OBJECTIVE:Ischemic tissue perfusion remains a major clinical challenge despite VEGF's central role in angiogenesis. Limited success of VEGF-based therapies underscores the need to understand endothelial heterogeneity, as distinct subsets exhibit differential responsiveness. This study explores conserved endothelial states that govern VEGF-driven angiogenesis across human organs and evaluates their functional significance. APPROACH:We performed single-cell and single-nucleus RNA-sequencing (scRNA-seq/snRNA-seq) analysis of endothelial cells (ECs) from eight human tissues using GTEx data, validated findings in independent skin and heart datasets, and conducted CRISPR-mediated PLCγ2 knockout in cultured ECs followed by scRNA-seq. RESULTS:Analysis of 209,126 nuclei revealed a universal arterial-like endothelial subset (cluster 2) enriched across all organs, characterized by high expression of PLCγ2, a critical VEGF signaling effector. PLCγ2high cells exhibited robust angiogenic and lymphangiogenic programs, including upregulation of VEGFC, NOTCH4, and JAG1, and enrichment of pathways for vasculature development and endothelial differentiation. Cell-cell communication analysis demonstrated exclusive BMP6, IGF2, and CXCL12 signaling from PLCγ2high cells to fibroblasts, pericytes, and immune cells, positioning this subset as a central angiogenic hub. Functional validation showed that PLCγ2 knockout depleted PLCγ2high clusters, suppressed VEGF signaling, and diminished BMP6 ligand secretion, confirming its role in maintaining proangiogenic endothelial states. INNOVATION:Ineffective targeting of the appropriate EC state may limit current therapeutic VEGF strategies, positioning PLCγ2high ECs as a clinically relevant target. CONCLUSION:We identify PLCγ2high arterial ECs as a conserved pan-organ population critical for VEGF responsiveness and vascular regeneration. These findings reimagine VEGF therapy by highlighting PLCγ2 as a critical regulator of a proangiogenic arterial-like endothelial state and a promising combinatorial target to overcome limitations of current angiogenic strategies.
OBJECTIVE:To benchmark zero-shot generative pre-trained transformer (GPT)-based multimodal large language models (MLLMs) for pressure injury (PI) staging from photographs and quantify the effects of prompt strategy, structured outputs, and clinically meaningful label granularity. APPROACH:We performed a retrospective observational benchmark using 1,091 public, de-identified PI photographs labeled Stage I-IV. In the standardized analysis, all 10 model/prompt conditions were evaluated using a standardized, resume-safe application programming interface pipeline with per-image logging. We evaluated exact four-class staging, three-class staging (I/II/III-IV), skin-break screening (I vs. II-IV), and an advanced-intervention threshold (I-II vs. III-IV). Reporting followed Strengthening the Reporting of Observational Studies in Epidemiology and artificial intelligence/machine learning guidance; metrics included accuracy, Wilson 95% confidence intervals, F1 scores, weighted kappa, and threshold sensitivity/specificity. RESULTS:All conditions yielded parsed predictions for all 1,091 images. The best accuracy was 93.77% for skin-break screening (GPT-5.2 structured JavaScript Object Notation [JSON]), 90.28% for the advanced-intervention threshold (GPT-5.1 full prompt, low reasoning), 83.78% for three-class staging (GPT-5.1 full prompt, low reasoning), and 65.08% for exact four-class staging (GPT-5.2 structured JSON). The best advanced-intervention condition achieved sensitivity 96.72%, specificity 83.79%, and negative predictive value 96.19%. Stage IV undercalling remained safety-relevant; GPT-5.2-pro had Stage IV recall 8.79% and false-negative rate 91.21%. INNOVATION:This prompt-transparent benchmark shows how outcome granularity, prompting, and structured outputs affect GPT-based PI staging and adds ordinal, threshold-based, and safety metrics. CONCLUSION:GPT-based MLLMs may support clinician-supervised triage and prioritization, but image-only autonomous exact staging is not clinically ready.[Figure: see text].
OBJECTIVE:Dressing changes after digit replantation can trigger pain, anxiety, and local wound cooling, yet the clinical impact of cleansing solution temperature remains unclear. This study evaluated whether warmed saline irrigation improves patient experience and physiological stability during wound care after digit replantation. APPROACH:In this single-center, parallel-group randomized controlled trial, 149 patients undergoing digit replantation were randomized to receive warmed or room-temperature saline irrigation during postoperative dressing changes. Primary outcomes were pain and digit temperature assessed before, during, and after dressing changes. Secondary outcomes included anxiety, comfort, complications, and digit survival. Analyses followed the intention-to-treat principle using linear mixed-effects models. Reporting adhered to CONSORT guidelines. RESULTS:Compared with room-temperature saline, warmed saline significantly reduced pain and anxiety and improved patient comfort over time (all p < 0.001). Warmed saline maintained peri-wound temperature during dressing changes, whereas room-temperature saline induced transient cooling. No between-group differences were observed in complication rates, C-reactive protein, or digit survival. Clinically meaningful improvements in pain, anxiety, and comfort were more frequent in the warmed-saline group. Exploratory analyses suggested greater benefit in younger patients and during colder seasons. INNOVATION:This trial provides preliminary randomized evidence in a microsurgical population demonstrating that warmed saline irrigation, a simple and low-cost modification, can improve patient-reported outcomes without compromising safety. CONCLUSION:Warmed saline irrigation offers a safe and practical strategy to enhance comfort and reduce distress during wound care after digit replantation. These findings highlight thermal management as an underutilized, patient-centered component of postoperative care and support its integration into routine practice.
OBJECTIVE:Burn injuries affect millions globally, with increasing survival rates due to advances in acute care. However, long-term cardiovascular outcomes including major adverse cardiovascular events (MACE), venous thromboembolism (VTE), and mortality in burn survivors remain under-investigated. APPROACH:We conducted a retrospective propensity score-matched cohort study using the TriNetX US Collaborative Network. Individuals aged 18 years or older who had an emergency department visit or hospitalization with a diagnosis of burn injuries occurring between January 1, 2014, and January 1, 2019, were identified and matched 1:1 to nonburn controls who were selected based on similar demographics, comorbidities, and medications. The primary outcomes were the hazard ratios (HRs) and absolute risk differences (ARDs) of MACE, VTE, and mortality occurring between 3 months and 5 years after the index date. Secondary cardiovascular and thromboembolic endpoints included the HRs and ARDs of coronary artery disease (CAD), cerebrovascular disease (CVD), pulmonary embolism (PE), and deep vein thrombosis (DVT). RESULTS:A total of 71,426 propensity score-matched pairs of burn survivors and nonburn controls were included. Burn survivors had significantly elevated risks of MACE (HR 1.95, 95% confidence intervals [CI] 1.84-2.07; ARD 0.9%), VTE (HR 1.99, 95% CI 1.80-2.19; ARD 0.4%), and all-cause mortality (HR 2.29, 95% CI 2.10-2.49; ARD 0.7%) compared with controls. Increased risks were also observed for CAD (HR 1.85, 95% CI 1.72-1.98; ARD 0.5%), CVD (HR 2.05, 95% CI 1.88-2.24; ARD 0.5%), PE (HR 2.09, 95% CI 1.77-2.47; ARD 0.1%), and DVT (HR 1.96, 95% CI 1.69-2.27; ARD 0.1%). INNOVATION:We demonstrate that burn injury is associated with sustained long-term cardiovascular and thromboembolic risks up to 5 years after injury. CONCLUSIONS:These findings establish burn injury as a chronic condition, requiring routine cardiovascular screening and targeted prevention in long-term care.
The Wound Healing Foundation (WHF) previously organized consensus panels on the management of chronic wounds (2022), acute wounds (2024), and diabetic wounds (2025). This WHF consensus statement, authored by a global interdisciplinary panel of clinicians and researchers, focuses on the management of infected wounds. The panel members reviewed the literature and reached consensus on elements of an evidence-based approach to infected wounds. Using a structured format, this statement progresses from discussing how wound infections develop, how to diagnose them, how to provide the most appropriate antimicrobial and surgical treatment, how to assess response to treatment, and how to further investigate instances of unsuccessful treatment.
SIGNIFICANCE:Pediatric pressure injuries (PIs) are a distinct and preventable clinical challenge, yet risk prediction models tailored to children remain underdeveloped. This systematic review critically evaluates existing pediatric PI prediction models to assess their methodological rigor, predictive performance, and clinical applicability. RECENT ADVANCES:Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, nine databases were searched to identify studies developing or validating PI risk prediction models for hospitalized patients younger than 18 years. Twelve models from nine studies were included. Risk of bias and applicability were assessed using the Prediction Model Risk Of Bias Assessment Tool (PROBAST) and PROBAST + AI tool. CRITICAL ISSUES:All models demonstrated acceptable discrimination (area under the curve [AUC] range: 0.612-0.978), with seven exceeding an AUC of 0.75. However, calibration was inconsistently reported, and only two models evaluated clinical utility-just one showed net benefit across a realistic threshold range. All models were rated as high risk of bias, and 10 had major concerns regarding applicability. Common methodological flaws included low events per variable <10, inappropriate categorization of continuous variables, poor handling of missing data, and lack of external validation. Most models were developed in single-center studies from China, limiting generalizability. Compared with adult PI models, pediatric models lacked age stratification, standardized outcome definitions, and robust validation. The first application of PROBAST + AI for evaluating machine learning prediction models highlighted algorithmic fairness and ethical risks within these models, but it showed insufficient interpretability regarding aspects such as the optimization process and the transparency of "black box" data leakage. FUTURE DIRECTIONS:To improve predictive accuracy and clinical relevance, future models should adopt the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis, PROBAST, and PROBAST + AI standards, use multicenter data, stratify by age and clinical setting, and focus on early-stage PIs. Incorporating objective measures and evaluating clinical utility will enhance model integration into practice. PROBAST + AI, in alignment with the advancements in information technology, requires widespread attention for its practical utility and ease of use to be further validated and optimized.[Figure: see text][Figure: see text]Conclusion:Current pediatric PI prediction models show promise but fall short in methodological rigor and clinical applicability. Addressing these gaps is essential to support early identification and targeted prevention in pediatric care.
OBJECTIVE:Diabetic foot complications (DFCs) are common diabetes complications. Existing tools for predicting incident DFCs remain insufficient. This study aimed to develop and validate a novel machine learning-based model for incident DFC prediction. APPROACH:Using UK Biobank data, we built a longitudinal incident DFC cohort, with DFCs identified using International Classification of Diseases codes. Clinical features were screened by Cox models, and a machine learning model (DFC-Clin) was developed using fivefold cross-validation and leave-one-center-out validation. Performance was compared with diabetic foot risk stratification tools using the DeLong test. A web-based tool and risk stratification system were also developed. RESULTS:Among 502,175 participants, 29,766 individuals formed the incident cohort, with 1,252 incident DFC events. Demographics, blood markers, lifestyle factors, and comorbidities were selected to construct DFC-Clin, with glycated hemoglobin and body mass index emerging as the most predictive features. The model showed improved discrimination compared with existing risk stratification tools, achieving area under the receiver operating characteristic curves of 0.782 ± 0.042, 0.766 ± 0.042, and 0.747 ± 0.021 for 5-year, 10-year, and overall incident DFC prediction, respectively. INNOVATION:DFC-Clin is a machine learning model for incident DFC prediction that uses accessible clinical features from a large population-based cohort and is coupled with a web-based application and risk stratification system. CONCLUSION:DFC-Clin estimates the risk of incident DFC across multiple time horizons and demonstrates improved discrimination compared with existing approaches. The web-based application and stratification framework are intended to support risk identification and preventive decision-making. Further studies are required for clinical deployment and evaluation on more clinical outcomes, including amputations, recurrence, and health care costs.[Figure: see text][Figure: see text][Figure: see text].
BACKGROUND:Diabetic foot ulcers (DFUs) represent one of the most severe complications of diabetes mellitus and are associated with limb loss, excess mortality, and substantial health care costs. Although DFUs are often approached as a localized wound condition, increasing evidence suggests that they reflect advanced systemic vascular and metabolic disease. However, large real-world longitudinal studies integrating wound outcomes, survival, and economic burden remain scarce. OBJECTIVES:The objective of this study is to evaluate long-term clinical outcomes, survival, and health care costs associated with DFUs in a large real-world cohort and to identify factors independently associated with mortality and limb loss. METHODS:We conducted a retrospective longitudinal cohort study including 5,698 adult patients with diabetes treated for active DFUs at a tertiary referral hospital. Minor and major amputations, survival outcomes, health care utilization, and estimated direct hospital costs were analyzed. Time-to-event analyses included Kaplan-Meier estimation, competing-risk regression, and multivariable Cox proportional hazards models. Disease trajectories were further explored using multistate modeling. RESULTS:During follow-up, 290 major amputations were recorded. Patients undergoing major amputation showed significantly worse survival compared with nonamputated patients or those with minor amputations (log-rank p < 0.001). Mean survival after major amputation was 35.3 months, compared with more than 47 months in patients without major limb loss. Five-year overall survival was 61.8%, decreasing to 32.1% among patients with major amputation. Increasing age, peripheral arterial disease, ischemic heart disease, end-stage renal failure, and prior major amputation were independently associated with mortality. Male sex emerged as the main independent predictor of major amputation in adjusted competing-risk models. DFU-related care was associated with high health care utilization and progressively escalating hospital costs. CONCLUSIONS:DFUs should be regarded as a marker of advanced systemic disease rather than an isolated wound condition, given their strong association with long-term mortality, limb loss, and economic burden. Early risk stratification and integrated multidisciplinary care strategies are essential to improve outcomes in this high-risk population.
SIGNIFICANCE:Wound healing is as much about opportunity (Gk. Karios) and sequence (Gk. Chronos). The sequential healing responses involve concerted responses of cells of various lineages along with both soluble (cytokines and growth factors) and insoluble (matrix composition and topology) that are precisely coordinated for ultimate healing. This motivated the current scoping review to examine the biological relevance and utility of current in vitro models of wound healing, focusing on specific cellular responses. RECENT ADVANCES:We examined PubMed, Web of Science, and EBSCO of Science for the years 2020-2025, using keywords in vitro wound healing and individual cell type, namely epithelial cells, keratinocytes, fibroblasts, macrophages, platelets, and endothelial cells. This identified 126 relevant studies were selected and categorized by healing stage, cell types, and prototypical biological responses such as proliferation, migration, and lineage-specific functions. CRITICAL ISSUES:This analysis outlined the utility of a temporal framework to organize current in vitro models as acute-initial, early and late, and chronic-delayed. Existing two-dimensional and three-dimensional models focus on platelet function (hemostasis), neutrophil or macrophage chemotaxis and phagocytosis (inflammation), epithelium (closure), fibroblast (matrix synthesis, contraction), and endothelial (angiogenesis). While these models provide key insights into specific phases, cell functions, and molecular mechanisms, they do not fully replicate the integrated, multiorgan processes of wound healing observed in vivo. FUTURE DIRECTIONS:Sequential combinations of these models lend themselves to the advances in artificial intelligence, machine learning, and robotic automation that are integral to developing prognostic and therapeutic wound care agents.
OBJECTIVE:High-density lipoprotein (HDL) functionality is emerging as a novel predictor of disease outcomes. The role of HDL functionality in patients with diabetes-related amputations is unexplored. We aimed to assess changes in HDL functionality in people with diabetes who had minor amputations and to determine the relationship between HDL functionality and wound closure (WC). APPROACH:Thirty patients with diabetes mellitus (DM) and 11 without (non-DM) undergoing minor amputations were recruited. Blood was collected at baseline (DM, n = 30; non-DM, n = 11), 1 month (DM, n = 22; non-DM, n = 5), and 6 months (DM, n = 14; non-DM, n = 3) postamputation and from 20 healthy gender- and age-matched control participants. HDL was isolated from plasma and functionality markers of macrophage cholesterol efflux, and anti-inflammatory and proangiogenic capacities in endothelial cells were assessed. The study adhered to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. RESULTS:HDL-cholesterol (HDL-c) levels positively correlated with WC (r = 0.44, p < 0.05). Cholesterol efflux capacity of DM HDL was reduced 1-month postamputation (-44% vs. non-DM HDL, d = -1.5, p < 0.05). Following inflammatory stimulation, DM HDL-treated cells had elevated levels of C-X3-C motif chemokine ligand 1 (+92%, d = 0.9), C-C motif chemokine ligand 2 (+49%, d = 0.8), vascular cell adhesion molecule 1 (+67%, d = 0.9), and intracellular adhesion molecule 1 (+58%, d = 0.9) (vs. non-DM HDL, p < 0.05). The capacity of endothelial cells to form tubules reduced linearly with time following DM HDL treatment (p < 0.05), concomitant with reduced vascular endothelial growth factor A (-47% vs. non-DM HDL, d = -1.2, p < 0.05). Endothelial cells treated with HDL from participants with delayed WC (<50%, 1-month postamputation) exhibited increased v-rel avian reticuloendotheliosis viral oncogene homolog A (RELA) expression (+52%, d = 1.2, p < 0.05). The impairment of HDL functionality in DM was concomitant with reduced apolipoprotein AI (-34%, d = 1.2) and paraoxonase 1 (-32%, d = -1.3, vs. non-DM, p < 0.05) protein in HDL 1-month postamputation. INNOVATION:An HDL panel, including HDL-c and HDL functionality and composition, could be used in early screening to identify patients who may benefit from early therapeutic intervention, guiding wound care management. CONCLUSION:Impaired HDL functionality, mediated through changes in HDL composition, may contribute to delayed wound healing.
BACKGROUND:Diabetic foot ulcers (DFUs) remain one of the most devastating complications of diabetes, accounting for over 80% of nontraumatic amputations and contributing to a 5-year mortality rate exceeding 30%. Despite significant clinical advances, profound disparities persist. Racial and ethnic minoritized populations, rural communities, and people with low socioeconomic resources experience disproportionate rates of severe ulceration, infection, delayed healing, and amputation. PROBLEM:Traditional research approaches, often developed in academic settings without community input, have insufficiently addressed the contextual, cultural, and structural factors shaping DFU risk and outcomes. APPROACH:Community-engaged research (CEnR) offers a promising pathway to address these inequities; yet, DFU-specific evidence remains limited and heterogeneous. In response, the Diabetic Foot Consortium (DFC), a national research network funded by the National Institute of Diabetes and Digestive and Kidney Diseases, has initiated multisite efforts to embed community advisory boards, faith-based partnerships, mobile outreach, and culturally aligned engagement into DFU research. MODEL:We propose the DFC-CEnR Model, a conceptual framework for integrating community-engaged approaches to DFU prevention, early detection, treatment, and research participation. The model distinguishes CEnR from related approaches (community-based participatory research, patient and public involvement, cultural humility, and equity-focused system interventions), outlining hypothesized mechanisms and evaluation domains. Illustrative consortium examples demonstrate how engagement domains may be operationalized and inform future testing of validated outcome measures. IMPLICATIONS:This article positions community engagement as a hypothesis-generating strategy that requires rigorous empirical testing to determine its impact on DFU outcomes and disparities.
SIGNIFICANCE:Chronic wounds such as diabetic foot ulcers, venous leg ulcers, and pressure ulcers are characterized by impaired healing and persistent inflammation. Cellular senescence, defined as irreversible growth arrest with a pro-inflammatory secretory phenotype (senescence-associated secretory phenotype), has emerged as a potential driver of these nonhealing states. While transient induction of senescence may aid acute repair, chronic accumulation of senescent cells is thought to disrupt tissue regeneration, promote extracellular matrix degradation, and sustain inflammation. RECENT ADVANCES:Single-cell RNA sequencing and spatial transcriptomics have revealed diverse cell states in chronic wounds, including senescent subsets. Studies in diabetic, venous, and pressure ulcers implicate senescent fibroblasts and immune cells in impaired remodeling, often triggered by oxidative stress, hyperglycemia, or ischemia-reperfusion injury. Therapeutic strategies targeting senescent cells in delayed wound healing have demonstrated promise in preclinical models; however, interventions must be timed and targeted precisely. CRITICAL ISSUES:Despite emerging evidence, the identity, abundance, and location of senescent cells in chronic wounds remain poorly defined. Reliance on nonspecific markers such as p21 or SA-β-gal complicates interpretation. Senescence appears to play context-dependent roles, with beneficial effects during acute healing but harmful persistence in chronic wounds, presenting challenges for therapeutic targeting. FUTURE DIRECTIONS:More studies using single-cell RNA sequencing, spatial transcriptomics, and longitudinal profiling are needed to define senescent subpopulations, map their spatial distribution, and track dynamics during wound progression. These approaches will help distinguish transient from persistent senescence. A deeper understanding of interactions with immune, epithelial, and stromal components will guide precisely timed, cell type-specific interventions to improve outcomes.
SIGNIFICANCE:Wound healing is an energetically demanding process that is easily disturbed by metabolic dysregulation. Metabolic dysregulation, induced by diabetes, obesity, insulin resistance, and various hormone imbalances, can disrupt each phase of wound repair, increasing the risk of post-operative complications, infection, wound dehiscence, and pathological scarring. We review the current evidence on the role of metabolic regulation in wound healing and highlight clinically relevant considerations for patient care. RECENT ADVANCES:Animal and human studies have advanced our understanding of how metabolic pathways influence inflammation, angiogenesis, fibroblast function, and extracellular matrix remodeling during wound healing. These insights have led to the development of novel therapies, including hormone-based topical agents and dressings that both sense and modulate metabolites during wound healing. CRITICAL ISSUES:Despite growing recognition of the role of metabolic syndromes and hormonal regulation in wound healing, these factors are insufficiently integrated into clinical wound management. Bridging this gap requires a clear understanding of how metabolic syndromes and hormonal derangements influence healing. FUTURE DIRECTIONS:The continued development of treatments that modulate metabolic and hormonal pathways may enhance wound healing while minimizing systemic risk. Clinicians should also integrate local metabolic optimization with medical and lifestyle management to create the optimal wound healing environment for patients.
OBJECTIVE:Oxidative stress limits mesenchymal stem cell (MSC) efficacy in tissue repair by reducing retention and survival at injury sites. Endogenous production of trehalose may enhance MSC resilience and promote skin wound healing. APPROACH:Trehalose-6-phosphate synthase 1-expressing MSCs (TPS1-MSCs) were engineered via adenoviral transduction. Trehalose content and synthase activity were assessed. Oxidative stress models (H2O2, 0% fetal bovine serum, CoCl2) were used to evaluate reactive oxygen species (ROS), apoptosis, and cell damage. TPS1-MSCs were transplanted into mouse wounds to track retention rate via in vivo imaging. Histology and immunofluorescence were used to assess wound healing, collagen deposition, and angiogenesis. Conditioned medium (CM) was used to evaluate paracrine functions. RNA-seq identified differentially expressed genes, and mechanisms were validated using the NRF2 inhibitor ML385. RESULTS:TPS1-MSCs exhibited TPS1 activity and synthesized trehalose. Under oxidative stress, these cells showed reduced ROS, enhanced viability, and decreased apoptosis. In vivo, TPS1-MSCs displayed higher retention, accelerated healing, and neovascularization. CM from TPS1-MSCs promoted keratinocyte migration, fibroblast collagen secretion, and enhanced the tube-forming capacity of endothelial cells. Transcriptome analysis revealed enrichment in the NRF2-HMOX1 pathway. TPS1-MSCs showed elevated levels of p62, nuclear NRF2, and HMOX1. ML385 treatment impaired the observed antioxidant capacity. INNOVATION:Engineering MSCs for endogenous trehalose synthesis enhanced oxidative stress resistance and retention through NRF2-HMOX1 activation, suggesting a potential novel MSC-based wound repair strategy. CONCLUSION:TPS1-MSCs improved antioxidant capacity and wound healing, potentially through the NRF2-HMOX1 pathway, and may represent a promising therapy for skin wounds. [Figure: see text] [Figure: see text].
Barrier function of human skin maintains hydration by preventing excessive transepidermal water loss (TEWL), blocks the entry of pathogens and allergens, regulates thermal and chemical exchange with the environment, and sustains immune equilibrium. A wound arises when this barrier is breached, resulting in a loss of structural integrity and barrier function. An invisible wound represents a focal loss of human skin barrier function without any visible cut, ulcer, or defect. Despite appearing intact, the skin in these regions is functionally compromised. Current U.S. Food and Drug Administration (FDA) criteria define complete wound closure as full re-epithelialization without drainage or dressing needs, confirmed during two assessments at least 14 days apart. Wounds may satisfy this structural requirement for wound closure yet fail to restore barrier function. Recent studies demonstrate that wounds closed meeting FDA closure criteria but exhibiting elevated TEWL at the wound site (i.e., invisible wound) are more likely to recur, highlighting the clinical importance of achieving functional wound closure. Invisible wounds occur across the lifespan and arise from a wide range of everyday and high-risk exposures. They can result from age-related skin thinning, sunburn, and the routine use of cosmetic chemicals on vulnerable or sensitized skin. They may also develop after minor trauma that leaves no laceration, from mechanical stress imposed by prosthetic use, and from barotrauma or other subclinical mechanical forces commonly encountered by warfighters. Although outwardly undetectable, these silent disruptions weaken the skin's protective barrier, undermine systemic health, and contribute to chronic morbidity.
OBJECTIVE:This study aims to systematically review and summarize existing prognostic models for all-cause mortality in patients with diabetic foot ulcers (DFUs). It further evaluates their characteristics, performance, and methodological quality to inform future model development and clinical application. APPROACH:We searched eight databases from their inception to February 24, 2025. Extracted data included general study characteristics and model-specific information. The prognostic models were classified using the transparent reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis guidelines and evaluated using the Prediction Model Risk of Bias Assessment Tool (PROBAST) to assess the risk of bias (ROB) and applicability. RESULTS:Of the 1,580 retrieved studies, 19 were included, reporting a total of 22 prognostic models. Reported mortality rates among DFU patients ranged from 4.2% to 48.5%, with follow-up durations varying from 12 weeks to 22 years. All studies exhibited a high ROB due to issues with data sources, small sample sizes, inadequate data handling, and model validation flaws. Across the included prognostic models, the most frequently reported predictors were age, cardiovascular disease, renal disease, ulcer severity, ischemia, and serum albumin. INNOVATION:Prognostic assessment of mortality risk in patients with DFUs is critical for effective clinical management. This study systematically evaluated 22 published prognostic models using the PROBAST, identifying key methodological limitations and commonly used predictors. The findings provide a scientific basis for the future development of higher quality, clinically applicable prognostic models. In addition, this work offers valuable insights to inform clinical risk stratification and decision-making for DFU patients. CONCLUSIONS:All included prognostic models demonstrated a high ROB according to the PROBAST assessment. Future research should focus on using larger sample sizes, rigorous study designs, and multicenter external validation to develop more reliable prognostic models. Given the multifactorial nature of mortality risk in DFU patients, multidisciplinary collaboration is essential to improve clinical outcomes.
OBJECTIVE:Diabetes mellitus affects over 25% of adults aged 65+ in the United States and is associated with a heightened risk of developing diabetic foot ulcers. Accumulation of senescent cells within the wound microenvironment can impair cutaneous repair, and senolytic therapies offer a promising approach to accelerate wound healing. APPROACH:In this study, topical fisetin, a flavonoid that promotes apoptosis of senescent cells, was evaluated for its impact on diabetic wound repair. Full-thickness excisional wounds were created on the dorsal skin of diabetic (db/db) mice. Animals were randomized to receive either topical vehicle (n = 12) or fisetin (n = 12) for three consecutive days per week, and wound healing outcomes were longitudinally assessed. RESULTS:Topical fisetin significantly increased the ratio of healthy dermis to granulation by day 7 (p = 0.04) and reduced dermal fibrosis by day 21 (p = 0.03). Fisetin decreased p16+ cells (p = 0.01) but increased p21+ cells (p = 0.02) at day 7 in the dermis, indicating varied effects on senescent cells. M1 macrophages (CD80+) were decreased in the fisetin-treated group (p = 0.05) at day 21, accompanied by a decrease in pro-inflammatory senescence-associated secretory phenotype cytokines, tumor necrosis factor alpha (p = 0.03), and interleukin-1beta (p = 0.01) at day 7. INNOVATION:Fisetin is the first topical seno-modulatory agent shown to enhance wound repair when administered after injury onset. Its favorable safety and efficacy in both modulating senescence and inflammation highlight its potential as a novel therapy for diabetic wounds. CONCLUSION:Topical fisetin enhances diabetic wound healing by reducing fibrosis and promoting healthy dermal regeneration through senescence and inflammation modulation. [Figure: see text].
OBJECTIVE:To determine whether frailty, as quantified using the Five-Item Modified Frailty Index (mFI-5), independently predicts postoperative complications in patients undergoing surgery for diabetic foot ulcers (DFUs), and to assess its utility as a clinical risk stratification tool. APPROACH:A retrospective cohort analysis was conducted using the American College of Surgeons National Surgical Quality Improvement Program database (2015-2021). Adults with type 2 diabetes and International Classification of Diseases, 10th Revision-coded DFUs (E11.621) undergoing elective surgery were identified and stratified into frail (mFI-5 >2) and prefrail (mFI-5 ≤2) groups. Preoperative variables, perioperative characteristics, and 30-day postoperative outcomes were compared using univariate tests, followed by multivariable logistic regression adjusting for clinically relevant confounders. The study design, reporting, and analysis followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for observational cohort studies. RESULTS:Among 2,819 patients, 714 (25.3%) were classified as frail. Frail patients had significantly higher rates of overall complications (50.6% vs. 32.9%), mortality (4.1% vs. 1.6%), and medical complications, including reintubation and urinary tract infection. In adjusted models, frailty independently predicted any postoperative complication (odds ratio [OR] = 1.34, 95% confidence interval [CI] 1.05-1.70, p = 0.02) and medical complications (OR = 1.53, 95% CI: 1.12-2.07, p = 0.007). INNOVATION:This is the first large-scale study applying the mFI-5 to DFU surgery, demonstrating that frailty provides prognostic information beyond traditional comorbidity-based assessments and offers a rapid, objective tool for perioperative risk evaluation. CONCLUSION:Frailty, as measured by the mFI-5, independently predicts postoperative morbidity and mortality after DFU surgery. Incorporating preoperative frailty screening may improve surgical decision making, resource allocation, and enhance outcomes in this high-risk population.
SIGNIFICANCE:Diabetic foot ulcers (DFUs) represent one of the most devastating complications of diabetes, leading to high rates of amputation and mortality. Their multifactorial pathogenesis-including neuropathy, ischemia, infection, and immune dysfunction-creates a chronic inflammatory microenvironment that impairs tissue repair and regeneration. RECENT ADVANCES:Emerging regenerative strategies using stem cells and extracellular vesicles (EVs) have demonstrated potential to restore vascularization and modulate inflammation. In particular, miRNA-enriched EVs regulate key wound-healing pathways such as angiogenesis, extracellular matrix remodeling, and oxidative stress response. Meanwhile, small-molecule drugs targeting hypoxia and inflammatory cascades are being explored to enhance re-epithelialization and fibroblast migration. Parallel advances in artificial intelligence (AI) and optical sensing-using visible, infrared, or hyperspectral imaging-enable automated wound detection, tissue classification, and healing prediction with high accuracy. CRITICAL ISSUES:Despite these developments, translation remains limited by unstable therapeutic efficacy, variable biomarker expression, and the absence of standardized evaluation systems. AI-based wound assessment requires robust datasets and clinical validation to ensure reliability across diverse populations. FUTURE DIRECTIONS:Integrating molecular-targeted therapies with AI-assisted diagnostic platforms could establish a next-generation DFU management framework-combining precise molecular intervention, automated wound monitoring, and personalized treatment planning-to achieve reliable, real-time, and patient-centered wound care.
OBJECTIVE:The expected increase in age-related health care costs over the coming decades underscores the need to characterize the effects of biological aging in our cells and tissues. Our objective is to use in vivo multiphoton microscopy (MPM) to find endogenous biomarkers of skin aging. APPROACH:MPM was performed on the skin of 2- and 21-month-old mice to measure the autofluorescence of metabolic cofactors, nicotinamide adenine dinucleotide (NADH) and flavin adenine dinucleotide (FAD), and second-harmonic generation signal from collagen. A suite of quantitative biomarkers with sensitivity to age-related changes in bioenergetic demands, mitochondrial organization, and collagen composition and organization was evaluated using these optical sources of contrast. RESULTS:An optical redox ratio of FAD/(NADH + FAD) autofluorescence, NADH fluorescence lifetime imaging, and mitochondrial fractal dimension measurements indicated that aged keratinocytes have more fragmented mitochondria that undergo less catabolism of carbon substrates. Analysis of the dermal regions indicated that aged collagen has more nonenzymatic cross-links and has a more fragmented organization. INNOVATION:This study identifies a suite of biomarkers from label-free MPM sensitive to intrinsic aging and provides the first in vivo demonstration of sensitivity to age-dependent metabolic changes in skin through multiple independent optical parameters. CONCLUSION:Our results demonstrate that surrogate markers of metabolic function, mitochondrial organization, collagen cross-linking, and fiber organization are sensitive to a loss of homeostasis with advanced age and may be used in future studies to longitudinally assess the progression of aging.
