OBJECTIVE -The purpose of this study was to evaluate the effectiveness of a removable cast walker (RCW) and an "instant" total contact cast (iTCC) in healing neuropathic diabetic foot ulcerations. RESEARCH DESIGN AND METHODS -We randomly assigned 50 patients withUniversity of Texas grade 1A diabetic foot ulcerations into one of two off-loading treatment groups: an RCW or the same RCW wrapped with a cohesive bandage (iTCC) so patients could not easily remove the device. Subjects were evaluated weekly for 12 weeks or until wound healing.RESULTS -An intent-to-treat analysis showed that a higher proportion of patients had ulcers that were healed at 12 weeks in the iTCC group than in the RCW group (82.6 vs. 51.9%, P ϭ 0.02, odds ratio 1.8 [95% CI 1.1Ϫ2.9]). Of the patients with ulcers that healed, those treated with an iTCC healed significantly sooner (41.6 Ϯ 18.7 vs. 58.0 Ϯ 15.2 days, P ϭ 0.02).CONCLUSIONS -Modification of a standard RCW to increase patient adherence to pressure off-loading may increase both the proportion of ulcers that heal and the rate of healing of diabetic neuropathic wounds. Diabetes Care 28:551-554, 2005A melioration of pressure, shear, and repetitive injury to the sole of the foot are principal tenets of neuropathic ulcer care. Total contact casts (TCCs) are considered the gold standard in redistribution of pressure over the plantar aspect of the diabetic foot (1-7). TCCs have been shown to reduce pressure at the site of ulceration by 84 -92% (8), and there is a large body of work that supports the TCC's clinical efficacy. In two randomized controlled trials comparing the proportion of healed ulcers treated with a TCC compared with other readily available and popular devices (removable cast walkers [RCWs], half-shoes, and therapeutic depth inlay shoes) TCCs, healed a higher proportion of wounds compared with other modalities (7,9). This was an interesting finding because certain types of RCWs, including one used in one of the above-mentioned trials, often reduce pressure on the plantar aspect of the foot as well as TCCs (9). If patients do not heal as well in the RCW and yet it off-loads pressure about as well as the TCC, then a logical explanation for their less effective clinical performance is that these devices are being removed by the patients that use them (10).In an effort to make the RCW more efficacious, we have modified it slightly by merely wrapping the traditional RCW in a layer of cohesive or plaster bandage. This technique has been termed the "instant" TCC (iTCC) (11). It has been our initial experience that this technique is clinically successful. If clinical results are superior to those with the RCW, we believe it could potentially auger a significant shift in the current standard of care in pressure reduction (off-loading) of diabetic wounds. We are unaware of any reports in the literature that have compared a standard RCW with the iTCC. The purpose of this project was to evaluate the effectiveness of a traditional RCW and the iTCC to heal neuropathic foot ulcerations in pa...

The identification of neurological symptoms caused by vitamin A deficiency pointed to a critical, early developmental role of vitamin A and its metabolite, reti-

How stem cells give rise to epidermis is unclear despite the crucial role the epidermis plays in barrier and appendage formation. Here we use single cell-RNA sequencing to interrogate basal stem cell heterogeneity of human interfollicular epidermis and find four spatially distinct stem cell populations at the top and bottom of rete ridges and transitional positions between the basal and suprabasal epidermal layers. Cell-cell communication modeling suggests that basal cell populations serve as crucial signaling hubs to maintain epidermal communication. Combining pseudotime, RNA velocity, and cellular entropy analyses point to a hierarchical differentiation lineage supporting multi-stem cell interfollicular epidermal homeostasis models and suggest that transitional basal stem cells are stable states essential for proper stratification. Finally, alterations in differentially expressed transitional basal stem cell genes result in severe thinning of human skin equivalents, validating their essential role in epidermal homeostasis and reinforcing the critical nature of basal stem cell heterogeneity.

Introduction: Currently, diagnosis of patients with postural instability relies on a rudimentary clinical examination. This article suggests an innovative, portable, and cost-effective prototype to evaluate balance control objectively. Methods: The proposed system uses low-cost, microelectromechanical sensor, body-worn sensors (BalanSens™) to measure the motion of ankle and hip joints in three dimensions. We also integrated resulting data into a two-link biomechanical model of the human body for estimating the two-dimensional sway of the center of mass (COM) in anterior-posterior (AP) and medial-lateral (ML) directions. A new reciprocal compensatory index (RCI) was defined to quantify postural compensatory strategy (PCS) performance. To validate the accuracy of our algorithms in assessing balance, we investigated the two-dimensional sway of COM and RCI in 21 healthy subjects and 17 patients with diabetic peripheral neuropathic (DPN) complications using the system just explained. Two different conditions were examined: eyes open (EO) and eyes closed (EC) for duration of at least 30 seconds. Results were compared with center of pressure sway (COP) as measured by a pressure platform (Emed-x system, Novel Inc., Germany). To further investigate the contribution of the somatosensory (SOM) feedback to balance control, healthy subjects performed EO and EC trials while standing on both a rigid and a foam surface. Results: A relatively high correlation was observed between COM measured using BalanSens and COP measured using the pressure platform ( r = 0.92). Results demonstrated that DPN patients exhibit significantly greater COM sway than healthy subjects for both EO and EC conditions ( p < 0.005). The difference becomes highly pronounced while eyes are closed (197 ± 44 cm2 vs 68 ± 56 cm2). Furthermore, results showed that PCS assessed using RCI is significantly better in healthy subjects compared to DPN subjects for both EO and EC conditions, as well as in both ML and AP directions ( p < 0.05). Alteration in SOM feedback in healthy subjects resulted in diminished RCI values that were similar to those seen in DPN subjects ( p > 0.05). Discussion/Conclusion: This study suggested an innovative system that enables the investigation of COM as well as postural control compensatory strategy in humans. Results suggest that neuropathy significantly impacts PCS.

OBJECTIVE -Pressure mitigation is crucial for the healing of plantar diabetic foot ulcers. We therefore discuss characteristics and considerations associated with the use of offloading devices. RESULTS -Of the 895 respondents who treat diabetic foot ulcers, shoe modifications (41.2%, P Ͻ 0.03) were the most common form of pressure mitigation, whereas total contact casts were used by only 1.7% of the centers. RESEARCH DESIGN AND METHODSCONCLUSIONS -This study reports the usage and characteristics of offloading devices in the care of diabetic foot ulcers in a broadly distributed geographic sample. Less than 2% of specialists use what has been termed the "gold standard" (total contact cast) for treating the majority of diabetic foot ulcers.