TO THE EDITOR: We read with interes...

TO THE EDITOR: We read with interest the newly come article, "Diabetic Foot Ulcers: Pathogenesis and Management," (1) through Dr. Frykberg. While debridement of an boil is important to provide a clean damage base conducive to wound granulation and healing, Dr Frykberg asserts that topical enzyme are ineffective as the alone debridement agent and cautions against soaking gatherings in patients with neuropathy. An effective adjunctive therapy for harm debridement that was not mentioned is maggot therapy.

Several papers (2-5) have described the utility of maggot debridement therapy (MDT) for debridement of diabetic twelve inches ulcers, specifically chronic nonhealing sore s having failed multiple conventional injury therapies. A recent retrospective thought (2) demonstrated that MDT was more effective for hurt debridement of nonhealing lower extremity festers compared with conventional therapies, and produc increased amounts of granulation tissue and a more rapid decrease in pain size. A large prospective trial will be necessary to evaluate whether MDT accelerates closure of diabetic lower extremity injurys but until then available studies and anecdotal reports indicate that MDT can be useful in treating this variety of anguish Importantly, MDT may help curtail the number (3) or length (4) of amputations, which is an aim of the "Healthy commonalty 2000" project. (2) One studious mood (3) reports that in five patients who were referr for leg amputation after multiple surgical and nonsurgical systems failed to heal their hurts the affected limb was salvaged at MDT without the need for amputation.

The advantage of MDT throughout sharp debridement is that it generally causes les line loss. A study (6) in succession the cost effectiveness of MDT compared with a standard hydrogel dressing for the one-month treatment of venous boils demonstrated that MDT, in addition to debriding the hurts more quickly, reduced the overall treatment prices by reducing the number of nursing visits, total nursing time and wages, and dressing costs

The primary disadvantages of MDT are esthetic and torture pain/pruritus, and the latter is treatable with analgesics. Rarely, patients may have influenza-like symptoms, transient pyrexia, or allergic reactions. MDT may be ineffective in treating near diabetic wounds, particularly in patients with strict hypoperfusion. (2) Also, wounds where the larvae may be crushed (such as those between the toes or the heel) may make MDT les efficacious, unles patients are specifically instructed to avoid walking or other activities injurious to the maggots. Although larvae enlist in one's serviceed in MDT typically ingest barely necrotic tissue and spare living tissue, detriments involving vital organs, exposed larger caliber descendants vessels, and tracheostomies are considered contraindications for larval use through some. But, MDT can be effective in treating more [i]or[/i] less chronic, nonhealing diabetic lower extremity festers and should be considered as an adjunctive therapy for this mark of wound.

REFERENCES

(1) Frykberg RG Diabetic paw ulcers: pathogenesis and management. Am Fam Physician 2002;66: 1655-62

(2) Sherman RA. Maggot therapy for treating diabetic lower part ulcers unresponsive to conventional therapy. Diabetes Care 2003;26:446-51

(3) Mumcuoglu KY Ingber A, Gilead L Stessman J Friedmann R Schulman H et al. Maggot therapy for the treatment of diabetic paw ulcers. Diabetes Care 1998;21:2030-1.

(4) Knowles A, Findlow A, Jackson N Management of a diabetic base ulcer using larval therapy. Nur Stand 2001;16:73-6

(5) Rayman A, Stansfield G Woollard T Mackie A, Rayman G Use of larvae in the treatment of the diabetic necrotic base Diabetic Foot 1998;1:7-13.

(6) Wayman J Nirojogi V Walker A, Sowinski A, Walker MA. The price effectiveness of larval therapy in venous gatherings J Tissue Viability 2000;10:91-4.

impel letters to Jay Siwek, MD Editor, American Family Physician, 11400 Tomahawk inlet Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@ aafp.org. Please include your without fault [i]or[/i] blemish [i]or[/i] flaw address, telephone number, and fax number. verbal expressions should be submitted on disk, double-spaced, fewer than 500 words, and limited to single in kind table or figure and six allusions Please submit a word consider Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a note will be construed as granting the AAFP permission to publish the literal meaning in any of its publications in any form. The editors may edit notes to meet style and space requirements.

JAMES BRADLEY SUMMER M MD

University of southern Alabama

P.O. driver's seat 16343

Mobile, AL 36616

JOSEPH KAMINSKI, MD

Medical literary institution [i]or[/i] seminary of learning of Georgia

1120 15th St

Augusta, GA 30912

IN REPLY: Dr Summer and Kaminski correctly mention that maggot debridement therapy is a potential option for the management of diabetic lower part ulcers, especially in the appearance of necrotic tissue. I have used biodebridement numerous times as an adjunct to sharp debridement. This therapy was not specifically addressed in my article (1) because of space constraints, its limited acceptance at the time of publication, and because it is not a particularly suitable treatment regimen for the average family physician. However, it was mentioned as an option in Table 4 of my article (1) and was referr to as "biodebridement." I continue to enlist in one's service maggot biodebridement therapy in my practice for picked patients and await further confirmation of its utility and efficacy with the publication of definitive randomized controll clinical trials.