Foot ulcer

Direct laser-assisted myocardial revascularization (DMR) is an approved technique in the US, Europe, and parts of Asia to create numerous myocardial channels. This results in the induction of a massive inflammatory reaction, which in turn induces angiogenesis. The other FDA-approved pro-angiogenic therapy is the use of recombinant human platelet-derived growth factor (Regranex) for use in the treatment of diabetic neuropathic foot ulcer s. 

The pathogenesis of diabetic foot infection stems from three key factors neuropathy, angiopathy, and immunopathy. Aerobic gram-positive cocci, such as S. aureus and P-hemolytic streptococci, are the predominant pathogens in acutely infected diabetic foot ulcers. However, chronically infected wounds are subject to polymicrobial infection and require treatment with broad-spectrum antibiotics. 

Foot ulcers and related infections are among the most common, severe, and costly complications of diabetes mellitus (DM). Fifteen percent of all patients with DM develop at least one foot ulcer, resulting in direct health care expenditures of approximately 9 billion annually in the United States.26,27 Diabetic foot ulcers and wounds are highly susceptible to infection. Related skin, soft tissue, and bone infections account for 25% of all diabetes-related hospitalizations.28 More than half of all nontraumatic lower extremity amputations (LEAs) performed each year in Western nations are linked to diabetic foot infection 80,000 LEAs are performed annually in the United States alone.29,30... 

Not all diabetic foot ulcers are infected. However, infection is often difficult to detect when perfusion and the inflammatory response are limited in the diabetic patient. The common signs and symptoms (i.e., pain, erythema, and edema) of infection may be absent.32 Still, the diagnosis of diabetic foot infection depends mostly on clinical evaluation. 

The most feared complication of infected diabetic foot ulcers is LEA. Diabetic patients are approximately 40 times more likely to require an amputation than nondiabetics.34 Morbidity and mortality rates are high following amputation. Mortality ranges from 40% to 80% after 5 years, generally secondary to comorbid conditions, including heart and renal disease.28,30... 

The nonpharmacologic treatment of diabetic foot ulcers may include off-loading, chemical or surgical debridement of necrotic tissue, wound dressings, hyperbaric oxygen, vascular or orthopedic surgery, and the use of human skin equivalents.30... 

None. Avoid treating uninfected diabetic foot ulcers. 

Claudication and nonhealing foot ulcers are common in type 2 DM. Smoking cessation, correction of dyslipidemia, and antiplatelet therapy are important treatment strategies. 

Platelet-derived growth factor treatment of diabetic foot ulcers March 2002... 

Exercise is an essential yet neglected aspect of treatment for type 2 diabetes especially in its early stages where insulin resistance may predominate. Accumulation of at least 30 0 minutes of moderate physical activity on most days of the week is recommended. For type 1 diabetes the emphasis must be on adjusting the therapeutic regimen to allow safe sports participation to prevent precipitation of ketoacidosis or hypoglycaemia. Extra care is required in cases with known complications like proliferative retinopathy, nephropathy, foot ulcers and cardiac or peripheral vascular disease. 

Finally, rehabilitation specialists can encourage patient compliance in the nonpharmaco-logic management of their disease. Therapists can emphasize the importance of an appropriate diet and adequate physical activity in both type 1 and type 2 diabetes. Therapists may also play an important role in preventing the onset of diabetic foot ulcers and infection by educating the patient in proper skin care and footwear. 

Diabetes mellitus is a disease related to carbohydrate metabolism in which insulin is absent, low in quantity, or a combination of both. It is characterized by hyperglycemia. Progress of the disease causes tissue or vascular damage, leading to diabetic complications such as retinopathy, neuropathy, cardiovascular disease, and foot ulcerations. 

Mr SA is 185 cm tall, weighs 83 kg and has a 15-year history of type 2 diabetes mellitus and hypercholesterolaemia. He is under the care of the diabetes clinic at the hospital for management of Charcot s arthropathy of the foot and diabetic foot ulcer. He also has a 5-year history of ischaemic heart disease and underwent coronary artery bypass grafting one year ago. He drinks half-a-bottle of red wine per day and smokes a pipe. He is allergic to penicillin. His current medications are ... 

On examination, he appears confused and disoriented and clinically dehydrated. He has an inflamed, malodorous foot ulcer with obvious purulent slough. Dorsalis pedis and posterior tibial pulses were palpable, suggesting adequate arterial supply... 

The patient is diagnosed with hyperosmolar non-ketotic (HONK) syndrome secondary to infection of a diabetic foot ulcer and the treatment plan is as follows ... 

Outline a pharmaceutical care plan for this patient with infected diabetic foot ulcer including advice to the clinician. 

What are the prognosis and potential long-term complications of diabetic foot ulcers ... 

Cavanagh PR, Lipsky BA, Bradbury AW and Botek G (2005) Treatment for diabetic foot ulcers. Lancet 366(9498) 1725-1735. 

Neuropathy of the sensory, motor and autonomic nerves, along with micro-vascular and macrovascular disease and impaired neutrophil function all contribute to the development of foot ulcers in diabetic patients. This patient has a neuropathic rather than an ischaemic ulcer. 

Diabetic foot ulcers are often colonised by multiple organisms that may or may not be pathogenic, therefore a swab of the ulcer surface is unreliable for identifying causative organisms in infection. The most reliable sample for culture is a specimen of deep tissue obtained by aspiration or biopsy without contact with the ulcer surface or draining lesions. 

Alternatives to piperacillin-tazobactam for a penicillin-allergic patient with infected diabetic foot ulcer include ... 

Foot ulcers cause significant morbidity and impaired quality of life and are the most important risk factor for lower extremity amputation. The lifetime risk of a foot ulcer is up to 15% for patients with diabetes and 15-27% of all ulcers result in surgical removal of bone (Jeffcoate and Harding, 2003). Major amputation incidence is around 0.5% of patients with diabetes per year (NICE, 2004). Peri-operative mortality for major amputations is 10-15% and 3-year survival rates can be as low as 50%. 

Diabetes mellitus is a major cause of blindness, renal failure, and cause for surgical amputation of legs or feet- The risk of cardiovascular disease is doubled in a person with diabetes mellitus. Thus, diabetes is a serious health hazard. How dt>es diabetes first present itself The initial symptoms of the disease include excessive thirst, excessive food consumption, excessive urination, weight loss, and blurred vision.. Diabetes often results in neuropathies leading to impotence (in males) and numb feet. Foot ulcers may occur, and in extreme cases, the foot must be amputated-Diabeles is a leading cause of blindness in adults. Diabetes often accelerates the development of cardiovascular disease, but the mechanism of this acceleration is not clear. 

Becaplermin (r-PDGF) Regranex(Chiron/N ovartis /Ortho-McNeil) Diabetic foot ulcer... 

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