JSUR Journal

Introduction

Pressure Injuries (PIs), also known as pressure ulcers, are localized tissue damage caused by prolonged exposure to pressure, shear, and friction, particularly over bony prominences [1]. In patients with Diabetes Mellitus (DM), the risk and severity of PIs are significantly elevated due to a combination of metabolic and vascular factors, including chronic hyperglycemia, peripheral neuropathy, microangiopathy, and immune dysfunction. Thesefactors collectively contribute to impaired tissue perfusion, sensory dysfunction, and delayed wound healing. Consequently, patients with diabetes are not only more vulnerable to PIs but also face prolonged healing times, higher infection rates, increased mortality, and elevated healthcare costs. These clinical characteristics underscore the urgent need for  in-depth research on the relationship between diabetes and pressure injuries [2-4]. In recent years, the global incidence of diabetes has continued to rise, and population aging has further accelerated research related to the disease. Notably, significant progress has been made in understanding the healing mechanisms of diabetic wounds. Many studies have investigated the molecular mechanisms underlying impaired diabetic wound healing and explored novel therapeutic approaches, including exosomes, antimicrobial hydrogels, and tissue engineering [5-7]. Despite continuous advances in this field, the rapid expansion of literature presents challenges in identifying research trends and integrating knowledge. Currently, there is a lack of quantitative analysis to systematically evaluate the research landscape, key topics, and collaboration networks in the field of diabetic pressure injury healing. Bibliometrics is a systematic and quantitative approach used to objectively assess developmental patterns, research structures, and dynamic changes within specific scientific fields. Unlike traditional systematic reviews, which focus on specific clinical or mechanistic issues, bibliometrics enables the construction of knowledge graphs, identification of core research contributors, and detection of research hotspots and emerging trends [8]. Given the continuous increase in basic and clinical studies on diabetic Pressure Injuries (PIs), a comprehensive bibliometric analysis is urgently needed to synthesize existing knowledge, identify key contributors, and guide future research directions. Therefore, this study aimed to conduct a comprehensive bibliometric analysis of the research landscape on diabetic pressure injuries using literature from the Web of Science Core Collection and visualization tools including CiteSpace, VOSviewer, and HistCite. The study investigates publication trends, geographic and institutional distributions, core authors and journals, as well as high-frequency keywords and their temporal evolution, aiming to provide a scientific foundation and reference for future basic, clinical, and translational research.

Materials and Methods

Data Sources and Search Strategy

In this study, English-language literature was retrieved from the Web Of Science (WoS) Core Collection using the search query: TS = (“pressure injury” OR “pressure ulcers” OR “pressure sore” OR “pressure sores” OR “pressure injuries”) AND TS = (“diabetes” OR “diabetic” OR “diabetic mellitus” OR “diabetes mellitus” OR “diabetics”). The search period covered the database’s inception through 5 December 2024. A total of 913 English-language articles were initially identified. Inclusion criteria comprised original research and review articles focused on pressure injuries in patients with type 2 diabetes mellitus (T2D). Exclusion criteria included conference abstracts, book chapters, and studies not directly related to diabetic pressure injuries. Two researchers independently screened the records according to predefined inclusion and exclusion criteria. Duplicate records were removed using the “Remove Duplicates” function in CiteSpace, resulting in 410 English-language articles included for further analysis (Figure 1).

Figure 1: Flow chart of literature screening.

Bibliometric Analysis and Data Visualization

All included literature records were downloaded in the “Full Records and Cited References” format and exported as plain text files. CiteSpace (version 6.3 R1), VOSviewer (version 1.6.20), R (version 4.3.3), and the online platform Bibliometric. com were used for bibliometric analysis and data visualization. Using CiteSpace, this study generated visual knowledge maps illustrating co-occurrence, clustering, and burst detection of authors, institutions, countries/regions, and keywords, along with a dual-map overlay analysis of journals. The time slice was set to one year per slice, covering the period from 1999 to 2024. The threshold (Top N per slice) was set to 50; the pruning algorithm used was Pathfinder, with all other parameters set to default. The international collaboration network among countries was further analyzed and visualized using VOSviewer and Bibliometric.com.

Results and Analysis

Global Research Landscape and National Collaboration Patterns in Diabetic Pressure Injury Studies

Of the 410 analyzed publications, 315 were original research articles and 95 were reviews, contributed by researchers across 44 countries. As shown in Figure 2A, the research output is primarily concentrated in North America, Europe, and parts of Asia. The United States ranked first with 160 publications (32.92%), followed by China (58, 11.93%) and Japan (22, 4.53%) (Supplementary Table 1). Figure 2B shows a steady increase in annual publication volume from 1999 to 2024, with a marked acceleration after 2018, indicating growing academic attention to this field. Among all contributimng countries, 20 countries issued more than five papers (Figure 2C-D). The top 10 countries were compared in terms of publication count, citation frequency, and international collaboration. The United States not only produced the highest number of publications but also had the highest citation count (6,176), demonstrating strong academic influence. Although China published fewer articles (58), its citation count has grown

rapidly (643), indicating increasing international recognition of its research output. Despite a relatively low number of publications, the United Kingdom had a high citation frequency, suggesting high research quality. In the international collaboration network, the United States had the closest ties with China and the United Kingdom and occupied a central position. Germany, although contributing only 15 publications, ranked first in centrality (0.47), highlighting its pivotal role in global scientific collaboration. Notably, Israel and Iran also ranked among the top ten, reflecting growing global attention to the risk assessment and management of diabetic pressure injury. Overall, North America, Europe, and several Asian countries have established a highly interactive, multinational scientific research network in this field (Supplementary Table 1).

Supplementary Table 1: The top 10 countries by number of published works.

Figure 2: (A) Geographic distribution of diabetic pressure injury, period 1994 to 2024; (B) The number of publication frequency for each year from 1994 to 2024; (C) Global cooperation in publishing; (D) Analysis of countries/regions.

Author Collaboration and Co-Citation Patterns in Diabetic Pressure Injury Research

This study utilized CiteSpace to perform an author-level analysis of 410 publications related to diabetic pressure injury, aiming to identify prolific authors and their co-authorship networks. As shown in Figure 3, the co-authorship network comprises 312 nodes and 403 links, with a network density of 0.0083, indicating relatively limited collaboration among research teams. Authors with three or more publications were classified as highly productive. Representative authors include Fromy B, Abdellatif Ahmed, Saumet JL, Breitbart AS, Kerstein MD, Levy Ayelet, and Mason JM, each of whom formed multiple relatively independent collaborative subnetworks. These subnetworks show strong internal cohesion but weak inter-network collaboration, suggesting that the research field remains relatively fragmented. The research team led by Abdellatif Ahmed has made significant contributions to studies on the mechanisms of diabetic pressure injury and the development of novel therapies. The team led by Kerstein MD (1999) focused on chronic wound treatment strategies, including biotherapy, tissue engineering, and home care, and has had a lasting academic impact in this field. The weak connections among major author groups in the overall network further confirm that current collaborations are mostly localized and lack interdisciplinary integration. Supplementary Table 2 lists influential authors in the field, with an average citation rate of 26.93 per article, reflecting strong academic impact. We also conducted an author co-citation analysis. When two authors are cited together in the same publication, they are considered to share a co-citation relationship; the higher the co-citation frequency, the closer their conceptual linkage. To further identify core authors, we extracted 11,610 first-author citation records from 410 publications, resulting in 13,946 total citation events, with a minimum citation threshold of 15. As shown in Supplementary Figure 1, the co-citation analysis generated a network of 70 researchers grouped into three major clusters. The most frequently cited authors were Robson MC (79 citations), Falanga V (67), and Cox J (58).

Figure 3: The visualized network of co-authorship of authors in the field of diabetic pressure injury researches. Nodes represent authors, the number of published papers is presented as the size of the node, and the connection represents the existence of a cooperative relationship between the two authors. The more collaborations you have, the thicker the connection. The denser the network of collaboration between authors, the closer the academic collaboration.

Supplementary Table 2: The top 10 authors by number of published works.

Supplementary Figure 1

Core Terminologies and Evolving Trends in Diabetic Pressure Injury Literature

Keyword co-occurrence analysis is effective for identifying research hotspots and developmental trends in the field of diabetic pressure injury. In this study, we used CiteSpace to analyze keywords from 410 articles and generated a co-occurrence network after merging synonyms (Figure 4). The top 10 high-frequency keywords, each appearing more than 28 times, are listed in Table 1. Keyword frequency and first appearance year reflect the importance and evolution of each research topic. Core keywords such as “pressure ulcers”, “risk factors”, “diabetic foot ulcers”, “wound healing”, and “management” appear frequently and serve as key nodes in the co-occurrence network, forming the structural foundation of research hotspots and showing strong connectivity with related terms. Among these, “pressure ulcers” and “risk factors” are the most frequently occurring. “Pressure ulcers” reflect multi-dimensional discussions on chronic wounds and their clinical management, including risk factor identification, nursing interventions, animal model development, and pathological assessment criteria. “Risk factors” primarily relate to risk assessment and preventive strategies in elderly populations and individuals with chronic diseases [9-14]. Additionally, “diabetic foot ulcers” and “wound healing” have received increasing attention in recent studies, reflecting a growing concern for diabetes-related chronic wounds [9,12]. Network centrality analysis indicates that “pressure ulcers” and “diabetic foot ulcers” are structural hubs, playing a central role in maintaining network stability. In summary, current research continues to emphasize the pathogenesis and risk factors of pressure ulcers and chronic wounds, particularly among diabetic patients, the elderly, and long-term bedridden individuals. Simultaneously, increasing efforts have been directed toward understanding wound healing mechanisms and optimizing preventive strategies [10,15,16].

Figure 4: Keyword co-occurrence diagram. Each keyword is usually represented by a node, and the size of the node indicates how often the keyword appears in the literature; The co-occurrence relationship between keywords is represented by a line, and the thickness of the line indicates the number of co-occurrences, and the thicker the line, the higher the co-occurrence frequency of the two keywords, and the closer the relationship. Keywords with large nodes and more connections in the network usually represent research hotspots in the field, and these hot topics are the focus of current scholars.

Table 1: The top 10 high-frequency keywords in the research frequency of diabetic pressure injury from 1999 to 2024.

Multistage development in 25 years of keyword evolution (1999-2024)

To more effectively refine research topics related to diabetic pressure injury, this study employed keyword clustering analysis using CiteSpace. Cluster numbers begin with #0 (the largest cluster) and decrease in size sequentially. Based on literature from 1999 to 2024, a keyword co-occurrence network was constructed using the Pathfinder algorithm with a 1-year time slice (Figure 5A). A total

of 10 clusters were identified, comprising 211 nodes and 328 links. The modularity (Q value) of 0.7639 indicates a well-defined clustering structure with reasonable separation. The average silhouette score was 0.8895/0.8937 (timeline chart), suggesting high internal consistency and strong reliability of the clusters. Keywords in cluster #0 include “diabetic foot ulcers”, “foot ulcers” “multicenter”, “platelet-rich plasma”, and “efficacy”. For details of keywords in other clusters, see Supplementary Table 3. These ten clusters can be grouped into three major research directions: (1) chronic wound types, including diabetic foot ulcers, diabetic ulcers, pressure ulcers, and pressure injuries. This line of research emphasizes innovative therapies, identification of key risk factors, and both technical and economic challenges associated with chronic wound management [17,18]. These studies underscore the clinical significance and societal burden of chronic wounds, providing valuable guidance for management and future investigations [14,19,20]. (2) Pathological mechanisms and epidemiology, covering complications, prevalence, risk factors, and endothelial dysfunction. The study examined the significant impact of chronic diseases (such as cardiovascular disease, diabetes, and kidney disease) and complications (including anemia, malnutrition, and incontinence) on the development of pressure ulcers in older adults. Studies indicate that chronic diseases significantly elevate the risk of pressure ulcers in the elderly, particularly in individuals with diabetes, and support the need for a multidisciplinary prevention strategy [9,21,22]. (3) Wound treatment and tissue repair, including topics such as biofilm formation and tissue regeneration. This research area focuses on the efficacy and mechanisms of novel biomaterials and molecular interventions [23]. Based on 410 publications from the Web of Science Core Collection, the CiteSpace keyword burst detection algorithm was applied to identify research highlights. After merging synonyms and setting the minimum burst duration to two years, 19 keywords with the highest burst intensities were identified (Figure 5B). Keywords with a burst intensity greater than 3.5 included “chronic pressure ulcers”, “risk”, “prevalence”, “pressure injuries”, and “ulcers”. Those with burst durations longer than four years were “chronic pressure ulcers” ,“chronic wounds”, “diabetic foot ulcers”, “prevalence”, and “predictors”. Keywords that remained active in recent years include “prevalence”, “predictors”, “pressure injuries”, “critical care”, “risk factors”, and “intensive care units”. The keyword time-zone map (Figure 5C) illustrates the dynamic evolution of research focus in this field over the past 25 years, which can be broadly categorized into three stages. During the first stage (1999-2007), keywords such as “management”, “care”, “diabetic foot ulcers”, “risk factors”, and “chronic wounds” reflected a primary emphasis on risk assessment and the treatment of pressure ulcers and chronic wounds [24,25]. In the second stage (2008-2015), the emergence of keywords like “prevention”, “therapy”, “wound healing”, “prevalence”, and “mortality” indicated a research shift toward epidemiological characteristics, predictive models, treatment strategies, and the economic burden of disease, contributing to the advancement of precision care [15,21,26,27]. In the most recent stage (2016-2024), research has increasingly focused on integrating risk prediction models with epidemiology, as highlighted by keywords such as “intensive care units”, “impact”, “predictors”, and “hospitalized patients”. Moreover, this phase marks a growing interest in novel therapeutic approaches, including nanostructured bioactive glass composite hydrogel membranes [28-30].

Figure 5: Analysis of keywords. (A) Keyword visualization clusters related to diabetic pressure injury; (B) The strongest citation burst; (C) The timeline viewer related to keywords.

Supplementary Table 3: Keyword cluster analysis based on co-occurrence data from diabetic pressure injury research using CiteSpace. Each row represents a keyword cluster ranked by size.

Institutional Collaboration Network Reveals Global Research Hubs and Evolving Partnership Trends

This study employs the Institution module in CiteSpace to analyze research institutions involved in diabetic pressure injury, with the threshold set at 8. As shown in Figure 6, the collaboration network comprises 184 nodes and 113 links, with a network density of 0.0067, indicating relatively weak inter-institutional collaboration. Leading institutions in publication volume include the Centre National de la Recherche Scientifique, Boston University, the University of California system, and Cardiff University. These institutions demonstrate strong expertise in clinical medicine, public health, and biomedical research. According to Supplementary Table 4, most top institutions are based in Europe and North America-particularly the United States, France, and the United Kingdom-highlighting the international nature of research in this field. The peak period of institutional collaboration occurred between 2000 and 2010, followed by a gradual expansion across regions and disciplines. Notably, participation from developing countries has increased in recent years; for instance, the Egyptian Knowledge Bank (EKB) has been active since 2011. Nevertheless, the current institutional collaboration network remains relatively fragmented. Strengthening cross-institutional and cross-regional collaboration is essential for advancing research and development in the field of diabetic pressure injury.

Figure 6: Institutional Collaboration Mapping Analysis. Node size is proportional to the number of publications from each institution, while link thickness represents the strength of collaboration.

Supplementary Table 4: Top 10 institutions in the number of publications.

Core Journal Clusters and Citation Pathways in Diabetic Pressure Injury Research

Co-citation analysis identified the most influential journals in the field, with Wound Repair and Regeneration, International Journal of Wound Care, Journal of Wound Nursing, Advances in Skin and Wound Nursing, Plastic and Reconstructive Surgery, and Advances in Wound Care being the most frequently cited. Three major clusters emerged in the co-citation network (Figure 7A). The largest cluster (red) focuses on wound management and geriatrics, led by the International Wound Journal, and includes studies on various wound types, pathophysiology, and care strategies. The second cluster (green) centers on wound healing, dermatology, and reconstructive surgery, with Wound Repair and Regeneration and Plastic and Reconstructive Surgery as representative journals. The third cluster (blue) highlights innovations in wound care, including care technologies, product applications, and biomaterials, with Advances in Wound Care and Biomaterials as core journals. The overlay visualization (Figure 7B) depicts interdisciplinary knowledge flow among journals. The yellow path indicates frequent citations from molecular and immunology journals to those in health, nursing, and medicine, while the green path represents citations to clinical medical journals. The Health, Nursing, and Medicine category shows the highest citation impact in the field (Supplementary Table 5).

Figure 7: Analysisi of co-cited journals. The dual-map overlay of journals related to diabetic pressure injury. Different colors represent different clusters, and the larger the node, the more times it will be co-cited. The thicker the line, the stronger the relationship between them.

Supplementary Table 5: Citation trends at a domain level.

Co-Citation Cluster Analysis Reveals Core Themes And Temporal Evolution in Diabetic Pressure Injury Research

A co-citation analysis of 410 publications was conducted using CiteSpace, resulting in a network comprising 371 nodes and 637 links. Ten major topic clusters were identified, demonstrating a well-defined structure modularity Q = 0.9294; average silhouette = 0.9763), indicating high clustering quality (Figure 8A). The largest cluster, #0 “risk factor,” reflects strong co-citation intensity around riskrelated research. A lower cluster number generally corresponds to higher relative importance in diabetic pressure injury research. Early research hotspots focused on clusters such as #8 “age-related changes” (1997), #4 “accelerated healing” (2001), and #7 “stressinduced cutaneous vasodilation” (2002). Mid-stage topics were represented by clusters including #9 “care” (2007), #6 “elderly person” (2014), #2 “infected diabetic pressure ulcer” (2016), and #0 “risk factor” (2016). Recent hotspots have shifted toward #1 “retrospective cohort study” (2018), #3 “intensive care patients” (2020), and #5 “chronic wound study” (2021), reflecting an increasing emphasis on clinical evidence, critical care, and chronic wound management in diabetic patients. These clusters revealed several pivotal studies that significantly contributed to the understanding of diabetic pressure injury. For example, Han G (2017), Armstrong DG (2017), and Mervis JS (2019) produced influential findings that advanced research in this field. The top 10 most-cited publications (Table 2) are primarily concentrated in clusters #0, #1, #2, #3, and #6, reflecting the evolution of the knowledge base and shifts in research focus within the field.

The emergent analysis (Figure 8B) illustrates the evolving research focus and the influence of key publications in the field of diabetic pressure injury. Nussbaum et al. (2018) exhibited the strongest citation burst (intensity = 5.7, 2020-2022), underscoring the clinical and economic urgency of the disease. Other key emergent works, such as Jaul et al. (2018) (intensity = 5.47), and more recent studies by Wei M (2020), Mervis JS (2019), and Chaboyer WP (2018), highlight growing attention to issues including prevalence, risk prediction, and aging populations. Crimson nodes represent emergent literature identified by the Kleinberg algorithm, marking pivotal turning points in the research field. Emerging themes such as “risk factor,” “ICU patient,” and “retrospective cohort study” are primarily concentrated in clusters #0, #1, #2, #3, and #6 (Supplementary Figure 2). Notably, cluster #1 shows a strong citation connection to literature published in 2022, with a citation share exceeding 12%, indicating its cutting-edge relevance (Supplementary Table 6). Scholars such as Mervis JS and Edsberg LE have substantial influence in the field and represent leading contributors to ongoing research.

Figure 8: Co-citation cluster analysis and citation burst detection of references in diabetic pressure injury research.

Table 2: Top 10 most frequently co-cited references.

Supplementary Table 6: Citing articles of cluster #1 retrospective cohort study.

Supplementary Figure 2