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Using Maggot Therapy in Wound Care

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The role of fly maggots in debriding and healing of wounds is knowledge that has existed in society for centuries. First introduced in the United States in 1931by group of clinical researchers, it was routinely put into use until the mid -1940s when the need to review its roles, applications and rose to higher levels. In addition to that, the discovery of antimicrobiols made the application of maggot therapy in wound care rare until its reintroduction in half a decade later. In early 1990, maggot therapy was introduced in a number of countries such as United Stares, United Kingdom, Israel and Japan.

The purpose of this dissertation paper is to investigate the role of maggot therapy in wound care. This will involve a critical and systematic review and analysis of available literature on the use of maggot therapy in wound care. The objectives of this paper will achieved through the critical analysis and evaluation of literature relevant to the nursing practice, systematic critique of the relevant literature and the eventual proposition and justification of the recommendations advanced from the studies analyzed.  Last, conclusion based on the implications and recommendations for future research will be identified.

The aging of our population has brought along a number of medical complications that have demanded more attention than in the past. The number of patients suffering from complex medical problems such as diabetes mellitus and peripheral vascular diseases has recorded an upward trend in the recent past. This translates to increase in chronic wound patients attributable to these medical complications.   It is medically proven that a chronic wound does not progress through the four overlapping phases of wound healing. This is because it is arrested at the inflammatory phase due to the presence of necrotic debris, slough and infection. The traditional approach of wound treatment involved application of dressing and debridement. In wound the process of debridement, the exudates, bacteria and foreign materials in the wound are removed for the allowance of the normal healing process.

The application of dressing not only prevents further contamination of the wound and entry of foreign materials but also aids in the removal of the exudates thereby aiding the process of healing (Pavillard & Wright, 1957).  The statistics are very grim in that a big number of the word population is experiencing challenges in regard to chronic wound treatment; majority is composed of diabetic foot ulcers. According to Sherman (2003), impaired wound healing is a common and costly problem for those with diabetes. Non-healing diabetic foot ulcers account for 25–50% of all diabetic hospital admissions, and most of the 60,000–70,000 yearly amputations in the U.S. In addition to the above, “Almost 15% of all diabetic patients will develop one or more foot ulcers, and 15–25% of those ultimately will require amputation”  (National Center for Health Statistics, 2001). It is no wonder that one of the disease prevention objectives outlined in the “Healthy People 2000” project was a 40% reduction in the amputation rate for diabetic patients. The sad fact is that this objective still remains elusive despite the fact that medical advances in wound care has been robust in the recent past.

The importance of knowledge in wound care in clinical nursing is not particularly hard to discern given the relevance of this technique in wound care and the increasing number of patients with chronic wound problems. The problem of wound care is so common in clinical practice and as such demands extensive knowledge in appropriate methods in handling chronic wounds. The Maggots’ abilities to kill bacteria and make the area in the wound sterile attests to the idea that maggot therapy is one of the most effective ways in wound treatment (Simmons, 1935). In addition, its ability to aid faster healing of the wounds with the production of granulation tissue calls for more concerted efforts towards more knowledge in this method. The relevance of advancing this knowledge within the discipline of clinical practice cannot therefore be undermined.

As opposed to a comparative literature analysis, this dissertation aims at achieving its objectives through a systematic and critical analysis of relevant literature on wound care, chronic wound care, wound treatment and related topics on the application of maggots. This approach aims at retrieving as much relevant information as on the use of maggot therapy on wound care. This is aimed at expanding the horizons in existing knowledge within this practice and underlining its relevance in addressing the increasing medical problem of wound care.

To effectively achieve the purpose of this dissertation paper, a total of five recent literatures will be systematically and analytically reviewed. This will include academic articles written within the last ten years because of their ability to provide up to date information on the topic under discussion. The critical literature review and analysis will seek to answer all relevant aspects of maggot therapy in wound treatment such as its history, its merits, limitations, relevance of research and design methods, and all relevant aspects of the literatures.

In appreciation of the fact that maggot therapy is one of the most effective methods in wound care and treatment, in depth knowledge on this topic would not only add rich study materials to the existing ones but will expound on my level of knowledge within the nursing practice. This becomes more poignant when an analysis of the current health status is brought to the fore. According to the Centers for Disease Control and Prevention [CDC], (2003), chronic disease and preventable illnesses account for approximately 72 percent of annual health care costs. The primary chronic diseases and preventable illnesses that contribute to health care costs are cardiovascular disease and stroke, obesity, cancer, diabetes, and arthritis. According to the CDC, there are three “modifiable health-damaging behaviors” that impact health care costs (CDC, 2003). These behaviors are smoking, physical inactivity and poor nutrition (CDC, 2003). One explanation for the high cost of health care for chronic disease is the aging population. While life expectancy of Britons has risen from an average of 59 years in 1950, to a current age of 77 there has also been a parallel rise in health care costs (CDC, 2003). Concerted efforts geared towards the understanding of problems of aging and diabetes especially in wound care will definitely be beneficial to the society but will also reduce costs associated with the management of these medical complications (Vistnes, Lee, & Ksander, 1986).  

Literature review

The findings of Kong, Chan, Fong, Leung, Patil and Leung (2007), Mumcuoglu,  Ingber, Gilead,  Stessman, Friedmann, Schulman,  Bichucher, Ioffe-Uspensky, Miller, Galun and Raz (2001), Sherman (2003), Barkur (2002) and Lagan (2007) shall be presented in this review.  Towards this, the review will discuss the major issues addressed in the research, techniques used by the researchers and the authors to go about addressing the issues, the numerical and statistical data presented the major findings and recommendations. In addition to the above, a detailed analysis on how the issues have been synthesized, methodologies employed by the researchers and the authors as well as how data has been analyzed shall be presented. The relevance of maggot therapy and the extent to which it is applied within the medical and clinical practices will be highlighted and any limitations pointed out.

From medical research perspective, the major question being raised is why explore the maggot therapy in the treatment of wounds? As a nursing student, what is the benefit of seeking to enlarge the scope of my knowledge in the application of maggot therapy in wound care? These are the questions this section will attempt to address by reviewing literature covering aspects of maggot therapy in wound care. Aspects of the maggot therapy in wound care include its applicability, relevance, limitations, historical perspectives, merits to the medical fraternity and its cost benefit analysis.

Significance of this Review

Billions of research dollars are spent each year to find better, more effective and curative treatment in various ailments with diabetes, cancer and HIV leading as the most expensive medical complications to manage. For wound care, these treatments currently vary depending on the type of wound, with conventional antibiotics and maggot therapy regimens being used along with traditional pain-control medications. Sherman (2003) illustrates that “Non-healing diabetic foot ulcers account for 25–50% of all diabetic hospital admissions, and most of the 60,000–70,000 yearly amputations in the U.S. In addition to the above, “Almost 15% of all diabetic patients will develop one or more foot ulcers, and 15–25% of those ultimately will require amputation” (Sherman, 2003). This is clear indication that wound care and wound treatment as a medical complication is a major health problem that is increasing in both developed and developing countries that requires very effective medical management techniques to reduce the pain and anxiety on its victims. This is in view of the fact that traditional medical management of patients’ symptoms does not consider the holistic nature of the disease and the human healing process. Patients then must be given the most effective form of care that not only fights the disease but also alleviates fear, anxiety, and pain (Robinson & Norwood, 1934).

 There is need to shift the focus of research addressing the problem to effective methods of wound curing and control.  Earlier forms of interventions have demonstrated very limited success in the solution to the complexity o this problem. Through these different background studies that do not only look at the role of wound care in line with diabetes but extends to other related wound complications such those caused by other related factors, the authors of these academic literatures have identified a study relevant to both nursing and clinical professions. This is based on the fact that nurses and clinicians, being key stakeholders in health programs that cater for the population, are better placed to institute informed and innovative ways of reducing health related problems such as diabetes in the society.  

History and evolution maggot therapy in wound care

Maggot therapy in wound care has revolved in the medical and nursing circles due to its effectiveness and cost benefits it avails to patients and medical services providers. These benefits include individual services relating to conveniences and low cost of medical bills in comparison to other available options in wound care.  The history of wellness and health care programs are well documented issues in available literature. Kong, Chan, Fong, Leung, Patil and Leung (2007), Mumcuoglu (2001), Sherman (2003), Barkur (2002), Lagan (2007)  

Fly maggots have always been known to have debriding capacity and heal wound for centuries. In fact as early as the period of Job, man had discovered the capacity of maggots to heal wounds. In the Bible (Job 7:5), Job complained that “my body is clothed with worms and scabs, my skin are broken and festering.” according to Barkur (2002), “The Ngemba tribe of New South Wales, Australia, commonly used maggots to cleanse suppurating or gangrenous wounds and it is said that the aborigines traced this practice back to their remote ancestors.” There is a wealth of historical facts on the evolution of application of maggot in wound care. During Napoleon era, maggot is demonstrated to have been used in the treatment of wounds sustained in war. The French discovery was led by the Confederate surgeon of Napoleon who accidentally discovered the capacity of maggots to aid the healing of wounds sustained after surgery and form bullets during war. The beneficial effects of using larvae in wounds were first noticed by Ambrose Paré in 1557; while treating battle wounds in Napoleon’s army, Baron Larrey observed that maggots enhanced granulation formation” (Kong et al, 2007). In addition to the above “The Hill Peoples of Northern Burma were observed during World War II placing maggots on a wound then covering them with mud and wet grass” (Barkur ,2002).

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The historical perspectives of maggot therapy in wound care is also well illustrated by Mumcuoglu,  Ingber, Gilead,  Stessman, Friedmann, Schulman,  Bichucher, Ioffe-Uspensky, Miller, Galun and Raz (2001) by stating that the origin of maggot therapy dates back to ancient years and has been practiced in some communities over generations. However it was not until 1930s when it was officially adopted in hospitals as the main cure to charonic wound sustained by soldiers in combat and thus its subsequent adoption in the formal medical field. The concept has been take with apprehension by some people dismissing it for lack of scientific backing while other have adopted it and attest to its positive effects.

Whereas a great deal of effort has put forward in the search for historical facts on the exact origin of the use of maggots in wound therapy, there is abidance in the fact that the founder of modern maggot therapy is William Baer (1872-1931). Described as “Clinical Professor of Orthopedic Surgery at the Johns Hopkins School of Medicine in Maryland, Baer used maggots on 2 patients in 1st World War” (Pechter & Sherman, 1983). According to Chan et al (2007) “Later, William Baer refined the technique by using sterile maggots to prevent maggot-induced wound infection. The therapy became increasingly more popular and was widely used for the treatment of chronic or infected wounds across North America and Europe during the 1930s”

The popularity of maggot therapy was gaining momentum because of the increasing patients who demanded proper wound care (Prete, 1997, Sherman, Tran & Sullivan, 1996). This was mainly composed of soldiers who sustained physical body injuries in combat. The eventual discovery of penicillin in 1940 and sulphonamides curtailed the growth of maggot therapy in wound care. The maggot therapy was therefore lost in clinical and nursing practice for almost a half decade until 1990. The resurgence of maggot therapy resurfaced in the clinical and medical circles because of the increasing resistance to antibiotics that that were the hall mark of wound care for almost half a decade.

Relevance of Maggot therapy

The initiatives and advancements in the application of maggot therapy in wound treatment were basically developed to promote the wellbeing of the patients suffering from chronic wounds workers and general population. Available literatures outline the importance of maggot therapy in wound debridement and abide in its capacity and effectiveness to debribe wounds. Furthermore, literatures also abide in the fact that there has been an increase in the use of maggot therapy in wound care (Moss, Klein & Klein, 1992).  The following therefore is a comprehensive review of both theoretical and empirical literature that will attest to the fact that maggot therapy is relevant in wound care and wound treatment. Kong et al (2007) Sherman (2003) and Lagan (2007) have provided a detailed study on the maggot therapy in wound treatment.  Kong et al (2007) have demonstrated in their study Maggot Debridement Therapy in Chronic Wound Care that through the mechanisms of debridement, disinfection and enhancement of wound healing, maggot therapy has the capacity to effectively heal chronic wounds. Through the application of sterile larvae to prevent contamination of the wound, Kong et al (2007) illustrate that

Newborn larvae should be used within 8 hours or stored in a refrigerator at 8º to 10ºC, so as to slow their metabolism. To maximize debridement, it is important to ensure an optimal body temperature, adequate oxygen supply and moisture, though too much moisture may kill the larvae. The use of occlusive dressings should be avoided, as larvae require oxygen to survive. Propylene glycol from hydrogel dressings can limit the growth and viability of larvae, while systemic antibiotics do not affect larval development.

Kong et al (2007) in their study have successfully presented a comprehensive and relevant academic, theoretical as well as empirical review of literature in their study and underlined the importance of critical steps in the application of maggot therapy in wound care. In addition to the above, the authors have presented their analysis on the requirements in this method of wound care as specific as possible. This is in line with the fact that they have not only demonstrated the type of larvae that is most appropriate, but they have also expounded on appropriate temperature levels and moisture.

In their analysis, Kong et al (2007) abide in the ability of the maggots to debride and heal chronic wounds. Debridement has been given as the first mechanism of maggot therapy by Kong and his group. Their presentation of the debridement mechanism is well articulated with the beginning of earlier postulation by past researchers on maggot therapy. Whereas the authors have made concrete revelations on debridement mechanisms, this section has fallen short of expected levels of comparative analysis on the clinical mechanisms of this process in wound healing. 

In expounding the debriding effect of maggot in wound care, Kong et al (2007) have first presented where early studies as well as more recent information that are coherent with this article. The author began by demonstrating the need to incorporate the element of a phenomenological approach so that the study could have an in-depth exploration of problems to be addressed in what he termed as “Seeing things up close’ – using the philosophy of Husserl as a base. In demonstrating connections to other academic works on the topic, Kong et al (2007) have achieved the relevance of this study to the current demands in understanding the problems and challenges that both clinical and medical fields face in the application of maggot therapy. Recent studies have focused on the need to concert more energy towards exploring strategies aimed at adopting maggot therapy in wound care and treatment because of its relevance. It is therefore prudent enough to confidently state that the aim of the research, the research question and research problem are comprehensively addressed and all literature used to support this study are relevant.

The relevance of this method in wound care is also demonstrated by Sherman (2003) in his article “Maggot Therapy for Treating Diabetic Foot Ulcers Unresponsive to Conventional Therapy.”  This is best achieved by the author is the assessment of “efficacy of maggot therapy for treating foot and leg ulcers in diabetic patients failing conventional therapy” (Sherman, 2003).  The aim and objective of this study is well illustrated by the author in brief and direct form. The aim of this study was to “To assess the efficacy of maggot therapy for treating foot and leg ulcers in diabetic patients failing conventional therapy” (1).  In addition to that Sherman has stated the research question in a clear manner and format by detailing down the aspect of questions this study is to address. The research question was to explore and amplify the Maggot Therapy for Treating Diabetic Foot Ulcers Unresponsive to Conventional Therapy, gain further understanding of the dynamics and processes involved, and discover information that can be used to inform support and development needs (2). Furthermore, the research study has expanded the scope of its question to address issues such as exploring and amplifying the experiences of nurses and doctors undertaking constant observations, including any effects this process may have on patients; to gain further understanding of the dynamics and processes involved (78).

Sherman (2003) has used various demographic variables in conducting this study. The inclusion criteria for this study were based on referral for advanced wound treatment from other institutions. “143 patients with 260 non healing wounds were referred to the maggot therapy service for evaluation and found to be appropriate candidates for maggot therapy. Non candidates were referred elsewhere, usually for surgical resection of steomyelitis or rapidly advancing soft-tissue infection” (Sherman, 2003). The inclusion criteria also involved a signed consent by the patients or their kin to participate in the study. 

The research design applied by Sherman in this study specifically fit into the accepted principles and procedures in clinical studies. The 260 wounds in the 143 patients included 31 non healing foot and leg ulcers in 26 diabetic patients, 145 non healing pressure ulcers in 103 patients and 84 chronic wounds which include venous stasis, traumatic and post-surgical wounds. According to Sherman (2003), 

Maggot therapy was administered by applying disinfected fly larvae to the wound, within a cage-like dressing, as previously described. Larvae of Phaenicia(_Lucilia) sericata, reared and disinfected in our insectary (18), were placed within the wound (five to eight larvae per square centimeter) with loose gauze.

The wound is then hydrocolloid that is freshly cut and disinfected to prevent contamination. This is placed onto the skin surrounding the wound. A porous nylon silk as also supported by a number of literatures such as Kong, Chan, Fong, Leung, Patil and Leung (2007), Mumcuoglu (2001), Sherman (2003), Barkur (2002) and Lagan (2007) that helps in the absorption of the necrotic drainage. This demonstrates that Sherman’s work is not only in line with other available literatures on the topic of maggot therapy in wound care. 

The relevance of maggot therapy is also supported by   Mumcuoglu,  Ingber, Gilead,  Stessman, Friedmann, Schulman,  Bichucher, Ioffe-Uspensky, Miller, Galun and Raz (2001) by stating that  maggot therapy and its effectiveness in the medical field have received a lot of attention in recent years. While scientists have aggressively pursued physical medications for treatment and control of various ailments affecting man, some people have argued that more utilization of energy medicine would result to better achievements. This idea was more advanced within the medical circles by the discovery of anti-biotic. Maggot therapy, according to Mumcuoglu et al (2001) can be used either as a compliment or a substitute to various diseases. The many other attributes associated by its proponents like inducing relaxation, improved adaptation etc if true would mean that maggot therapy has a place in the human health.

Sherman (2003) in his study which sought to establish the effectiveness of maggot therapy on both non healing foot and leg ulcers and chronic wounds (venous stasis, traumatic and post surgical wounds); the decrease in pain, relaxation of the patients and the participation of the patients after administering and observing the therapy. In this study 146 participants were involved and were grouped according the type of wound complication they exhibited. 260 wounds in the 143 patients included 31 non healing foot and leg ulcers in 26 diabetic patients, 145 non healing pressure ulcers in 103 patients and 84 chronic wounds which include venous stasis, traumatic and post-surgical wounds.

Measurable variables in the course of the treatment included were pain, absorption, health and general improvement recorded in the course of therapy administration and monitoring. These included size (cm2), circumference (cm), depth to periosteum or into bone, Necrotic tissue (% total surface) and Granulation tissue (% total surface) (Sherman, 1996; Sherman, 1997, Sherman, 1998; Sherman, 2000). The results showed an appreciable reduction of pain in the patients and an improvement in the ability to not only record high rates of recovery but a large number also recorded full recovery. Both Chan et al (2007) and Mumcuoglu et al (2001) found almost similar results in their studies which sought to establish if patients undergoing recovery from chronic wound had improved outcomes when maggot therapy was administered. Chan et al (2007) reviewed a list of articles from Pub Med and Medline performed from 2007.  Their study selection involved “Original and major review articles related to maggot debridement therapy were reviewed with key words used in the literature search were ‘maggot debridement therapy’, ‘wound healing’, and ‘chronic wound management.”

In the research study by Mumcuoglu et al (2001), the sample used was composed of twenty five subjects who were drawn from diverse background and were suffering mostly from chronic leg ulcers and pressure sores in the lower sacral area, were treated in an open study using maggots of the green bottle fly, Phaenicia sericata.  This sample was grouped in to different styles three just like Sherman (2003) study – those who maggot therapy was administered, partial intervention group and those who no intervention was done. Outcomes assessed include length of stay, amount of time for recovery, Necrotic tissue (% total surface) and Granulation tissue (% total surface). The results of the study showed there was a significant reduction in the level of anxiety and length of stay in the patients that Maggot Therapy was administered. There was however no reduction comparative analysis on the number of sterile maggots used in the patients. According to Mumcuoglu et al (2001) “Complete debridement was achieved in 38 wounds (88.4%); in three wounds (7%), the debridement was significant, in one (2.3%) partial, and one wound (2.3%) remained unchanged. In five patients who were referred for amputation of the leg, the extremities were salvaged after maggot therapy”. The results of this research therefore abide with those of Sherman (2003), Chan et al (2007) and Lagan (2007) on the effectiveness of this method in wound care and treatment.

Lagan (2007), just like Chan et al (2007) reviewed a number of articles on Larval Therapy in Wound Management. His sample involved a number of relevant articles that have presented the topic of wound management by the application of maggot larvae. The articles were analytically reviewed to retrieve as much relevant information as possible on Larval Therapy in Wound Management. Most of the articles reviewed by Lagan (2007) had patients who received Larval therapy, a simulated version of Maggot therapy. A number of outcomes have been projected by Lagan in the review of the literatures in his work. The results of the discussion as presented by Lagan showed that most of the patients who underwent Maggot therapy recorded considerable reduction in the levels of severity of their wounds with a considerable fraction fully recovered.  Of all the literatures reviewed in this dissertation paper, Lagan has presented the best analysis on the benefits of Maggot therapy in comparison to other forms of conventional treatments.

Lagan (2007) has achieved this comparative analysis by illustrating that Anecdotal evidence has consistently suggested that larval therapy results in a reduction in wound pain and odour, and promotes the healing process with relatively few side effects. Larval therapy is also reported as being cost-effective in comparison with conventional wound dressings. An important study investigated the efficacy and cost-effectiveness of larval therapy vs. hydrogel, and reported that all wounds treated with larval therapy were successfully debrided following one application at a median cost of £78.64. Treatment with hydrogel was proven to be less efficient where it was noted that, following 1 month of treatment, one-third of wounds still continued to require treatment. The median cost of treatment for this group was £136.23. 

In addition to the above, while other authors have demonstrated more on the benefits of this method in wound care, Lagan (2007), has effectively analyzed the disadvantages of maggot therapy in wound care and treatment. In his analysis as presented by the number of articles reviewed, Lagan has pointed at the negative perception of maggot larvae by patients and practitioners and pain experienced by the patients during the feeding process by the larvae. 

Barkur (2002) on the other hand adopted a different approach in his study to find out the effect of Maggot therapy by examining the effect of Maggot’s therapy for treatment of Leg ulcers. Fibroblasts, tendon cells and bone cells were subjected to the presence of maggot larvae and monitored through a period of time to examine notable changes in the wounds. This was done for more than one month after the administering of a varying number of maggot larvae to into the wounds. The wounds were then examined and two outcomes were assessed; there was a noted debridement of the wounds as time progressed (Robinson, 1933).

Two notable authors in the group of these reviewed articles have taken the best approach in an attempt to explain the effectiveness of Maggot Therapy in treatment. Both Mumcuoglu et al (2001) and Sherman (2000) in their reviews have sought to give a neuro-scientific explanation for the effectiveness of Maggot therapy in relieving pain and treatment of chronic wounds. They have come up with a model that can be applied in getting a scientific explanation to the mechanism that maggot therapy relives pain and cures chronic wounds.  In their method they set out with the notion that healing is as a result of sensory reorganization and he explores the action of maggot larvae in the excretion of products that deactivates thriving bacteria in the wounds. Their studies involved examining and classifying the various maggot therapy types and their effectiveness in wound debridement, wound healing and wound disinfection. They suggest very strongly the mechanisms of maggot larvae action in the above processes (Frykberg, 1999)

In this regard, Barkur (2002) states that Maggots secrete proteolytic enzymes from their secretions and digest the dead tissue and make a soup and then these are ingested by the maggots. This produces debridement of dead or necrotic tissue. It is better than doing the debridement by surgical means. These maggots also kill the bacteria and make the area in the wound sterile. They also secrete juices which limit the spread of infection and make the healing better. The maggot therapy has shown healing rate is better and faster healing with production of granulation tissue which is very important for healing of wounds. They produce fibroblast stimulating chemicals which encourage fibroblasts to start granulation process.

Kong et al (2007) illustrates that “Maggots use a pair of mandibles/hooks for movement and attachment, and it was believed that the probing from the hooks may facilitate wound debridement”. Sherman (2003) has taken a deeper approach in an attempt to examine the effectiveness of Maggot therapy. He collected data and undertook a review of the various studies previously carried out in order to establish if Maggot Therapy results to reduction of pain, anxiety and eventual healing in diabetes patients with chronic wound ulcers. He examined a number of cases and reviewed studies by various authors in the introductory part of the article and concluded that Maggot therapy results to a reduction in pain, anxiety and eventual treatment of diabetic patients with chronic wounds. In his closing remarks, Sherman (2003) summarizes his research findings by stating that

The present analysis demonstrated that maggot therapy is more effective and efficient in debriding non-healing foot and leg ulcers in diabetic male veterans than the typical conventional treatment currently prescribed. Maggot therapy was also associated with a more rapid decrease in wound size and an increase in granulation tissue, making the wounds ready for surgical closure. A high number of patients were actually demonstrated to achieve complete wound closure within the 8-week study period.

Through the different methods examined under the various authors it is clear that Maggot therapy has a positive effect in management of pain, anxiety and wound care. The study by the three authors discussed; Kong, Chan, Fong, Leung, Patil and Leung (2007), Mumcuoglu (2001), Sherman (2003), Barkur (2002) and Lagan (2007) sought to establish the effect of maggot therapy on patients under conditions of post surgical pain and diabetes which are the precipitating factors in the development of wound care and treatment. The effects were varying but broadly included the effect on pain, anxiety, and treatment of chronic wounds. All these studies showed that Maggot therapy has a positive effect on these conditions resulting to reduction in pain, relaxation, improved participation and eventual healing in chronic wounds.

The scientific approaches by Sherman (2003) and Mumcuoglu et al (2001) showed that this method of wound care and wound treatment have the capacity in wound healing process. Barkur (2002) review attempts to give a neroscientific explanation to the positive action in treatment process brought about by maggot therapy. Individuals may cast their doubts and attempt to disapprove the effectiveness on maggot therapy by applying the philosophical approaches that various philosophers have advance but as the authors argue that it is important that we take a more open minded approach while approaching the subject of maggot therapy (Baer, 1931). Utilization of maggot therapy as a compliment to the various available medications and further research into its mode of action would result to an improved health management.

Furthermore, the authors have analyzed the emerging concepts in the mechanisms of wound treatment. These involve wound debridement, wound disinfection and enhancement of wound healing.  Whereas the articles have managed to achieve the objectives of their studies through both scientific and non scientific approaches, there is need to take stock of emerging issue within this effective method in wound care. The emerging issues such as contra indications and side effects, poor perception of this therapy within patients and medical personnel circles and the need to address the pain experienced by patients while the larvae are feeding on within wound.

The studies’ limitations would seem to rest from the fact that the demographic characteristics such as age were not factored in by almost all the authors. This therefore denied us the opportunity to carry out an examination on variables that would exist as a result of differences in age. The coping measure developed would therefore seem to have rested on the believe that all the impacts and reporting was done. It would however be possible that some of factors associated with method of wound care and associated impacts were not reported and therefore utilized in the course of the studies. at that Conversely, it is recommended that a different model of adjustment/coping be employed in the assessment of impacts of maggot therapy on the subjects (Baer, 1929).  

It is advised that future studies replicate this study in order to ascertain whether the above findings are true by employing a bigger sample size and adopting different assessment criteria for subjects of different ages. The reviewed studies may also have failed to incorporate the appraisal aspect of maggot therapy and the need to apply different approaches and methodologies in the course of future research endeavors.   It is therefore further recommended that future studies between shift impacts include fresh and new approaches that would capture the merging issues within this clinical method of wound care.

The authors have settled on a relevant topic that fills the gap between the past and current literature in understanding the position of medical personnel as the carry out their duties to patients suffering from chronic wounds.  Such important findings are and implications are the basis of policy formulation and provide the insight towards into the experience of medical personnel as a profession. The recommendations of this research study will be relevant to heath care staff, policy makers and managers in health care sector. The areas of preparation and support, skills training and observance policies can then be enhanced for greater positive value in the caring of terminally or mentally patients.

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