Nursing 论文代写 : 糖尿病足溃疡化脓性病变和疼痛的疾病代谢性并发症引起的脚。感觉下降减少injury.3h此外意识，伤口愈合障碍导致不断的暴露和伤口感染。细菌可以进入血流，威胁着患者的lives.3f一些慢性感染伤口的普通居民是真菌和protozoan.3i
Diabetic foot ulcers are suppurating lesions and sores on the feet induced by metabolic complications of the disease. Decreased sensation reduces the awareness of injury.3h In addition, impaired wound healing leads to constant expose and infection of the wound. Bacteria can enter the bloodstream and threaten patients' lives.3f Some of the common inhabitants of chronically infected wounds are fungi and protozoan.3i
Statistic revealed that around one out of four people diagnosed with diabetes tends to develop foot problems.3a This complications are growing dramatically and have the potential of becoming a more devastating epidemic. It is now the most common cause of non-traumatic lower extremity amputations with risk of 15 to 46 times higher in diabetics than those who do not have diabetes.1a,1b
In chronic cases, debridement is necessary and vital in order to remove waste, infectious matter and dead tissue from wounds. It prepares a wound for the application of specialty healing aids and stimulates natural healing. What is the option for debridement for chronic and infected diabetic foot ulcer? I'm going to discuss about this in this report.
DiabeticFootUlcer350w.jpg
Diagram 1: Chronic foot ulcer
http://biofilmbook.hypertextbookshop.com/public_version/contents/chapters/chapter003/section002/blue/page001.html
A Possible Solution - Maggot Debridement Therapy
In my opinion, maggot debridement therapy (MDT) is a very effective and simple method of debridement for chronic and infected diabetic leg ulcer.
As of 2008, maggot therapy was being used in around 1000 medical centers in Europe and over 300 medical centers in the United States.
Ngan 20083r
The most commonly used maggot is Phaenicia sericata (P. sericata), the larvae of green blowfly.3l It is categorized in the Diptera order of insects.3r In 12 to 24 hours, the larvae can hatch from eggs.3q They are available in sterile form, thus patients don't have to worry that they'll convert into pupa or flies while inside the wound.3m
Maggots can be applied on the wounds either directly or with a dressing.3b Normally, a range of five to ten maggots are placed on each centimetre square of a wound.3d The maggots are removed after 2-3 days and are constantly replaced until thorough debridement is carried out. However, it is imperative to note that the ulcer is kept moist and well aerated.3q 200px-Maggots.jpg
Maggots in a wound
http://en.wikipedia.org/wiki/Maggot_therapy
There are several mechanisms that maggots work in the process of debridement. First of all, they secrete proteolytic enzymes to digest the necrotic tissue and thus remove unwanted tissue.3c They can consume necrotic tissue precisely without damaging the healthy tissue. 3j
Besides that, maggots can combat bacterial infections through one of its waste product - ammonia.2a As ammonia increases the wound pH, it makes the whole condition alkaline which is unfavourable for the survival of many bacteria species.3p
In addition, larvae of P. sericata carry in their midgut a commensal, Proteus mirabilis. These commensals produce agents such as phenylacetic acid (PAA) and phenylacetaldehyde (PAL), with known antibacterial properties.
Yamni Nigam, Alyson Bexfield, Stephen Thomas and Norman Arthur Ratcliffe
Oxford Journal2a
As it digests the wound bacteria, they are killed as they pass through the maggot's digestive tract.3k It also exudes powerful antibacterial agents that can inhibit or kill harmful pathogens.3o
Maggot therapy improves healing of wound by producing fibroblast stimulating chemicals. This chemical encourages the start of granulation process by fibroblast. As granulation tissue is formed, the defect is filled and wound is healed.3c A significant decrease of offensive odour emanating from the necrotic tissue and the intense pain accompanying the wound can also be observed. 3e
Efficiency of Maggot Debridement Therapy
Maggots had been known for centuries as excellent micro-surgeons. Below are some experiment data and case study that have been collected to prove the reliability and validity of maggot therapy.
In 1995, an 86-year-old female who has four-year history of circumferential leg ulceration with Pseudomonas and MRSA infections regain healthy granulation tissue after only four days of larval treatment. Besides, signs of infection are no longer observed.3g Throughout military history, many other positive comments are also recorded.3q
Ronald A. Sherman, MD, MSC from California had successfully conducted an experiment showing the speed of debridement and the generation of new healthy tissue in 20 chronic and non-healing wounds in maggot therapy as compared to conventional therapy.2c
MDT-treated wounds saw a 50% reduction in necrotic surface area ("half-debrided") in 9 days, whereas conventionally treated wounds did not reach that stage until day 29 (PÂ < 0.001). Within 4 weeks, maggot-treated wounds were completely debrided, whereas wounds treated with conventional therapy for an average of 5 weeks were still covered with necrotic tissue over 33% of their surface (PÂ = 0.001).
American Diabetes Association2c
Table below are the summary of all the experiments conducted that compare the debridement rate of maggot therapy and with hydrogels.Capture2.PNG
http://www.zoobiotic.co.uk/literature/JWC-Nov-06-Zoobiotic-Pages.pdf2d
Meanwhile, Robinson and Norwood reported the destruction of ingested microbes in maggot's digestive tract. The stomach and crop were contaminated with viable bacteria.2a This is confirmed by Mumcuoglu et al by showing ingestion of fluorescent Escherichia coli in the alimentary tract of P. sericata using confocal microscopy.1c
Pascal Steenvoorde, Catherien E Jacobi, Louk Van Doorn and Jacques Oskam also conducted an experiment on 101 patients who have chronic leg ulcer. Of the 117 wounds treated with MDT, 67% had beneficial outcomes while 33% had unsuccessful outcomes. Nevertheless, all wounds with septic arthritis (n = 13) failed to heal. This turns out to be one of the limitations of the therapy.2b Table below are the data collected by them.Capture.PNG
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2121226/pdf/rcse8906-596.pdf2b
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Another study of secretions from aseptically raised larvae whose immunological profile was unaffected by microbial contact were conducted by Thomas et al.. By demonstrating ultrafiltration fractions against S.aureus using a turbidometric assay, he showed that >10kDa was free of antibacterial activity.2a This is clearly portrayed in figure(a).
nel022f1.jpeg
http://ecam.oxfordjournals.org/cgi/content/full/3/3/3032a
In conclusion, Maggot therapy has shown its reliability in treating chronic and infected diabetic leg ulcer through various experiments and case studies.
Implications
Below are some implications encountered by maggot therapy.
Ethical
Should the patients have the choice of choosing the method of debridement? This ethical issue arises due to psychological and esthetical considerations. It is imperative to note that maggots are generally characterised as "disgusting creatures" as they are commonly found on dead bodies where necrotic tissue are abundant. Therefore, not all the people can accept the fact that there are larvae crawling in their legs all the times while the debridement is carried out.3k Some people could have strong sense of phobia towards maggots. In fact, in some cases, patients might tend to have the tickling sense of maggots in their legs and even pain which may not be true and are resulted from their constant stress and fear. Â
Nevertheless, in a significant number of patients, it might results in amputation and thus loss of complete movement ability if maggot therapy is not carried out.3e Furthermore, in some countries, there might not be enough awareness and publication of maggot therapy that can results in ignorance of patients over the existence of such therapy and its efficiency. Therefore, whether patients should have control over the method of debridement has become an issue to be solved.
Social
Another issue to be discussed and looked over is the use of sterile maggots and look for licensed professional practitioner. There are thousands of other species of maggots despite of the fact that the species used to make medical grade maggots are found in the wild. There are case reports of allergy to Asticot larvae in occupationally exposed workers.3t Hence, patients need to be aware that not all the species are safe, effective and suitable to be used on the ulcers. Furthermore, wild maggots may carry pathogens that are even more harmful than the one already on the wound which in turn put your life at risk. Therefore, it is vital that medical grade maggots have been demonstrated to be germ-free, safe and effective.3s Normal methods of sterilization such as autoclaving cannot be utilized.3w People from poor background might simply test on maggots available, hoping that it will bring cure to the ulcer. It's vital for them to understand that maggot therapy is to be carried out under recommended and licensed medical doctor.3t
Benefits and risks
Benefits
With the possibility and efficiency that maggot therapy can offer, people with chronic and infected diabetic foot ulcer gain hope in healing. There is reduced risk of undergoing amputation. Patients recovered from maggot therapy able to retain their full ability of motion. Moreover, it doesn't contribute to another antibiotic-resistant bacterium.
On the other hand, maggot therapy saves cost in ulcer management.
Recent articles reported costs for non operable treatment of a single ulcer to be $7,000-$8,000. Treatment of infected ulcers cost more than $17,000, while amputations cost almost $45,000.
The Wound Institute3u
Even as we compare between the costs of debridement, the cost of maggot therapy is so much lower than another conventional therapy. This can be clearly observed in the table below in which maggot therapy is not only faster in progress, but also cheaper. This makes the therapy more affordable for people from all walks of life.
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http://www.zoobiotic.co.uk/literature/JWC-Nov-06-Zoobiotic-Pages.pdf2d
Risks
Everything comes with a risk, so do maggot therapy. Firstly, the MDT dressings should also be handled in a very cautious way. After treating the ulcers, they are also highly contaminated. Simply disposal might cause the spread and outburst of disease. According to waste management policies, the maggot dressings should be sealed twice with plastic bags. After that, the bags are to be placed in an autoclave or incinerated within 24 hours.3s
Besides that, it is advised that maggot therapy is not used when the large open wounds are close to major veins and arteries, because this would make it difficult to remove the larva after the therapy without running the risk of damaging these vessels. Patients who are allergic should also be avoided from taking the treatment due to an increased chance of allergic reaction to the therapy.3v
Alternative solutions
Evaluation of sources
1) Oxford Journal
Oxford Journals is a division of Oxford University Press, which is a department of Oxford University. As a major international publisher of academic and research journals, Oxford Journals publishes and develops titles in partnership with the world's most prestigious learned societies. They have published over 230 academic and research journals covering a broad range of subject areas. Oxford Journals work with over 100 society partners to maximise the global reach of journals. According to the 2008 Journal Citation Reports, over one quarter of their titles are in the top 10% and approximately three quarters in the top 50% of their subject category. Therefore, I believe that this site is very trustable as a part of the world's oldest and largest university press and more than 500 years of publishing expertise behind them.
2) American Diabetes Association
American Diabetes Association is an organization that is not profit oriented. They are meant to provide diabetes patients with right information about the disease and the best ways to fight and cushion the effects diabetes. It is formed in 1940 and ever since then, has been helping check the spread of diabetes in the world. Diabetes projects and researches are funded with the aims of coming out with information that could be beneficial to diabetes patients. No doubt, many diabetics, averaging over 24 million have benefited immensely from this gesture. Hence, I found this website a very trustable place.
