Consensus statements and guideline for the diagnosis and management of plantar fasciitis in Singapore.

Introduction: Plantar fasciitis (PF) is a common cause of heel pain among the general population. The lack of standard practice guideline in Singapore presents challenges in education and clinical practice for this painful condition. These consensus statements and guideline were developed to streamline and improve the management of PF, covering key aspects such as diagnosis, investigations, risk factors, treatment modalities, monitoring and return to work/play. Method: A multidisciplinary expert panel consisting of 6 sports physicians, 2 orthopaedic surgeons, 2 podiatrists and 1 physiotherapist from SingHealth Duke-NUS Sport & Exercise Medicine Centre (SDSC) was convened based on their clinical and academic experience with PF. The Grading of Recommen-dations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of the evidence and subsequently prepare a set of clinical recommen-dations pertaining to the manage-ment of PF. A modified Delphi process was used to reach consensus. Results: Eighteen consensus statements were developed to cover key components of PF management, from initial diagnosis to treatment modalities and finally, clinical progression. They were subsequently consolidated under a proposed treatment pathway guideline for PF. Conclusion: The SDSC consensus statements and guideline provide concise recommendations for the management of PF in Singapore.

Effects of a novel exercise training protocol of Wingate-based sprint bouts dispersed over a day on selected cardiometabolic health markers in sedentary females: a pilot study.

PURPOSE: Sprint interval training (SIT) provides a strong stimulus for improving cardiovascular fitness, which is among the key markers for premature mortality. Recent literature demonstrated that SIT protocols with as few as two stacked 20 s Wingate Anaerobic Test (WAnT) cycle sprints provide sufficient training stimulus for a robust increase in maximal aerobic power. However, this effect is lost when only one bout is performed. This suggests training adaptation is still dependent on the volume of SIT. Therefore, the purpose of this study was to determine the effects of three dispersed 30 s WAnT bouts, done over a day but interspersed with 4 hours of recovery time, on selected cardiometabolic health markers. METHODS: Eighteen sedentary women, age 36±8 years, were recruited and underwent 8 weeks of supervised training using the WAnT protocol, 3 days a week. Criterion measure of cardiovascular fitness (ie, V̇O2peak), skinfolds and blood lipids such as triglyceride, low density lipoprotein (LDL) and high density lipoprotein (HDL) were measured before and after training intervention. RESULTS: V̇O2peak improved by a mean of 14.0% after training (21.7±5.7 vs 24.7±5.7 mL/kg/min, p<0.01). No significant change was observed for body fat and lipid profile. CONCLUSION: Performing three dispersed WAnT bouts with a 4-hour recovery period between bouts throughout a day, 3 days per week for 8 weeks provides sufficient training stimulus for a robust increase in V̇O2peak, which is comparable with other previous SIT protocols with very short recovery intervals. However, no other changes in the other cardiometabolic health markers were detected.

Buruli Ulcer, a Prototype for Ecosystem-Related Infection, Caused by Mycobacterium ulcerans.

Buruli ulcer is a noncontagious disabling cutaneous and subcutaneous mycobacteriosis reported by 33 countries in Africa, Asia, Oceania, and South America. The causative agent, Mycobacterium ulcerans, derives from Mycobacterium marinum by genomic reduction and acquisition of a plasmid-borne, nonribosomal cytotoxin mycolactone, the major virulence factor. M. ulcerans-specific sequences have been readily detected in aquatic environments in food chains involving small mammals. Skin contamination combined with any type of puncture, including insect bites, is the most plausible route of transmission, and skin temperature of <30°C significantly correlates with the topography of lesions. After 30 years of emergence and increasing prevalence between 1970 and 2010, mainly in Africa, factors related to ongoing decreasing prevalence in the same countries remain unexplained. Rapid diagnosis, including laboratory confirmation at the point of care, is mandatory in order to reduce delays in effective treatment. Parenteral and potentially toxic streptomycin-rifampin is to be replaced by oral clarithromycin or fluoroquinolone combined with rifampin. In the absence of proven effective primary prevention, avoiding skin contamination by means of clothing can be implemented in areas of endemicity. Buruli ulcer is a prototype of ecosystem pathology, illustrating the impact of human activities on the environment as a source for emerging tropical infectious diseases.

Effectiveness of purified methylene blue in an experimental model of Mycobacterium ulcerans infection.

Mycobacterium ulcerans is responsible for Buruli ulcer, characterised by extensive, disabling ulcers. Standard treatment combining rifampicin and streptomycin exposes patients to toxicity and daily painful injections. In this study, the in vitro susceptibilities of 3 M. ulcerans strains, 1 Mycobacterium marinum strain and 18 strains representative of eleven other Mycobacterium species and subspecies to methylene blue were determined. Whilst growth of M. ulcerans was inhibited by 0.0125 g/L methylene blue, growth of all other tested strains was not inhibited by 1 g/L methylene blue. The effectiveness of methylene blue in a murine model of M. ulcerans infection was then tested. Topical treatment by brushing a methylene blue solution on the skin lesion, systemic treatment by intraperitoneal injection of methylene blue, and a combined treatment (topical and systemic) were tested. The three treatment groups exhibited a significantly lower clinical score compared with the non-treated control group (P <0.05). Moreover, subcutaneous nodules were significantly smaller in the systemic treatment group (excluding males) (3 ± 0.7 mm) compared with the other groups (P <0.05). The M. ulcerans insertion sequence IS2404 and the KR-B gene were detected in all challenged mice, but not in negative controls. The density of M. ulcerans (mycobacteria/cell) was significantly lower in the combined treatment group compared with the other groups. These data provide evidence for the effectiveness of purified methylene blue against the initial stage of Buruli ulcer.

Detection of Mycobacterium ulcerans DNA in the Environment, Ivory Coast.

BACKGROUND: Ivory Coast is a West African country with the highest reported cases of Buruli ulcer, a disabling subcutaneous infection due to Mycobacterium ulcerans. However, the prevalence of environmental M. ulcerans is poorly known in this country. METHODS: We collected 496 environmental specimens consisting of soil (n = 100), stagnant water (n = 200), plants (n = 100) and animal feces (n = 96) in Ivory Coast over five months in the dry and wet seasons in regions which are free of Buruli ulcer (control group A; 250 specimens) and in regions where the Buruli ulcer is endemic (group B; 246 specimens). After appropriate total DNA extraction incorporating an internal control, the M. ulcerans IS2404 and KR-B gene were amplified by real-time PCR in samples. In parallel, a calibration curve was done for M. ulcerans Agy99 IS2404 and KR-B gene. RESULTS: Of 460 samples free of PCR inhibition, a positive real-time PCR detection of insertion sequence IS2404 and KR-B gene was observed in 1/230 specimens in control group A versus 9/230 specimens in group B (P = 0.02; Fisher exact test). Positive specimens comprised seven stagnant water specimens, two feces specimens confirmed to be of Thryonomys swinderianus (agouti) origin by real-time PCR of the cytb gene; and one soil specimen. Extrapolation from the calibration curves indicated low inoculums ranging from 1 to 102 mycobacteria/mL. CONCLUSION: This study confirms the presence of M. ulcerans in the watery environment surrounding patients with Buruli ulcer in Ivory Coast. It suggests that the agouti, which is in close contacts with populations, could play a role in the environmental cycle of M. ulcerans, as previously suggested for the closely related possums in Australia.

Experimental Survival of Mycobacterium ulcerans in Watery Soil, a Potential Source of Buruli Ulcer.

The reservoir of Mycobacterium ulcerans causing Buruli ulcer (BU) remains unknown. Here, sterilized watery soil was mixed with 2 × 10(6) colony-forming units (CFU)/g of M. ulcerans Agy99 or M. ulcerans ATCC 33728 and incubated in a microaerophilic atmosphere in the presence of negative controls. Both M. ulcerans strains survived in soil for 4 months with a final inoculum of 300-440 CFU/g. Further, three groups of five mice with and without footpad scarification were exposed to control soil or M. ulcerans-inoculated soil. Although no specific clinical and histopathological lesions were observed in control animals, red spots observed on 8/20 scarified feet in 8/10 challenged mice yielded inflammatory infiltrates and positive real-time polymerase chain reaction detection of M. ulcerans DNA in five mice. BU can be acquired as an inoculation infection with watery soil as a transient source of infection. These experimental observations warrant additional field observations.

Exercise-Induced Weight Loss is More Effective than Dieting for Improving Adipokine Profile, Insulin Resistance, and Inflammation in Obese Men.

The adipokines chemerin and adiponectin are reciprocally related in the pathogenesis of insulin resistance and inflammation in obesity. Weight loss increases adiponectin and reduces chemerin, insulin resistance, and inflammation, but the effects of caloric restriction and physical activity are difficult to separate in combined lifestyle modification. We compared effects of diet- or exercise-induced weight loss on chemerin, adiponectin, insulin resistance, and inflammation in obese men. Eighty abdominally obese Asian men (body mass index [BMI] ≥ 30 kg/m(2), waist circumference [WC] ≥ 90 cm, mean age 42.6 years) were randomized to reduce daily intake by ~500 kilocalories (n = 40) or perform moderate-intensity aerobic and resistance exercise (200-300 min/week) (n = 40) to increase energy expenditure by a similar amount for 24 weeks. The diet and exercise groups had similar decreases in energy deficit (-456 ± 338 vs. -455 ± 315 kcal/day), weight (-3.6 ± 3.4 vs. -3.3 ± 4.6 kg), and WC (-3.4 ± 4.4 vs. -3.6 ± 3.2 cm). The exercise group demonstrated greater reductions in fat mass (-3.9 ± 3.5 vs. -2.7 ± 5.3 kg), serum chemerin (-9.7 ± 11.1 vs. -4.3 ± 12.4 ng/ml), the inflammatory marker high-sensitivity C-reactive protein (-2.11 ± 3.13 vs. -1.49 ± 3.08 mg/L), and insulin resistance as measured by homeostatic model assessment (-2.45 ± 1.88 vs. -1.38 ± 3.77). Serum adiponectin increased only in the exercise group. Exercise-induced fat mass loss was more effective than dieting for improving adipokine profile, insulin resistance, and systemic inflammation in obese men, underscoring metabolic benefits of increased physical activity.

Tropical Plant Extracts Modulating the Growth of Mycobacterium ulcerans.

Mycobacterium ulcerans, the etiologic agent of Buruli ulcer, has been detected on aquatic plants in endemic tropical regions. Here, we tested the effect of several tropical plant extracts on the growth of M. ulcerans and the closely related Mycobacterium marinum. M. ulcerans and M. marinum were inoculated on Middlebrook 7H11 medium with and without extracts from tropical aquatic plants, including Ammannia gracilis, Crinum calamistratum, Echinodorus africanus, Vallisneria nana and Vallisneria torta. Delay of detection of the first colony and the number of colonies at day 7 (M. marinum) or day 16 (M. ulcerans) were used as endpoints. The first M. ulcerans colonies were detected at 8 ± 0 days on control Middlebrook 7H11 medium, 6.34 ± 0.75 days on A. gracilis-enriched medium (p<0.01), 6 ± 1 days on E. africanus- and V. torta-enriched media (p<0.01), 6 ± 0 days on V. nana-enriched medium (p<0.01) and 5.67 ± 0.47 days on C. calamistratum-enriched medium (p<0.01). Furthermore, the number of detected colonies was significantly increased in C. calamistratum- and E. africanus-enriched media at each time point compared to Middlebrook 7H11 (p<0.05). V. nana- and V. torta-enriched media significantly increased the number of detected colonies starting from day 6 and day 10, respectively (p<0.001). At the opposite, A. gracilis-enriched medium significantly decreased the number of detected colonies starting from day 8 PI (p<0.05). In conclusion, some aquatic plant extracts, could be added as adjuvants to the Middlebrook 7H11 medium for the culturing of M. marinum and M. ulcerans.