Comparación de la sensibilidad del pie entre adultos y ancianos con lesión cerebrovascular / Comparison of foot sensitivity between adults and the elderly with stroke

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Elefantiasis verrucosa nostra / Elephantiasis nostra verrucosa

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The Concept of Chronic Edema-A Neglected Public Health Issue and an International Response: The LIMPRINT Study.

Lymphedema has always been a neglected global health care problem. A central requirement for the development of any chronic disease is the clear use of public health definitions that can be used internationally to define populations. The term "lymphedema" has historically been defined as either primary, resulting from failure of lymphatic development, or secondary, following damage to the lymphatics (e.g., cancer treatment, injury, or filariasis). Attempts to integrate causes of edema arising from damage to the venous system or the effects of gravity, immobility, and systemic disease have rarely been integrated. More recently, the prominent role of the lymphatics in tissue fluid homeostasis in all forms of chronic edema has been recognized. These advances led to the development of the term: "Chronic edema: a broad term used to describe edema, which has been present for more than three months." It can be considered an umbrella term that includes not only conventional "lymphedema" but also chronic swelling, which may have a more complex cause. This definition has been adapted in the international epidemiology study (LIMPRINT) that identified people throughout the health and social care systems in participating countries. Clearer definitions will allow for examination of this important public health problem that is likely to escalate given the projections of an aging population with multiple comorbidities. It will be possible to define both the hidden mortality and morbidity associated with complications, such as cellulitis and the impact on health-related quality of life. This evidence is urgently required to lobby for increased resource and effective health care in an increasingly competitive health care arena in which more established conditions have greater priority and funding.

Determinants of Podoconiosis, a Case Control Study.

BACKGROUND: Podoconiosis is a non-filarial swelling of lower extremity endemic in tropical regions, North America and India. The etiology and pathophysiology of the disease remain unknown. The objective of this study was to identify the determinants of Podoconiosis. METHODS: Unmatched case control study design was conducted. The sample size was calculated using Epi-info soft ware: 95% CI, 85% power, control to case ratio of 2:1, expected frequency of barefoot among controls 50%, odds ratio of 1.5 and non-response rate of 10% yielding 1148 study participants. Binary logistic regression was used to identify the determinants of Podoconiosis. RESULTS: A total of 1113 study participants (379 cases and 734 controls) were included giving for a response rate of 96.95%. Positive family history (AOR, 2.81 [95% CI: 1.7-4.64]), bare foot (AOR, 3.26 [95% CI: 2.03-5.25]), poor foot hygiene (AOR, 2.68 [95 CI: 1.72 - 4.19]) increase the risk of Podoconiosis. Female gender (AOR, 0.26 [95% CI: 0.15-0.44]), good housing condition (AOR, 0.17 [95% CI: 0.1-0.3]), medium income (AOR, 0.12 [95 % CI: 0.07- 0.22]) and primary education (AOR, 0.02 [95% CI: 0.01-0.04]) decrease the risk of Podoconiosis. CONCLUSION: Podoconiosis control and prevention programmes should involve the low income and uneducated populations.

Depression and disability in people with podoconiosis: a comparative cross-sectional study in rural Northern Ethiopia.

BACKGROUND: Little is known about depressive symptoms in podoconiosis despite the independent contribution of depression to worse health outcomes and disability in people with other chronic disorders. METHOD: Two-hundred and seventy-one individuals with podoconiosis and 268 healthy neighbours (individuals from the nearest household in any direction) were investigated for depressive symptoms using a validated Amharic version of the Patient Health Questionnaire (PHQ-9). The WHO Disability Assessment Schedule II (WHODAS II) tool was used to measure disability. Logistic regression and zero inflated negative binomial regression were used to identify factors associated with elevated depressive symptoms, and disability, respectively. RESULTS: Among study participants with podoconiosis, 12.6% (34/269) had high levels of depressive symptoms (scoring 5 or more points on the PHQ-9, on two assessments two weeks apart) compared to 0.7% (2/268) of healthy neighbours (p<0.001). Having podoconiosis and being older were significantly associated with increased odds of a high PHQ-9 score (adjusted odds ratios [AOR] 11.42; 95% CI: 2.44-53.44 and AOR 1.04; 95% CI: 1.00-1.08, respectively). Significant predictors of a higher disability score were having podoconiosis (WHODAS II multiplier value: 1.48; 95% CI: 1.39-1.58) and having a high PHQ-9 score (1.07; 95% CI: 1.06-1.08). CONCLUSION: We recommend integrating evidence-based treatments for depression into podoconiosis interventions.

Podoconiosis treatment in northern Ethiopia (GoLBet): study protocol for a randomised controlled trial.

BACKGROUND: Podoconiosis is one of the forgotten types of leg swelling (elephantiasis) in the tropics. Unlike the other, better-known types of leg swelling, podoconiosis is not caused by any parasite, virus or bacterium, but by an abnormal reaction to minerals found in the clay soils of some tropical highland areas. Non-governmental Organizations (NGOs) have been responsible for the development of simple treatment methods without systematic evaluation of its effectiveness. It is essential that a large scale, fully controlled, pragmatic trial of the intervention is conducted. We aim to test the hypothesis that community-based treatment of podoconiosis lymphoedema reduces the frequency of acute dermatolymphangioadenitis episodes ('acute attacks') and improves other clinical, social and economic outcomes. METHODS/DESIGN: This is a pragmatic, individually randomised controlled trial. We plan to randomly allocate 680 podoconiosis patients from the East Gojjam Zone in northern Ethiopia to one of two groups: 'Standard Treatment' or 'Delayed Treatment'. Those randomised to standard treatment will receive the hygiene and foot-care intervention from May 2015 for one year, whereas those in the control arm will be followed through 2015 and be offered the intervention in 2016. The trial will be preceded by an economic context survey and a Rapid Ethical Assessment to identify optimal methods of conveying information about the trial and the approaches to obtaining informed consent preferred by the community. The primary outcome will be measured by recording patient recall and using a simple, patient-held diary that will be developed to record episodes of acute attacks. Adherence to treatment, clinical stage of disease, quality of life, disability and stigma will be considered secondary outcome measures. Other outcomes will include adverse events and economic productivity. Assessments will be made at baseline and at 3, 6, 9 and 12 months thereafter. DISCUSSION: The evidence is highly likely to inform implementation of the new master plan for integrated control of Neglected Tropical Diseases (NTDs), in which podoconiosis is identified as one of eight NTDs prioritised for control. Potentially, an estimated 3 million patients in Ethiopia will therefore benefit from the results of this trial. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number. REGISTRATION NUMBER: ISRCTN67805210. Date of registration: 24 January 2013.

Novel genomic signals of recent selection in an Ethiopian population.

The recent feasibility of genome-wide studies of adaptation in human populations has provided novel insights into biological pathways that have been affected by adaptive pressures. However, only a few African populations have been investigated using these genome-wide approaches. Here, we performed a genome-wide analysis for evidence of recent positive selection in a sample of 120 individuals of Wolaita ethnicity belonging to Omotic-speaking people who have inhabited the mid- and high-land areas of southern Ethiopia for millennia. Using the 11 HapMap populations as the comparison group, we found Wolaita-specific signals of recent positive selection in several human leukocyte antigen (HLA) loci. Notably, the selected loci overlapped with HLA regions that we previously reported to be associated with podoconiosis-a geochemical lymphedema of the lower legs common in the Wolaita area. We found selection signals in PPARA, a gene involved in energy metabolism during prolonged food deficiency. This finding is consistent with the dietary use of enset, a crop with high-carbohydrate and low-fat and -protein contents domesticated in Ethiopia subsequent to food deprivation 10 000 years ago, and with metabolic adaptation to high-altitude hypoxia. We observed novel selection signals in CDKAL1 and NEGR1, well-known diabetes and obesity susceptibility genes. Finally, the SLC24A5 gene locus known to be associated with skin pigmentation was in the top selection signals in the Wolaita, and the alleles of single-nucleotide polymorphisms rs1426654 and rs1834640 (SLC24A5) associated with light skin pigmentation in Eurasian populations were of high frequency (47.9%) in this Omotic-speaking indigenous Ethiopian population.

Elephantiasis nostras verrucosa of lower limb: a case report.

Elephantiasis nostras verrucosa (ENV) is a rare condition in which hyperkeratosis, fibrosis and disfiguration of dermis occurs. It is caused mostly by non infectious diseases such as surgery, trauma, tumors, and venous obstructions. To our knowledge there is not any case report of ENV in Middle East region. In this patient, ENV caused by trauma and Patient presented with enlargement of right lower limb.

Elefantiasis nostras verrucosa / Elephantiasis nostras verrucosa

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Assessment of skin barrier function in podoconiosis: measurement of stratum corneum hydration and transepidermal water loss.

BACKGROUND: Podoconiosis is a common cause of lymphoedema in barefoot workers in Ethiopia and other countries. It has severe consequences for patients' physical function, quality of life and economic status. AIMS: To investigate stratum corneum (SC) hydration and transepidermal water loss (TEWL) in patients with podoconiosis compared with controls. METHODS: In total, 55 patients and 20 controls were recruited. For each study subject, SC and TEWL measurements were taken, along with foot and lower leg circumferences. Measurements were compared between the patient and control groups. RESULTS: Foot circumferences tended to be higher in patients with podoconiosis, with the mean foot:leg circumference ratio being 1·19 (95% confidence interval 1·11-1·28) times that for controls (P = 0·001). There was no detectable difference between patients and controls in TEWL values (P > 0·05); however, SC hydration was significantly lower in patients vs. controls for the foot (P = 0·004) and lower leg (P = 0·046) sites. CONCLUSIONS: Patients with podoconiosis have significantly lower SC hydration in the skin of their lower legs and feet than controls, which may lead to cracking and splitting, and increased risk of lymphoedema and infection.

Treatment of pretibial myxedema with dexamethazone injected subcutaneously by mesotherapy needles.

Pretibial myxedema (PTM) is a rare extrathyroidal manifestation of Graves' disease that requires treatment when the clinical picture is markedly evident. In addition to topical treatment with steroid ointments, there have been previous reports of subcutaneous injections of steroids. This procedure may cause nodular degeneration of the skin due to fat atrophy when standard needles are used. In the present study, we have tried a novel modality of treatment of PTM by injecting a solution of dexamethasone in the subcutaneous tissue using needles employed for mesotherapy. These needles are ≤4 mm long and deliver the medication within the dermis or the first layer of the subcutaneous fat. We have treated five patients, four with diffuse and one with elephanthiasic PTM. We utilized multiple injections of a solution of dexamethasone, lidocaine, and saline in the PTM plaque and in the pretibial area, both in the PTM plaque and in the area surrounding the lesions, once a week for three consecutive weeks. Two patients with a more severe form of PTM underwent another two cycles four to six weeks after initial treatment. Patients were studied before and after treatment by clinical assessment and ultrasound of the pretibial skin. The treatment was well-tolerated, with only moderate pain upon injection of the solution. One month after treatment, all patients showed improvement of PTM at clinical assessment and a reduction of the thickness of the lesions at ultrasound of ∼15%, involving mostly the dermis. Moreover, all patients reported amelioration of the leg appearance. The present study, although preliminary, shows that intralesion steroid injection with mesotherapy needles in PTM is effective and well tolerated, and does not cause undesired long-term modifications of the skin. More studies are warranted to standardize such treatment in larger groups of patients.

Elefantiasis verrucosa nostras en paciente afectado de trastorno depresivo mayor / Elephantiasis nostras verrucosa in a patient with major depressive disorder

La elefantiasis verrucosa nostras es una entidad poco frecuente que se caracteriza por pápulas, lesiones verrugosas, fibrosis y deformidad de la región afectada. Se debe a un linfedema obstructivo crónico que puede ser congénito o secundario a una infección no filariásica (tuberculosis, micosis, sífilis), cirugía, radioterapia, traumatismo, obstrucción neoplásica, obesidad, hipertensión portal o insuficiencia cardíaca congestiva. No hay un tratamiento estándar para estas raras manifestaciones cutáneas. Dependiendo de la causa y la severidad, el tratamiento puede ser médico o quirúrgico. Presentamos el caso de un varón que acudió a nuestro hospital con una depresión mayor y lesiones en la piel de ambas piernas compatibles con elefantiasis verrucosa nostras, que se trató con éxito con desbridamiento quirúrgico y medidas conservadoras (AU)

Elephantiasis nostras verrucosa is a rare condition characterised by papules, verrucous lesions, fibrosis and deformity of the affected area. It is caused by chronic lymphedema that could be congenital or produced by a non-associated infection (such as tuberculosis, mycotic infection, syphilis), surgery, radiotherapy, trauma, neoplastic obstruction, obesity, portal hypertension, or congestive heart failure. There is no standard treatment for this rare skin disorder. Depending on the cause and the severity, the treatment can be medical or surgical. We report the case of a man seen in our hospital with a major depression and elephantiasis nostras verrucosa skin lesions on both legs, who was successfully treated with surgical debridement and conservative measures (AU)

The role of transforming growth factor-beta1 and oxidative stress in podoconiosis pathogenesis.

BACKGROUND: Podoconiosis (endemic nonfilarial elephantiasis) occurs in susceptible individuals who go barefoot in regions of irritant volcanic soil. Silicate particles absorbed via the skin are thought to induce an inflammatory process and a consequent endolymphangitis of the lower leg lymphatics. OBJECTIVES: To establish which oxidative stress biomarkers play a part in the inflammatory process, and to test whether transforming growth factor (TGF)-beta1 also has a pathogenetic role. PATIENTS AND METHODS: We enrolled 50 patients with early clinical stage disease, 43 patients with advanced stage disease and 35 local healthy controls. Oxidative stress biomarkers included serum total peroxides (TP), total antioxidant capacity (TAC), total nitrate plus nitrite (TN), malondialdehyde (MDA) and total superoxide dismutase (SOD) activity. The oxidative stress index (OSI) was also determined. Serum total TGF-beta1 was assayed using sandwich enzyme-linked immunosorbent assay. RESULTS: Compared with healthy controls, patients with early stage disease showed significantly higher mean levels of TP (P < 0.001), MDA (P < 0.05) and OSI (P < 0.01); and significantly lower mean concentrations of SOD (P < 0.001) and TGF-beta1 (P < 0.001). Mean levels of TGF-beta1 were even lower among patients with advanced stage disease (P < 0.001). Mean TAC levels were significantly lower among patients with advanced disease than either other group (P < 0.001). CONCLUSIONS: This is the first study, to our knowledge, to attempt to elucidate the molecular pathogenetic events in podoconiosis. We conclude that TGF-beta1 may have a pathogenetic role, with oxidative stress playing a minor role in the early stages of disease.

Compression therapy and liposuction of lower legs for bilateral hereditary primary lymphedema praecox.

In this report, we describe a case of bilateral non-syndromic hereditary lymphedema praecox of lower legs. The patient was diagnosed at age 16. Ten years later, he was unable to ambulate due to increased bilateral lower leg volume, continuous pain, and recurrent episodes of cellulitis. He was treated at our tertiary-care center with compression therapy and circumferential liposuction of lower legs, ankles, and dorsum of feet in order to remove hypertrophic fat deposits, facilitate conservative therapy, and decrease further risk of cellulitis. No complications were seen and compression therapy was continued. Fourteen month follow-up reveals no increase in leg volume over time, absence of pain, and no further episodes of cellulitis with complete ability to ambulate and return to normal activities. Even when it does not eliminate the underlying cause of primary lymphedema, combined therapy consisting of compression and liposuction is safe and is able to achieve control, at least on a short term, of clinically disabling conditions associated with advanced stages.

Assessment of respiratory function in patients with podoconiosis.

The respiratory effects of silicate particles have never been studied in patients with podoconiosis (a lower limb silicosis). We assessed whether lung function in patients differed from that of controls in the same silica-exposed environment. We assessed lung function using portable turbine spirometers on 110 adult patients with podoconiosis and 110 controls, and compared mean percentage predicted forced expiratory volume in 1second (FEV(1)) and forced vital capacity (FVC) between these groups. Percentage predicted FEV(1) and FVC were low in both groups, but the difference between groups was not statistically significant (FEV(1) 82.24 vs. 85.32, P=0.187; FVC 70.93 vs. 73.59, P= 0.197). The mean FEV(1) of both groups was significantly lower than that of Ethiopian adults living on low-silica soil.