Symptoms and Treatment of Diabetic Foot - Essay Example

Diabetic Foot A b s t r a c t Foot problems are an important cause of morbidity in-patients with diabetes. Both vascular and neurologic disease contributes to this problem. These individuals are predisposed to foot infections because of a compromised vascular supply. These occur in setting of good dorsalis pulse. Impaired microvascular circulation hinders white cell migration in the area of infections and limits the ability of antibiotic reach the infected area. The diabetic foot maybe predisposed to both common and unusual infectious or non-infectious process. This is because of the complex of nature of diabetes, it's associated vascular, and neuropathic complications. Therefore, imaging presentation will vary due to lack of specificity in complex clinical circumstances. This should only be ordered to confirm a suspected diagnosis and direct patient management. Introduction Having diabetes means blood sugar levels are too high. The normal homeostatic mechanism maintains blood glucose level within a marrow range of 3.5 to 6.5 mmol/l. A simple definition of diabetes is a disorder of metabolism. It is a serious disease that can be developed from lack of insulin production in the body. Most of the food we eat is broken into glucose. This glucose is the form of sugar and the main fuel of the body. Glucose passes into the bloodstream where it is used for the growth and energy. Insulin must be present in order for the glucose gets into the cells. It is a hormone produced by pancreas gland that helps the process of food we eat and turn it into energy. The symptoms of diabetes may begin gradually and can be hard to identify first. These may include feeling tired or ill, slow healing of infections and genital itching. When there is extra sugar in blood, one way the body gets rid of it is through frequent urination. This loss of fluid in the body causes extreme thirst. According to Burke A. Cunha diabetes often goes undiagnosed because of it's harmless symptoms like frequent urination, excessive thirst, extreme hunger, irritability and blurry vision. Complications can be associated with diabetes. This disrupts the vascular system that affects many areas of the body such as eyes, kidneys, legs and feet. However, people with this kind of disease should pay special attention to their feet because the smallest of the injuries can lead to a medical emergency. This is because the common problems of people with diabetes are foot infections. These individuals are predisposed to foot infections because of a compromised vascular supply. Moreover, patients with diabetes can have a combined infection involving bone and soft tissue called fetid foot. Pathophysiology Diabetes is a chronic metabolic disorder in which the body cannot metabolize carbohydrates, fats and proteins because of a lack of insulin. A disorder that affects microvascular circulation is diabetes mellitus. The microvascular disease due to sugarcoated capillaries limits the blood supply to deep structures. Pressure due to ill-fitting shoes further compromises the blood supply at the microvascular level that affects a person to infection. The infection may involve the skin, soft tissues, bone or all these tissues. The primary problem in diabetic foot infection is microvascular compromise, these occur in setting of good dorsalis pulse. Impaired microvascular circulation hinders white cell migration in the area of infections and limits the ability of antibiotic reach the infected area. The chronic osteomyelitis represents an island of infected bone. This bone fragment that are isolated have no blood supply. However, administered antibiotics do not penetrate the devascularized infected bone fragments. They can only enter through the remaining blood supply. In conclusion, antibiotic therapy alone cannot cure patients with chronic osteomyelitis without surgical debridement to remove these isolated infected elements. Epidemiology Diagnosed diabetes is most prevalent in middle-aged and elderly populations. The highest rates occurring in people aged 65 years and older. A common feature of inpatient admission with foot ulceration was high rates of amputation, which is 33 percent, and death is 50 percent when amputation for severe neuro-ischemic lesions was not performed. These include unrecognized foot trauma from walking barefoot or in flip-flops, poverty, lack of diabetes education and lack of access to medical care. Moreover, in general epidemiology of diabetes affects around seven percent (7%) of the population in developed countries with large geographic and ethnic variations in incidence. The prevalence of impaired glucose tolerance was 1734% in men and 15.4% in women. Aetiology This is mainly used in medicine where it is the science that deals with the causes or origin of disease. In diabetes, due to selective destruction of pancreatic beta cells by an autoimmune process - assuming to occur in environmental and genetically trigger in susceptible individuals absolute insulin deficiency. The insulin resistance also creates a relative insulin deficiency. In addition to, insulin resistance can be due to abnormality in insulin molecule, defects in target cells or tissues which is the most common cause and lastly, excessive amounts of antagonists. Consensus is that the aetiology is a multifactorial interaction of environmental and genetic factors. Genetics For Type 1 diabetes, genetic susceptibility predispose to diabetes is around 40%. However, the majority of those who are genetically predisposed do not develop diabetes. Risks of developing diabetes when close relative has diabetes are 30% for identical twins, 5% for siblings and 6% for offspring. However, for Type 2 the genetic predisposition is stronger than Type 1. The concordance rate in monozygotic twins is almost 100%. Environment Immune response by environment could be viral, diet and stress. Viruses may initiate mediated damage to beta cells by direct destruction and the generation of cytokines that can damage the beta cells or by molecular mimicry. Thus, for the Type 2 diabetes, most patients are obese, but only a few obese people develop diabetes. The malnutrition in utero has also shown an inverse relationship between weight at birth and in late adulthood. Imaging The diabetic foot maybe predisposed to both common and unusual infectious or non-infectious process. This is because of the complex of nature of diabetes, it's associated vascular, and neuropathic complications. Therefore, imaging presentation will vary due to lack of specificity in complex clinical circumstances. This should only be ordered to confirm a suspected diagnosis and direct patient management. However, imaging has assumed a huge role in the management of patients, whether hospitalized or not. Depending on the patient's population and clinical problem. Varieties of imaging modalities are available for use, some appropriate than others. Plain radiographs should be the initial imaging study in diabetic patients with signs and symptoms of diabetic foot. Radiographs can detect osteomyelitis, fractures, and dislocations seen in neuropathic and structural foot deformities. The bone scanning or also known as bone scintigraphy provides the functional image of the bones. Bone scans are one of a number of methods of bone imaging, which are used to visually detect bone abnormalities. Such imaging studies magnetic resonance imaging (MRI), X-ray, computed tomography (CT) and in the case of bone scans nuclear medicine. The patient is injected with a small amount of radioactive material such as 600MBq of technetium-99-MDP and then scanned with gamma camera, a device sensitive to the radiation emitted by the injected material. The bones localize about half of the radioactive material. The more active the bone turnover, the more radioactive material will be seen. This nuclear scanning test to find abnormalities in bone is primarily used to diagnose a number of conditions relating to bones, locating sources of bone pain and diagnosing fractures that may not be seen easily in traditional X-ray images. It is also often used in diabetic foot infection to determine the presence of osteomyelitis. Although it is highly sensitive, this modality lacks specificity in the neuropathic foot. However, a negative bone scan is strong evidence against the presence of infection. To improve the specificity of nuclear imaging, white blood cells can be labeled with Tc99 hexamethylpropyleneamineoxine (Tc-99 HMPAO). Indium-111is more specific for acute infections than Tc-99 scanning. Chronic infections and inflammation are not well imaged with indium-111, it's because chronic inflammatory cells predominate and are not labeled with indium. According to Poon Michael, MR and CT imaging are emerging as promising complementary imaging modalities in the primary diagnosis of CAD and for the detection of subclinical atherosclerotic disease. Both CT and MRI are becoming available for a routine of clinical evaluation. The high negative predictive value when combining two or more of these modalities allow the exclusion of significant CAD with high certainty, provided that the patients are selected appropriately. The primary goal of current investigations using this combined imaging approach is to reduce the number of unnecessary diagnostic coronary catheterizations. CT and MRI have shown potential to directly image the atherosclerotic lesion, measure atherosclerotic burden and characterize the plaque components for screening for subclinical disease. Prevention Taking good care of your feet is very important if you have diabetes. Poor foot care can lead to serious problems. As a person with diabetes, you are more vulnerable to foot problems because the disease can damage your nerves and reduce blood flow to your feet. Taking proper care of feet is the most serious problems can be prevented. David Armstrong said that the meticulous attention to foot care and proper management of minor foot injuries are key to preventing ulcer formation. Daily foot inspection is the cornerstone of proper foot care. Gentle cleansing with soap and water, followed by the application of topical moisturizers, helps to maintain healthy skin that can better resist breakdown and injury. The best and most cost-effective way of preventing diabetic foot disease and amputation is to interrupt the pathway to amputation by preventing ulcer formation. Toenails Long or ingrown toenails can produce ulceration or infection. Regular and proper nail care is an important preventive measure in managing a patient with lower extremity neuropathy. Educating the patient regarding safe and effective nail care methods is critical. They should trim the nails parallel with the distal surface of the toe. Calluses Localized callus formation on the plantar surface of the foot indicates an area of high mechanical stress and is a risk factor for ulceration. To prevent further complication, discoloration beneath a callus on the lateral border of a callus requires immediate debridement. An effective way to reduce pressure is regular removal of calluses. Minor foot injuries and home remedies that impeded healing can unintentionally exacerbate infections like cuts, scrapes, blisters and tinea pedis. Patients should be reminded to avoid hot soaks, heating pads and harsh topical agents such as hydrogen peroxide, iodine and astringents. Gentle cleansing of minor wounds and the application of a topical antibiotic to maintain a moist wound environment can help to prevent ulcer formation. In addition, immediately consult physician if there's any minor wound that does not heal rapidly. Treatment Treatment is an absolute must for people with diabetes. Aside from injection of insulin, exercise and diet is also important. Insulin Treatment There are many forms of insulin to treat diabetes. They are classifies by how fast they start to work and how long their effects will last. These types include: Rapid-acting insulin - this covers insulin needs for meals eaten at the same time as the injection. This type of insulin used with longer-acting insulin. Short-acting insulin - this covers insulin needs for meals eaten within 30 to 60 minutes Intermediate-acting insulin - this covers insulin needs for about half day or overnight. This type of insulin is often combined with rapid or acting insulin. Long-acting insulin - covers insulin needs for about 1full day. This type of insulin is often combined, when needed with rapid or short acting. Pre-mixed.- these products are generally taken twice a day before mealtime. This is a combination of specific of intermediate-acting and short-acting insulin in one bottle. Exercise Vigorous exercises even if its done only once a week has a protective effect against diabetes. It does not only promote weight loss but lowers blood sugar as well. There is evidence that both men and women who gain weight in adulthood increase their risk of diabetes. As a matter of fact, 90 percent of diabetics are overweight. Diet The use of diet low in calories and saturated fat is an ideal strategy for preventing diabetes. Diabetic Foods Insulin production, blood sugar levels, and the types of foods a diabetic eats all play a large role in the management of diabetes. It is very important that diabetics adhere to a healthy diet. Several nutritional elements may be helpful in managing diabetes-related issues such as: 1. Focus on foods that are lower on the glycemic index like beans and whole-grain breads. These foods contain healthy complex of carbohydrates. 2. Incorporate a protein food every time you eat and try to avoid eating carbohydrate foods alone. By adding protein food lowers the glycemic index rate of the combines foods. 3. Increase magnesium-rich foods such as spinach, tofu, broccoli and pumpkinseeds. 4. Antioxidants help protect the body from complications associated with diabetes. Samples of antioxidant-rich foods are berries, fruits, legumes, vegetables, cereals and spices. Conclusions Having diabetes means blood sugar levels are too high. This can damage the nerves or blood vessels. Damage nerve can cause lose feeling of feet. People with diabetes may not feel a cut, a blister or a sore. Foot injuries such as these can cause ulcers and infections. Serious cases may even lead to amputation. Damage to blood vessels can also mean that feet do not get enough blood and oxygen. It is harder for the foot to heal, if you do get a sore or infection. To help avoid foot problems control first the blood sugar levels and good foot hygiene is also crucial. To further understand which modality to use for a particular problem, all imaging modalities must be reviewed with emphasis on method of generating an image, cost, strengths and weaknesses and associated risks. One of this is the MRI that is use of radio frequency pulses in a magnetic field. This is good for bones, CNS and joints however, there is a weight limit and claustrophobia sometimes is a big problem. Another is the nuclear medicine wherein radioisotopes are injected into a patient and emit rays of known energies. Camera can collect energy from the emitted beams, showing areas of increased or decreased activity. This is excellent at delineating function, however, it is not good for interventional procedures and has a weak anatomical analysis. Therefore, foot lesions, especially ulceration, are common in-patients with diabetes. If treatment is delayed or inappropriate treatment is rendered, the lesion can become infected, resulting in gangrene and/or amputation. Physicians, clinics, and wound-healing centers that follow a rigid protocol, including aggressive therapy, revascularizaton when indicated, therapeutic shoes when indicated, a team approach, and repeated education of the patient in foot care, have reduced amputation rates by 50% or more. In addition, having a high level of blood sugar is the cause of being diabetic. To prevent this, regular exercise and diet control is necessary. People with diabetes may feel like their food choices are very restricted. It's true that they have to pay more attention in what to eat, but it does not mean they have to keep track of every single calorie and carb. Basic Questions About Diabetes 1. What is diabetes 2. What are the causes of diabetes 3. What are the symptoms of diabetes 4. What is the treatment for diabetes 5. Can diabetes be prevented 6. Who are more prone to be diabetic 7. Is there a food restrictions for diabetes 8. How can amputation be prevented 9. Are there types of insulin to be considered to treat diabetes 10. Is diabetes transferable Sources Armstrong DG, Lavery LA, Quebedeaux TL Walker SC, Surgical Morbidity and The Risk of Amputation Due to Infected Puncture Wounds In Diabetic Versus Nondiabetic Adults, South Med J, 1997;90:384-9 Cunha MD, BA, Diabetic Foot Infections, State of University of New York of Medicine, June 23, 2008, http://www.foot.com Read More