells.

The discovery of induced pluripotent stem cells (iPSCs) in 2006 was a major breakthrough for regenerative medicine. The establishment of patient-specific iPSCs has created the opportunity to model diseases in culture systems, with the potential to rapidly advance the drug discovery field. Current methods of drug discovery are inefficient, with a high proportion of drug candidates failing during clinical trials due to low efficacy and/or high toxicity. Many drugs fail toxicity testing during clinical trials, since the cells on which they have been tested do not adequately model three-dimensional tissues or their interaction with other organs in the body. There is a need to develop microphysiological systems that reliably represent both an intact tissue and also the interaction of a particular tissue with other systems throughout the body. As the port of entry for many drugs is via topical delivery, the skin is the first line of exposure, and also one of the first organs to demonstrate a reaction after systemic drug delivery. In this review, we discuss our strategy to develop a microphysiological system using iPSCs that recapitulates human skin for analyzing the interactions of drugs with the skin.

Engineering extracellular matrix structure in 3D multiphase tissues.

In native tissues, microscale variations in the extracellular matrix (ECM) structure can drive different cellular behaviors. Although control over ECM structure could prove useful in tissue engineering and in studies of cellular behavior, isotropic 3D matrices poorly replicate variations in local microenvironments. In this paper, we demonstrate a method to engineer local variations in the density and size of collagen fibers throughout 3D tissues. The results showed that, in engineered multiphase tissues, the structures of collagen fibers in both the bulk ECM phases (as measured by mesh size and width of fibers) as well as at tissue interfaces (as measured by density of fibers and thickness of tissue interfaces) could be modulated by varying the collagen concentrations and gelling temperatures. As the method makes use of a previously published technique for tissue bonding, we also confirmed that significant adhesion strength at tissue interfaces was achieved under all conditions tested. Hence, this study demonstrates how collagen fiber structures can be engineered within all regions of a multiphase tissue scaffold by exploiting knowledge of collagen assembly, and presents an approach to engineer local collagen structure that complements methods such as flow alignment and electrospinning.