Risk Factors and Treatment of Diabetic Foot - Term Paper Example

Risk factors and treatment of diabetic foot Introduction This review of the literature will be based on the discussion of the background and also the importance of an issue in the field of nursing with consideration of the relevance of the issue in professional practice. It will involve the discussion of the issue, potential benefits of studying the issue and also the purpose of the literature review. The sections that will be included in this literature review are the methods, the critique and summary of this literature, the findings and also the future recommendations. The issue that has been under investigation is the diabetic foot treatment and the risk factors. The aim of the issue investigation is to identify the methods of diabetic foot treatment by analysing the associated risk factors. Background As the population increases, the incidences of the complications that are related to diabetes also increase. Foot problems are one of the complications related to diabetes and it leads to non- traumatic limb amputation if not attended effectively. The feet of most people having diabetes can be easily affected by foot deformity, ulcers, neuropathy, infections, peripheral arterial disease and gangrene (Bevilacqua, Rogers, & Armstrong 2006). These diabetic foot problems create a significant impact on the quality of the patient’s life such as reduction in mobility which may cause depression, loss of employment, loss or damage of limbs. The problems have also significant impact on finance through the cost on outpatients, increase in the occupancy of beds and stays that are prolonged in hospitals. Problems in diabetic foot needs urgent attention as any delay in its management and diagnosis will increase mortality and morbidity and in turn contribute to higher rates of amputations (NHS 2011). According to Frykberg (2007), 25% of the diabetic people are affected by diabetic foot ulcers during their lifetime. The problem of foot ulcers usually act as portals for any infection making the people with diabetes cases to have an immune system that is compromised leading to rise in the likelihood for any infection. All problems on diabetic foot cannot be prevented but there is a possibility of effecting the dramatic reductions in their morbidity and incidence through a suitable evidence based management and prevention protocols. By utilizing an approach that is multidisciplinary, there have been consistence improvements rates in limb salvage worldwide. In recent history, there have been advances in the treatment of wounds for the people with diabetic complications. The aim of the treatment of foot infection in diabetics avoidance of amputations and loss of sift tissue and to eradicate of the infection clinical evidence. However, the primary or the main goal in the treatment of foot ulcers associated with diabetes is to attain a closure of the wound. The management of foot ulcers is associated by the risk factors that are considered in the treatment (Frykberg, & Armstrong 2000). Exploration of these factors in relation to various methods of care employed in the treatment of diabetic foot will be of benefit to the people with diabetics, nurses, professionals and the organisations that provide health care. Method In this literature review, primary sources were required. The search on electronic databases for the literature was the Google scholar and also the reference lists containing the studies which have been already done were used. The keywords used for the search of databases were diabetic foot disease, diabetic foot treatment, wounds, infection, risk factors, graftskin, negative pressure wound therapy, neuropathy, depression, amputation, apligraf, platelet release, hyper oxygen therapy and larval therapy. Studies on guidelines on treatment and assessment of diabetic foot ulcers in various settings were also included. The term diabetic treatment foot treatment was employed to broadly include different methods used by health care organisations for its treatments. The time frame for this study was limited to the last 12 years. Studies in different countries have as well being put into consideration with limits to studies in English and if they are applicable and also fit in the criteria used for inclusion. The inclusion criteria put into consideration the qualitative and quantitative studies in the risks factors applied in the treatment of the diabetic foot. The exclusion criterion was on the studies in diabetic foot treatment that were older than 12 years. Use of multiple searches to obtain the articles used for this review was employed because most of the articles appeared to fit in the criteria but after further analysis they were older than 12 years. A search using the search term treatment of diabetic foot lead to many articles but was narrowed down to 10 articles by alteration of search terms to risk factors and methods of care or treatment. Critique of the literature The critical appraisal tool employed in this review is the SECREV model used to read the articles and then breaking them down making the literature review easier to understand. This is accomplished through surveying, examining, reading critically, evaluating and finally visualizing (Borbasi 2004). The review consists of nine methods of care for diabetic foot treatment and one study in a specific study for evaluation of clinical and bacteriological of patients with diabetic foot (Singh, Varma, & Gupta 2007). The number of patients involved in the review varies within the range of 30-450 except one case where the number of patients or subjects is 26,559 (Malgolts et al. 2001). Since diabetes treatment takes long, the foot diabetic treatment in this review comprises both inpatient and outpatient. The methodologies employed in this review are similar and the also the design applied fits with the purpose if this study. All the studies reviewed were primary and use both qualitative and quantitative methods. The calculation of the weight or magnitude of each risk factor associated with patients healing the wounds was done using the multivariable logistic regression (Malgolts et al. 2000). In order to calculate a given risk factor effect, pooled unadjusted (single ration) (OR) odds ratios and (95% CIs) 95% confidence intervals were then estimated by use of ordinary regression models. Estimation Odds ratios that were fully adjusted was done using imputation algorithm for the missing data for wound duration. For better understanding of the data, the representation of the results was tabular, showing different variations in provided care against the risk factors. Findings Factor Total Duration of the wound 10/10 The area or size of the wound 10/10 Age 2/10 Ethnicity 1/10 Duration of the wound Wound duration was found to the most common factor considered in the treatment of diabetic foot with all ten citing duration of the wood as the risk factor. (Edmonds, 2009, Veves, Falanga, & Sabolinski, 2011, Malgolts et al. 2000,2001, Hawthorne & Davidson 2010, Kalani et al. 2001, Blume et al. 2008, Singh, Varma, & Gupta 2007, Faglia, Mantero, & Caminiti 2002, Sobotka et al. 2007). The duration of the wound was also dependent on the method of care. Use of sodium hyaluronate, improved the healing of the wound hence the duration of the wound was less as compared to the standard method of care. Use of the sodium hyaluronate depicted a healing of the patients within the first few weeks of treatment depending on the extent and the nature of the wound (Sobotka, et al. 2007). The subjects treated using apligraf had the likelihood of shorter period healing compared to standard therapy. The efficacy of the study was the time that was required to obtain a complete healing of the diabetic wound. The Kaplan Meier curves reflected a shorter time period in the group applying apligraf with relation to the control group (Edmonds 2009). Graftskin was reserved for the chronic ulcers that had long duration before the start of the treatment. The rate of healing for the patients related with graftskin lead to higher percentage levels and the curves produced the results which were considered as optimum (Veves, Falanga, & Sabolinski 2011). Use of hyperbaric oxygen therapy reduced the period of the healing of diabetic foot patients having peripheral arterial disease. The results of the patients who continued therapy or received the HBO therapy indicated that they tolerated well after being followed for a period of three years but only very few patient that experienced side effects. (Kalani et al. 2001). Use of infrapopliteal in treatment of diabetic foot ulcers earlier reduced the risk of amputation. Early application of larval therapy showed significant improvement on healing of the wound (Faglia, Mantero & Caminiti 2002). Use of negative pressure wound therapy (NPWT) leads to a decrease in the time length for diabetic ulcer healing as compared to advanced moist wound therapy. The addition of NPWT to the standards of care that have been established lead to successful closure and healing of the diabetic foot ulcers. From the results, higher percentage of patients that received NPWT achieved a complete closure of the ulcer as compared to AMWT (Blume et al. 2008). The effects of the platelet releasate (PR) during the treatment of diabetic neuropathic ulcers on the foot are greater in the wounds that are chronic with longer duration. Patients that were treated using platelet releasate had more likelihood of healing as compared to the ones that were not treated with PR (Malgolts et al. 2001). From the case study of a diabetic foot in Uttaranchal in India, further delay in the process of seeking treatment for diabetic foot will lead to increased infection (Singh, Varma, & Gupta 2007). Area or the size of the wound The size or the area of the wound was also a common factor for all studies (Edmonds 2009, Veves, Falanga, & Sabolinski 2011, Malgolts et al. 2000,2001, Hawthorne & Davidson 2010, Kalani et al. 2001, Blume et al. 2008, Singh, Varma, & Gupta 2007, Faglia, Mantero, & Caminiti 2002, Sobotka et al. 2007). The analysis which was unadjusted depicted that diabetic foot ulcer patients are likely to be healed within the first 20 weeks given that they had smaller wounds or the existence of the wound for a shorter period prior to the beginning off the treatment (Malgolts et al. 2000). The trend of healing diabetic foot ulcers as shown by the Kaplan- Meier curves indicates a complete healing for a shorter time for smaller wounds with application of apligraf in relation to the control group. Fewer than half of the subjects in control group did not accomplish a complete closure of the wound which make it difficult to obtain the median using the curve. Ten out of the 72 subjects enrolled experienced serious events during treatment due to failure in closure of the wound. Use of apligraf also reduced fatal events in the treatment process (Edmonds 2009). Chronic diabetic foot ulcers are usually large in size and the fail to respond to the standard care which is current. The graftskin application is more effective but costly and are mainly reserved for the treatment of the diabetic foot that is chronic. Within at most 4 weeks, graftskin achieved a higher rate of healing for chronic ulcers as compared to the standard care (Veves, Falanga, & Sabolinski 2011). Large diabetic foot ulcers may lead to the possibility of amputations. The results on HBO therapy indicated that there was acceleration of the healing of the ulcers for HBO group in comparison to a control group with similar treatment (Kalani et al. 2001). Large size wounds caused increased loss of tissue leading to possibility of a major amputation. PTA particularly infrapopliteal revascularization has led to increase in the likelihood of performing minor amputations as opposed to major amputations using standard care. Results show that higher percentages of minor amputations achieved during the foot ulcer treatment through employment of infrapopliteal care (Faglia, Mantero & Caminiti 2002). As complete closure is the closure of skin without dressing or drainage, the size of wound also determined the complete ulcer closure. Use of Negative pressure wound therapy achieved an ulcer closure that was complete in less time of closure than the advance moist wound therapy (Hawthorne & Davidson 2010). Patients with larger wounds, higher grade wounds and older wounds require advanced method of care. Although platelet relesate increases the ratio of foot ulcers which heal after 32 weeks of care than the standard one, PR has more likelihood of resulting to larger wounds (Malgolts et al. 2001). The complete healing depends on the nature of the wound. From the results a complete healing of diabetic foot ulcers can be achieved within six to twenty weeks of the beginning of the treatment (Sobotka et al. 2007). The foot ulcers classification was based in the size of the wound. The classification according to thickness was either limb or non limb. Non limb threatening contained less than 2cm ulceration and it was associated with minor amputations. Limb threatening classification had ulceration thickness greater than 2cm with high rates of major amputations (Singh, Varma, & Gupta 2007). Age Age is also considered in two out of ten studies (Malgolts et al. 2000, Kalani et al. 2001). Age significantly varied between groups and the hyperbaric oxygen therapy treatment of a group that is younger than the standard care group may lead to a potential to wound healing as compared to old group (Kalani et al. 2001). From the data aggregation on clinical trials, the mean age and also thee range was obtained. Age of patents, seemed as if it was not associated to wound healing probability (Malgolts et al. 2000). Ethnicity This factor was considered only in one of the studies (Malgolts et al. 2000). The results showed that neuropathic diabetic foot patients had the likelihood of healing within the first 20 weeks if only their wound were considered smaller than 2cm or had duration of a shorter period before the medical trial began or provided the patients were non white. Discussion The literature review shows that the main risk factors associated with the treatment of diabetic foot treatment are the duration of the wound and the size of the wound. Other factors such as age and ethnicity are least associated with the treatment of the diabetic ulcers. The two main factors are also dependent on the method of care applied. Looking at the standard care for treatment of diabetic foot, the method becomes effective in treatment of patients whose size of wound is smaller and also if the duration of the wound is less or brief. Using this information, the dermatologists are in a better position of determining if to use the standard care or to adopt a new treatment method or involve a specialty centre for the treatment of the patient (Malgolts et al. 2000). Use of the sodium hyaluronate and iodide complex reduced the duration of diabetic foot treatment as the results showed achievement in treating of 12 patients within the first 6 to 20 weeks of treatment. The effectiveness of treatment was also accomplished depending on the nature of the wound such as the size (Sobotka, et al. 2007). The effectiveness of platelet releasate in diabetic foot ulcers is felt in greater quantities for treatment of patients with wounds that are larger and with high grade where patients were more likely to heal using PR as compared to standard care. Duration of treatment was reduced as explained by the results showing that 43% of the using PR healed within the 32 weeks of the initiation care (Malgolts et al. 2001). In the negative pressure wound therapy (NPWT) comparison with advanced moist wound therapy (AMWT), the effectiveness of the duration of closure of the wound was at higher percentages for NPWT as compared to AMWT treatment of ulcers. This was displayed in the results indicating 60.8% achievement of ulcer closure for NPWT in comparison to 40% for the closure in AMWT. The size of closure for large wounds takes longer as compared to closure of smaller wound with NPWT maintaining higher efficiencies than the AMWT (Blume et al. 2008). Larval therapy in treatment of chronic diabetes foot ulcer is evidence as being clinically and cost effective in the treatment of foot ulcers that in chronic conditions. Larval therapy has been applied in the treatment of chronic wounds whose duration at the start of the treatment is long. The treatment using larval therapy is effective in healing the chronic wounds that contains greater areas (Hawthorne & Davidson 2010). Percutaneous transluminal angioplasty (PTA) in particular the infrapopliteal as used for ischaemic diabetic foot treatment has achieved the maximum revascularization available down to the foot independent of diffusion and severity of obstructive wounds. The PTA reports the treatment of small size and isolated wounds (Faglia, Mantero & Caminiti 2002). Use of hyperbaric oxygen (HBO) in diabetic wound healing depicts positive effects in ulcer healing and also the reduction of the rate of amputation to the diabetic patients with local hypoxia and foot ulcers that are chronic. The duration of the chronic wound was considered and its size put into consideration in order to achieve the ulcer healing (Kalani, et al. 2001). Graftskin is apllied to resistant chronic diabetic foot ulcers. From the results, in a shorter duration period of a maximum of four weeks, it achieves a higher rate of healing in comparison to the existing treatment method. It has also been successful in healing of the diabetic chronic wounds of different sizes without any side effects (Veves, Falanga, & Sabolinski 2011). Studies conducted on apligraf in the treatment of diabetic ulcers that are neuropathic suggested that use of apligraf led to shorter duration time in healing of the wound. It also resulted to high percentages and greater proportion of the target ulcers that were healed ranging from small to large size wounds (Edmonds 2009). From a case study in diabetic foot in Uttaranchal, India the evaluation of bacteriological and clinical patients’ profile with diabetic foot ulcers considered the duration of the diabetic treatment as an important factor in the study. The study then classified ulceration on the basis of size or the thickness and the classification was either limb or non limb threatening (Singh, Varma, & Gupta 2007). Recommendations The process of the treatment of diabetic foot is complicated. Resistance to the healing of the diabetic foot ulcers depends on variety of factors which includes presence infection, inadequate limb perfusion and offloading. The wound will always persist if all the above factors are not addressed. Addition of other diseases like the peripheral arterial disease creates more complications to the wounds which is also related to the high risks of amputations. These complications in the treatment of diabetic foot require adoption of new technologies to cope with the increasing cases of diabetic ulcers. It is very essential to prevent the initial foot lesion in order to prevent the cases of amputation. The best and convenient approach to address this issue is employment of a multidisciplinary professional’s team who are dedicated to limb salvage. There should be laws that should institute these multidisciplinary teams for they will enforce dramatic reductions in amputations of lower extremity and also improved rates in healing of primary ulcer. There should be plans for educating the patients as it plays a central role in any treatment. This education should also put into considerations the instructions on the daily inspection, foot hygiene, proper footwear and also the necessity of treating new lesions without delay. Regardless of the treatment, the diabetic ulcers readily end up becoming chronic wounds. There have been negligence in planning and health care research on diabetic foot ulcers as the clinical practice is somehow based on opinion than the scientific facts. To overcome this, there is a need for extensive research on treatment of diabetic foot. Conclusion Identification and acquiring a better understanding of risk factors associated with the treatment of diabetic foot is very important as there is observed increase in cases in diabetic foot ulcers. However, study of these factors must incorporate the existing methods or standards of care. The duration of the wound and the size of the wound are identified as the main risk factors involved in the treatment of diabetic foot. Other factors such as age, sex and ethnicity seemed as if they were not associated to the treatment of the diabetic foot. More research on treatment of the diabetic foot will create new technologies in this field. References Bevilacqua, NJ, Rogers, LC & Armstrong, DG 2006, Developments in Treatments for Diabetic Foot Ulcers. U S Dermatology review. Blume, PA, Walters, J, Payne, W, Ayala, J & Lantes, J 2008, Comparison of Negative Pressure Wound Therapy Using Vacuum-Assisted Closure With Advanced Moist Wound Therapy in the Treatment of Diabetic Foot Ulcers, Diabetes Care, Volume 31. Borbasi, S 2004, Reading Research: Critical approach to effective understanding‟, in Navigating the maze of nursing research: An interactive learning adventure. Faglia, E, Mantero, M & Caminiti, M 2002, Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischaemic diabetic foot ulcers: clinical results of a multicentric study of 221 consecutive diabetic subjects, Journal of Internal Medicine; 252: 225–232 Hawthorne, G & Davidson, B 2010, use of larval therapy in a chronic diabetic foot ulcer: a case study: diabetic foot journal vol 13 No. 3. Singh, DG, Varma, A & Gupta, P 2007, Diabetic Foot in Uttaranchal. Department of Medicine, 62, Prakash Lok, Shimla road, Dehradun (UA), Vol. 9 No. 1, Malgolts, DJ, Kantor, J, Santana, J & Strom BL 2001, Effectiveness of Platelet Releasate for the Treatment of Diabetic Neuropathic Foot Ulcers, Diabetes Care, Volume 24, Number 3. Malgolts, DJ, Kantor, J, Santana, J & Strom BL 2000, Risk Factors for Delayed Healing of Neuropathic Diabetic Foot Ulcers, Arch Dermatol. 2000; 136:1531-1535 Sobotka, L, Msahelowa, Pastorova, J, P & Kisalova, 2007, A Case Report of the Treatment of Diabetic Foot Ulcers Using a Sodium Hyaluronate and Iodine Complex; the International Journal of Lower Extremity Wounds. Kalani, M, Jorneskog, G, Naderi, N, Lindi, F & Brismar, K 2001, Hyperbaric oxygen (HBO) therapy in treatment of diabetic foot ulcers Long-term follow-up, Journal of Diabetes and Its Complications 16. Edmonds, M 2009, Apligraf in the Treatment of Neuropathic Diabetic Foot Ulcers;The International Journal of Lower Extremity Wounds. Vol. 8, No. 1 NHS, 2011, Diabetic foot problems Inpatient management of diabetic foot problems. Centre for Clinical Practice Frykberg, RG 2007, Diabetic Foot Ulcers: Pathogenesis and Management. Des Moines University, Iowa. Volume 66. Frykberg, RG & Armstrong, DG 2000, Diabetic Foot Disorders A Clinical Practice Guideline. American. The Journal of Foot & Ankle Surgery, College of Foot and Ankle Orthopedics and Medicine, Volume 39. Veves, A, Falanga, V, Amstrong, DG & Sabolinski, ML 2011, Graftskin, a Human Skin Equivalent, Is Effective in the Management of Noninfected Neuropathic Diabetic Foot Ulcers, Diabetes Care, Volume 24, Number 2. List of reviewed articles Blume, PA, Walters, J, Payne, W, Ayala, J & Lantes, J 2008, Comparison of Negative Pressure Wound Therapy Using Vacuum-Assisted Closure With Advanced Moist Wound Therapy in the Treatment of Diabetic Foot Ulcers, Diabetes Care, Volume 31 Faglia, E, Mantero, M & Caminiti, M 2002, Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischaemic diabetic foot ulcers: clinical results of a multicentric study of 221 consecutive diabetic subjects, Journal of Internal Medicine; 252: 225–232 Hawthorne, G & Davidson, B 2010, use of larval therapy in a chronic diabetic foot ulcer: a case study: diabetic foot journal vol 13 No. 3. Singh, DG, Varma, A & Gupta, P 2007, Diabetic Foot in Uttaranchal. Department of Medicine, 62, Prakash Lok, Shimla road, Dehradun (UA), Vol. 9 No. 1, Malgolts, DJ, Kantor, J, Santana, J & Strom BL 2001, Effectiveness of Platelet Releasate for the Treatment of Diabetic Neuropathic Foot Ulcers, Diabetes Care, Volume 24, Number 3. Malgolts, DJ, Kantor, J, Santana, J & Strom BL 2000, Risk Factors for Delayed Healing of Neuropathic Diabetic Foot Ulcers, Arch Dermatol. 2000; 136:1531-1535 Sobotka, L, Msahelowa, Pastorova, J, P & Kisalova, 2007, A Case Report of the Treatment of Diabetic Foot Ulcers Using a Sodium Hyaluronate and Iodine Complex; the International Journal of Lower Extremity Wounds Kalani, M, Jorneskog, G, Naderi, N, Lindi, F & Brismar, K 2001, Hyperbaric oxygen (HBO) therapy in treatment of diabetic foot ulcers Long-term follow-up, Journal of Diabetes and Its Complications 16. Edmonds, M 2009, Apligraf in the Treatment of Neuropathic Diabetic Foot Ulcers;The International Journal of Lower Extremity Wounds. Vol. 8, No. 1 Veves, A, Falanga, V, Amstrong, DG & Sabolinski, ML 2011, Graftskin, a Human Skin Equivalent, Is Effective in the Management of Noninfected Neuropathic Diabetic Foot Ulcers, Diabetes Care, Volume 24, Number 2. Read More