Prevalence of Type 2 Diabetes in Australia - Research Paper Example

Chapter Two 2. 0 Literature Review The prevalence of type 2 diabetes is increasing in Australia and the most common and severe complications allied to diabetes are diabetic foot complications (Blatchford et al 2015). According to Lavery et al (2012), foot ulceration in people with diabetes is the most common precursor to amputation. Individuals with diabetes have a higher likelihood of having amputation as compared to individuals without diabetes (Lavery et al, 2012). Lu et al (2015) is in line with this study and explains that lower extremity complications in individuals with diabetes have become significant public health problem and lower extremity complications that begin with neuropathy and consequent diabetic foot wounds commonly result to infection as well as amputations even when there is no critical limb ischemia (Alavi et al, 2012). Burns & Jan (2010) also demonstrates that amputations occur 10-30 times higher in patients with diabetes in comparison to patients without diabetes and 70% of the amputations occur in individuals with diabetes, 85 percent of which follow diabetic foot ulcer. The incidence of amputation is 25.8/1000/year in individuals with diabetes in comparison to 1.1/1000/year in individuals without diabetes (Burns & Jan, 2010). This therefore shows that foot ulceration in people with diabetes contributes to amputation and hence effective management of diabetic foot ulcers can greatly reduce the rate of amputation in persons with diabetes. Studies also show that amputations from complications allied to type 2 diabetes place a person at a risk for more amputations and also these individuals have a 5 year mortality rate of 39-68 percent (Zubair et al, 2015). As studies indicate, the most common risk factors for lower extremity amputation after foot ulcers encompass; the presence of peripheral vascular disease, severity of neuropathy, structural foot deformity in addition to concomitant infection (Burns & Jan, 2010). Most aetiological factors that contribute to the development of diabetic foot ulcer can be identified early and this can prevent amputations that occur due diabetic foot ulcers. Blatchford et al (2015) shows that diabetes foot complications can be prevented through appropriate risk assessment and diligent follow-ups and this can in turn reduce the rate of amputations. As (Blatchford et al, 2015) further emphasizes, it is vital to make sure that individuals with diabetes undergo risk screening in accordance with evidence-based guidelines to identify people at risk for developing diabetic foot ulcer complications in order to institute the required preventative care (Burns & Jan, 2010). In addition, individuals with diabetic foot ulcers have a reduced health-related quality of life when compared the general population. Appropriate preventative and prophylactic foot care have been shown to reduce morbidity and also the risk for amputations (Formosa et al, 2012). The preventative and prophylactic foot care which encompass identifying risk factors, patient education as well as intensive podiatric foot care have been shown to be effective in reducing lower extremity amputations. Levin (2010) also shows that the major cause for hospital admission of individuals with diabetes is foot ulcer. In United States, 6 percent of individuals with diabetes who are admitted in hospitals every year are due to diabetic foot ulcers (Zubair et al, 2015). Similarly, a study conducted in India at the India Institute of diabetes indicated that more than 10 percent of all admissions in the institution were due to diabetic foot ulcers (Shashi et al, 2012). In addition, 70 percent of the patients needed surgical treatment and 40 percent of the treatments included amputation. Another study conducted in the UK found out that 50 percent of patients with diabetes admitted in hospitals are due to diabetes foot ulcers. Another large study within the UK indicated that patients who attend diabetes clinics 2% of them had foot ulcers while 2.5 percent of them had undergone amputation. In Australia, every year there are approximately 10, 000 hospital admissions due to complications related to diabetic foot ulcers and most of these patients end up being amputated (Bergin et al, 2012). These studies show that foot ulceration is a serious complication in people with diabetes and hence it is necessary to have strategies that can prevent deterioration of foot ulcers as well as preventing foot ulcers by identifying the risk factors to the complication through appropriate diabetic foot care assessment. Studies further show that all people with diabetic foot ulcers require clinical assessment for aetiology of the ulcerations and also factors that might hinder healing of the ulcer (Alavi et al, 2012). Comprehensive and appropriate diabetic foot assessment can assist in guiding investigation and management of the diabetic foot ulcers (Schofield et al, 2009). In addition, appropriate foot assessment helps in documenting and assessing the progress of the ulcer over time and this information is important in treatment of the diabetic foot ulcer. Blatchford et al (2015) supports this and argues that the initial response to treatment can be an important predictor to the healing of the diabetes foot ulcer. Since there are no clear yardsticks for healing times of diabetes foot ulcers, appropriate foot care assessment can help in identifying indicators for immediate referrals to emergency departments or multidisciplinary foot care team (Amirmohseni & Nasiri, 2014). Some of indicators for immediate referrals consist of gangrene, ascending cellulitis, deep ulcers, serious ischaemia and also if there are indicators of infection or abscess in the ulcer. Successful identification of these indicators during foot care assessment can lead to the appropriate interventions being implemented and hence prevent worsening of the ulceration and even healing of the ulceration and this goes a long way in preventing amputation (Wraight, 2012). Accordingly, for effective management of diabetic foot ulcers, all factors that affect the healing are supposed to be tackled simultaneously. Therefore, it is necessary for nurses who perform foot care assessment to have the required clinical skills to appropriate carry out the assessment (Alaa et al, 2012). As evidence shows, most diabetic foot ulcers occur together with peripheral sensory neuropathy, foot deformity, peripheral arterial disease as well as infection and this further complicates factors that prevent or delay healing of foot ulcers (Alavi et al, 2012). However, Alaa et al (2012) says that the main factors for diabetic foot ulcer that can even cause gangrene and amputation include peripheral neuropathy, peripheral vascular disease and infection. On the other hand, Etnyre et al (2011) emphasize that peripheral neuropathy is the major cause of foot ulcers in individuals with diabetes. Such aspects are vital for neurological assessment as the initial criterion for screening individuals who are at risk of foot ulcers (Alavi et al, 2012). During foot care, nurses are responsible for carrying out diabetic foot examination and this means that nurses can be able to identify foot ulcers during early stages of care and therefore appropriate treatment is administered before it is too late. Diabetic foot examination can hence detect diabetic foot problems early and identify individuals who are at risk and put in place the appropriate plans to lower the risk of diabetic foot ulcers (Etnyre et al, 2011). This coincides with Blatchford et al (2015) who explain that simple criteria involving numerous testing and assessment measures can assist in identifying patients at high risk for foot ulcer and amputation. Individuals with diabetes who have all normal criteria are classified as low risk whereas the individuals having insensitivity, deformity, no pulses or individuals who previously had foot ulcers or underwent amputation are classified as high-risk (Alaa et al, 2012). Etnyre et al (2011) supports this and provides that trained healthcare providers should assess the feet of diabetic people as this enables risk factors for ulceration to be detected. This shows that when nurses perform foot assessment appropriately individuals at high-risk of amputation can be identified easily. A study project carried out by Lowe et al (2015) trained nurses and other healthcare providers in Guyana on how to perform foot assessment. After the project, it was established that the number of major amputations due to diabetic foot ulcer had reduced where the number of mean monthly amputations was 7.95 before the training was done and 54 months after training of nurses and healthcare providers on foot assessment rate of amputation dropped significantly to 3.89 (Lowe et al, 2015). Similarly, the same study project found out that there was 68 percent decrease in the rate of major amputations in the first 22 months after the foot assessment training (Lowe et al, 2015). This study confirms the findings of the previous studies on the benefits of nurses being equipped with the required education and training regarding foot care assessment. Alavi et al (2012) explain that foot care assessment consists of examining the foot sensation through monofilament or vibration, taking foot pulses, examining any foot deformity and foot wear and classifying foot risk to ulceration. The National Health and Medical Research Council (NHMRC), Australia classifies risk as: Low risk: no present risk factors such as no infection or loss of sensation and no other risk factors Moderate risk: one risk factor present such as loss of sensation or indications of peripheral arterial disease but no deformity or callus High risk: previous foot ulcer or previously had amputation or having more than one risk factor such as loss of sensation or indications of peripheral arterial disease with deformity or callus Active: presence of active foot ulcer, infection, critical ischemia, gangrene or inexplicable hot, red, swollen foot with or without pain. As Formosa et al (2012) provides, during foot care assessment nurses should ensure that diabetic individuals who are at low risk of foot ulcers always undergo normal sensation and palpable pulses and a management plan that should include foot care education with every individual is instituted. On the other hand, for individuals who are at moderate risk of foot ulcers, a nurse should make arrangements for regular review and during every review the patient’s feet should be inspected, vascular assessment should be performed, the individual’s footwear should be evaluated, as well as enhancement of foot care education. For the care of individuals at high risk of ulceration, the nurse should make arrangements for the patient’s regular reviews and during each review the patient’s feet should be inspected and vascular assessment should also be performed. Arad et al (2011) further add that for the individuals who are at high risk of foot ulcers it should be ensured that they undergo extensive foot care education, their footwear and insoles are evaluated and also they receive skin and nail care. Generally, such grading can help the healthcare provider identify the individuals with the highest clinical need for podiatry services and resources and also mechanisms are implemented on how to care for these patients to prevent their conditions from worsening and hence prevent unwarranted amputations (Zubair et al, 2015). This is supported by Redmon et al (2014) who argue that assessment of risk factors and grading patients in accordance with their risk for diabetic foot ulcer helps in stratifying people with diabetes based on risk of developing diabetic foot ulcer and this informs appropriate preventative measures taking into account risk stratification. However stratifying of risk is just one aspect of foot care assessment as it also encompasses arraying interventions to effectively prevent diabetic foot ulcer, like patient education and making referrals to secondary care. (Zubair et al (2015) elaborate this and stresses that putting focus on preventative interventions based on risk lead to significant decrease in occurrence of diabetic foot ulcer and allied complication. Brand et al (2015) take a different approach and explains that provision of nursing foot care is done in a holistic context to promote health, maintain health and prevent illness through nursing process. The foundation of the basic concepts that underlie the provision of nursing foot care and assessment is on education regarding foot care assessment (Brand et al, 2015). These basic concepts that nurses need to be educated on regarding diabetic foot care consist of anatomy and physiology, microbiology, nutrition, preventative health care for the skin and nails, as well as distinctive nursing care for patients with health conditions which may compromise the integrity of the feet like peripheral vascular disease and diabetes. Aalaa et al (2012) provides that some nurses do not have education on these basic concepts of foot care and also they lack knowledge on effective treatment. As a result, nurses as key members of diabetic foot team require training to increase their awareness of diabetic foot ulcer risks as well as enhance their skills in performing diabetic foot ulcer assessment and treatment as well. 2.1 Study Justification Studies show that type 2 diabetes is on the rise and so is diabetic foot disease whose outcome is poor and this has led to increased rate of amputations (Zubair et al, 2015). With appropriate foot assessment, rate of amputations as well as other complications that result from diabetic foot disease can be reduced. The literature review indicates that nurses play an important role in preventing diabetic foot ulcers and reducing lower extremity amputations through assessment for high-risk individuals, provision of educational interventions and also through provision of nursing care. Evidence has shown that appropriate foot assessment for people at high risk as well as patient education regarding foot care is effective in preventive foot ulceration (Blatchford et al, 2015). Only through education and training will nurses have the required skills and competence on foot care assessment and be able to detect ulceration early enough as well as identify high-risk individuals and institute the required treatments (Wraight, 2012). This forms the justification of this study because most amputations and other complications due to diabetic foot ulcer can be prevented through appropriate foot assessment and lack of the required education and skills to perform diabetic foot assessment among nurses is among the contributing factors to the rising rate of amputations. It is evident that with the rising prevalence of type 2 diabetes and its most common and grave complication diabetic foot ulcer, there is an indisputable need to educate nurses on how to perform foot assessment appropriately. Chapter Three 3.0 Research Design and Research Methods This chapter provides a description of how empirical data underlying this study was produced. This study is based on analysis and review of the available literature on “the benefits of educating nurses to perform foot assessment on people with type 2 diabetes to identify high risk diabetic foot”. Empirical data was collected procedurally in studies not older than five years. The collected data was then analysed. 3.1 Search Methods Google Scholar, OVID and CINAHL databases were used to search English-language journal articles published between 2010-2015. The medical subject headings (MeSH) that were searched included “Type 2 Diabetes, Diabetic Foot Ulcers and High risk Diabetic” combined with and “educating nurse and role of nurse” and “foot care” and “foot assessment” and “amputation”. Similarly, the following search terms were used: Type 2 Diabetes, Diabetic Foot Ulcers and High risk Diabetic” combined with and “educating nurse and role of nurse” and “foot care” and “foot assessment” and “amputation”. Abstracts were excluded since they basically contain inadequate information for assessing the validity of the study. Dissertations, clinical papers as well as clinical guidelines were excluded since the available abstracts had inadequate information for review and the full text was mostly not available. Review of the titles of all extracted articles was done to assess their relevance to the “the benefits of educating nurses to perform foot assessment on people with type 2 diabetes to identify high risk diabetic foot” and if possibly relevant, the full text article was retrieved. Even though only studies published in English language were included in the analysis, the search strategy did not have any restriction on language. The reference lists of all studies that were considered relevant were evaluated and searched for more studies. In addition, previously studies on “the benefits of educating nurses to perform foot assessment on people with type 2 diabetes to identify high risk diabetic foot” were reread in search for more studies. No attempts were done to identify unpublished studies. 3.2 Study Selection Only systematic review studies were selected because evidence shows that systematic review studies contains exhaustive review of current literature and supports maximum validity and casual inference. Only studies which had the subject diabetes foot, diabetes type 2, foot care, amputation, and nurse education were reviewed. Whenever the type of diabetes was not clear, the study was included if it had other subjects such as foot care and nurse education. The following inclusion and exclusion criteria were used: Inclusion criteria Exclusion criteria Published between 2010 - 2015 Published before 2010 Published in English Not Published in English Article Book Primary research articles Secondary research articles Full text available Full text unavailable Related to the questions Does not relate to the questions A two-step process was used to screen articles. First the titles and abstracts were used in establishing if the article met the general inclusion criteria. Every article was rated as “include,” “exclude,” or “unclear.” Retrieval of the full texts of all articles that were categorised as “include” or “unclear” was done for formal review. Next, every retrieved article was assessed using the above inclusion/exclusion. 3.3 Grading the Body of Evidence To evaluate strength of evidence for the main outcome (benefits of educating nurses to perform foot assessment on people with type 2 diabetes to identify high risk diabetic foot), the approach created by the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) working group by was used. The approach evaluates the evidence basing on: the strength of the study designs providing the evidence, the quality of the studies, the reliability of the estimates of effect across studies, the level of certainty surrounding an effect estimate, and lastly the directness of the connection between interventions and outcome measures (Marie et al, 2010). The strength of evidence was categorised as high, moderate, low, or very low. Only the articles whose strength was rated as high and moderate were used in this study. 3.4 Data Extraction Data extraction from studies that were eligible consisted of descriptive information, analysis methods, as well as results. Data extraction was not blinded since there is no evidence that shows that results’ blinding in systematic reviews reduces bias. The titles of the studies identified through search in the databases as well as their reference lists were evaluated. The full texts of the chosen articles were reread for further review. The list of included studies was completed on 25th October 2015. There were no trial studies that met inclusion criteria and therefore no such study was included in the analysis. The following aspects were used in describing every study: author and date; aim/objective; sample and setting; methods and methodology; major findings; limitations and rigour/validity; significance to the issue. Extraction of all relevant data and results that were to be used in the study was then done. 3.5 Validity Assessment Quality assessment of the selected studies was established using what was reported in all articles. Assessment of internal validity was done using the criteria for Cochrane methodology for selecting sources. The likelihood of selection bias was examined by assessing the description of study methodologies and allocation concealment. Four types of bias were assessed. Evidence shows that these kinds of bias have substantial effects on measured outcomes in studies. It was noted whenever such bias was found in an article. Modification of the criteria for bias was done from those used in Cochrane methodologies since all the selected articles did not fulfil all specifications for bias absence. Generally, in order to avoid selection bias, allocation schedule is concealed to avoid patients and researchers influencing assignment sequence. Nonetheless, since most studies that were selected for use in this study did not comment on allocation method and considering most studies that were used were systematic reviews, allocation concealment was not utilised as a necessary criterion for the absence of selection bias. To avoid performance bias, study subjects are blinded and this is not possible in diabetes education studies. Consequently, blinding of the study subjects was not utilised as a validity criterion. Attrition bias consists of the systematic variations between comparison-groups in regard to the loss of study subjects in a study (Marie et al, 2010). In this study, assessment of attrition bias was done by examining the rates of withdrawals of the study participants in all selected articles. Because attrition bias can significantly affect the study and hence it would in turn affect the results of this study, this information was searched. Using a validated checklist for assessment of study quality (rating of 1-10), 20 articles rated as being good quality articles and these are the articles that were used in the study. Good quality articles were the ones that had a score of 8 and above. All these articles provided adequate information regarding the aim/objective; sample and setting; methods and methodology; major findings; limitations and rigour/validity details. 3.6 Data Analysis Data was analysed using a narrative review because it was deemed not suitable to combine the included studies in a meta-analysis owing to the heterogeneity of studies’ aspects such as different outcomes and differences in study populations and comparators, it was not possible to combine outcomes in a meta-analysis and alternatively a narrative review was used in the analysis (Marie et al, 2010). 3.7 Ethical Considerations The ethics of obtaining the collected data from various sources were carefully considered ad informed by ethics advice issues by the university. This study did not need additional ethical approval for the below reasons: Researchers of all primary studies that were used in this study has obtained ethical approval from the suitable local ethics committee and written informed consent from the study subjects before carrying out studies This data seeks anonymized information whereby the identification of persons who were employed in the primary studies is not possible. In this study, anonymised data of all collaborators from the original studies was conveyed in a way considered most convenient to the primary study researchers. Formatting of the data in a consistent manner was then done to allow re-analysis of the data. Storage of the data was done in file protected using passwords and the data was only accessible to the authorized persons. This procedure integrates a data confidentiality agreement and this signifies the significance of de-identifying individual study subjects. The procedure also incorporates a guarantee that the primary researchers in all the articles that were used in this study have local ethical approval for carrying out their studies (Marie et al, 2010). Chapter Four 4.0 Study Results The final Google Scholar search using inclusive combination of the key terms “Diabetes or Type 2 Diabetes and Diabetic Foot Ulcers and High risk Diabetic and educating nurse and role of nurse and foot care and foot assessment and amputation” yielded 69 articles. Refined search using Ovid database yielded 9 articles while search at CINAHL retrieved several articles as well. Every Title and Abstract and if necessary the full article was reviewed to establish eligibility and this yielded 14 relevant systematic review articles and Randomised Clinical Trials (RTC) articles that documented either primary or secondary evidence on “benefits of educating nurses to perform foot assessment on people with type 2 diabetes to identify high risk diabetic foot”. The systematic review studies consisted of 2 articles on diabetic foot ulcer and foot assessment; 2 articles on role of healthcare providers and foot assessment; 2 articles on type 2 diabetes and foot care; and 2 articles on education and diabetes foot assessment. The RCT consisted of 2 studies on type 2 diabetes and foot ulceration; 2 studies on prevention of diabetic foot ulcers; and 2 studies on diabetes foot assessment. None of all these 14 studies primarily focused on “the benefits of educating nurses to perform foot assessment on people with type 2 diabetes to identify high risk diabetic foot” but each and every study had varying evidence and hence the results were classified in to the following two broad themes. 4.1 Preventing foot ulcers and amputations in patients with diabetes Arad et al (2011) assessed the benefits of several interventions in preventing diabetic foot ulcers. The study was a systematic review and searched for and reviewed RTCs on prevention of diabetic foot ulcers and assessed their efficacy and scientific validity basing on a set systemic grading system. This study identified 13 RTCs. The study found out foot assessment is beneficial in prevention of future diabetic foot ulcers and identifying high-risk populations. Blatchford et al (2015) examined risk stratification in diabetic foot ulcer. The study was a retrospective clinical audit that was carried out for 26 months at the Albury-Wodonga Aboriginal Health service, New South Wales. According to the study results, regular foot assessments assist in stratification of individuals with diabetes according to risk status and this guides preventative measures and treatment to decrease the probability of developing foot ulcer and amputation. Redmon et al (2014) performed a systematic review to assess evidence published on type 2 diabetes. Literature search was done using databases such as PubMed and Cochrane and only studies that were in English language were included. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to rate the evidence. Jenkins et al (2011) reviewed different strategies that have been implemented to reduce amputations in African Americans by the Racial and Ethnic Approaches to Community Health (REACH) Charleston and Georgetown Diabetes Coalition. The basis of the interventions was on an expanded Chronic Care Model that laid changes within policies, health as well as education systems, and other community systems for individuals with diabetes and their support systems. Metta et al (2015) conducted an explorative study through 9 focus group discussions with adult patients as well as community members. Principles of grounded were used to analyse data and cultural schema theory used as a deductive framework. The study found out that people should be encouraged to seek out treatment basing on their cultural system. 4.2 Role of a nurse in diabetic foot ulcer and assessment Aalaa et al (2012) conducted a review on the nurse’s role a nurse in diabetic foot ulcer. This review established that nurses have active involvement in preventing and early detection of diabetes and the complications such as diabetic foot ulcer. Nurses primarily play the role of foot assessment and educating patient in preventing foot ulcers and foot injury. Etnyre et al (2011) present an article on the role and benefits of nurses having education and training on foot and nail care. The article argues that there are few professionals with the required skills to perform routine foot and nail assessment and therefore it would be extremely beneficial for nurses to gain knowledge and skills on foot care and foot assessment in order to improve foot health in people with diabetes and also prevent amputation. Oudeh et al (2011) set to explore the contents of nurses’ skills and practices allied to the management of diabetic foot ulcer. The study investigated 3 primary health clinics namely UNRWA health clinic (Balata camp, Asker camp and Al-ain), Nablus city, Palestine. A qualitative methodology research design was adopted and a sample of 12 registered nurses was investigated. The study results found out that practically nurses significantly more malpractice when it comes to the management of diabetic foot ulcer and that competency of nurses can be increased through education and training programs to decrease diabetic foot ulcer complications and enhance the quality of care. Lavery et al (2012) purposed to improve the learner’s competence with knowledge of efficacy of shear-reducing insoles to prevent diabetic foot ulcer in individuals with high-risk diabetes. The target audience for the study was doctors and nurses who specialized in skin and wound care. 299 patients with diabetic neuropathy and loss of protective sensation, foot deformity and history of diabetic foot ulcer were randomized using a therapy group. Evaluation of the study subjects was done for 18 months. The result study showed that shear-reducing insole has higher efficacy when compared to traditional insoles in prevention of foot ulcers in high-risk individuals with diabetes. Kuhnke et al (2014) aimed at enhancing the competence of learners on knowledge regarding use of qualitative methodologies in understanding diabetic foot ulcers and amputations. The target audience was the healthcare providers. The study found out that when nurses completed tis educational activity they were able to use qualitative health research to research on diabetic aspects such as diabetic foot assessment. Turns (2015) conducted a systematic review on how diabetic foot assessment should be performed. This systematic review demonstrated that educated, trained and skilled healthcare providers should assess the feet of the patients with diabetes to identify the risk factors for diabetes foot ulcer. Foot assessment should encompass: palpation of foot pulses; examining foot sensations; assessing for callus or deformed nails; examining for any structural deformity; taking any previous history on ulceration; examining for signs of ulceration; pain assessment; as well as footwear inspection. Lowe et al (2015) is a peer review of a project conducted in Guyana South America due to the high prevalence of type 2 diabetes in the region. Pre-intervention: 41.4 percent of people diabetic ulceration underwent amputation at the national referral hospital. The hospital staff underwent training on how to perform diabetic foot assessment and the outcome was that the rate of hospital admissions due to diabetic foot ulcer drastically reduced and the rate of amputations in the hospital had also reduced. Bergin et al (2012) was a review on management of diabetic foot ulcer. The review established that suitable assessment and management of diabetic ulceration plays an important role in reducing the risk of amputation. The review recommends that all individuals with diabetic foot ulcer to be managed by physicians and a podiatrist. The review also recommends that when healthcare providers are not able to offer suitable care for individuals with diabetic foot ulcer are supposed to make referrals to healthcare professionals with the appropriate knowledge and skills. Reference List Aalaa M, Malazy T, Sanjari M, Peimani M & Mohajeri M, 2012, Nurses’ role in diabetic foot prevention and care; a review, J Diabetes Metab Disord, 11( 24). 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Metta E, bailey A, Kessy F, Geubbels E, Hutter I & Haisma H, 2015, In a siatuion of rescuing life: Meaning given to diabetes symptoms and care-seeking practice among adults in Southeastern Tanzania: A qualitative inquiry, BMC Public Health, 15(224). Oudeh K, Al-Haqash D & Yahiya S, 2011, Evaluation of the Nursing Practice of Diabetic Foot Ulcer in UNRWA Health Clinics: A qualitative study, Nablus, Palestine. Zubair M, Malik A & Ahmad J, 2015, Diabetic foot ulcer: A review, American Journal of Internal Medicine, 3(2): 28-49. Read More