The medical management of diabetes mellitus with particular reference to the lower extremity: the Jamaica experience

Predisposing factors for the diabetic foot include peripheral neuropathy, peripheral vascular disease (PVD), hyperglycaemia and increased duration of diabetes. From the records of patients admitted to the University Hospital of the West Indies with the diabetic foot, we reviewed the results of the microbiology of wound swabs from diabetic foot ulcers. We noted the high prevalence of PVD (66.6 percent), peripheral neuropathy (50 percent), hyperglycaemia (75.6 percent) and increased duration of diabetes (17.5 years). A history of past foot ulcers was common and 87.2 percent had polymicrobial infection. The commonest organisms were gram positive organisms which were usually sensitive to the 2 antibiotic regimes that were commonly used. Euglycaemia, a favourable lipid profile, control of blood pressure, yearly foot examination and institution of measures to prevent foot trauma are important in the prevention of foot ulceration.(Au)

Diabetes, lower extermity amputations and podiatry

We are all worried and simultaneously frustrated by the increasing prevalence of diabetes mellitus (DM) throughout the world and the anticipated increase in diabetes-associated complications, including lower-extremity amputations (LEAs). At the same time, we realize that primary prevention programmes for both Types 1 and 2 diabetes, and/or a "cure" are both still a few years into the future; and secondary (controlling blood glucose, blood pressure, and blood lipids) and tertiary (detecting complications early and treated appropriately) prevention programmes have been scientifically and economically validated. However, even with this knowledge, we are frustrated by two things: the "gap" between what we all should be doing and what is actually happening in daily clinical and public health practice; and between information we need about important and practical health services research questions about LEAs, e.g. how often should we really be examining the feet of someone with diabetes and with what methodology. With this background, where do podiatric health care professional fit into efforts to address diabetes-related LEAs? While certainly the rigour and completeness of podiatric training programmes in many countries legitimize their more active role in preventive care practices for people with DM, my own experience is that the podiatry community has skills, interests, abilities relevant to LEAs, beyond care. Both within academic centres and from practice, podiatrists have added and can add to the understanding and knowledge base about diabetes-related lower extermity disorders. Further, based on experiences with the CDC-NIH supported National Diabetes Education Programme (NDEP), podiatrist have embraced and enhanced general secondary prevention and public awareness activities about diabetes. Podiatrists have demonstrated their thoughtfulness and "power" by addressing a very large United States of America governmental agency - the Health Care Financing Administration (HCFA) - to begin to seriously address prevention programmes for diabetes-related LEAs, i.e. changing policies. While there are and will always be tensions within and among various diabetes disciplines, "today's podiatry is not your father's podiatry".(Au)

Surgical management of critical limb ischaemia in the French West Indies

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age ñ SEM:73 ñ 15 yrs) admitted for critical limb ischaemia. 145 (84 percent) had tissue loss at admission: toe gangrene or ischaemic ulcer in 77, and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularisation were performed at iliofemoral (n = 20), suprapopliteal (n = 22) or infrapopliteal level. The postoperative mortality rate was 14 percent in the "Amputation" group and 9 percent in the "Revascularisation" group but the difference was not statistically significant. Infective complications were comparable in both groups, although 5 to 14 deaths after amputation were directly related to infection and all deaths after revascularisation resulted from cardiovascular complications. The early limb salvage rate after revascularisation was 82 percent. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p < 0.03) and had significantly higher rates of heart disease and nonambulatory status (respectively, 24 vs 17 percent, p < 0.05; and 37 vs 13 percent, p < 0.001) than patients in whom revascularisation was performed. Ischaemic rest pain and tissue loss confined to digit gangrene or ischaemic ulcer occurred more frequently than extensive gangrene in the "Revascularisation" group (p < 0.0001), while extensive gangrene extending beyond the forefoot occurred more frequently than ischaemic rest pain and tissue loss in the "Amputation" group (p < 0.0001). Late presentation of patients and enhanced tissue loss are probably the reasons for the higher primary amputation rate in our patients compared to that observed elsewhere. In patients amenable to revascularisation (56 percent), arterial reconstruction for critical limb ischaemia improves the chances of limb salvage.(AU)

Foot revascularisation in the diabetic with severe tibial artery disease - abstract

It is commonly believed that diabetics have "small vessel" disease causing severe ischaemia and gangrene foot. This is supported by the fact that, often enough, such patients have a popliteal pulse. In most centres world-wide, these patients are not offered revascularisation options and lose their limbs. Recently, there have been a few reports supporting the value of tibial artery bypass in diabetes with infrapopliteal arterial disease. We have used short vein bypasses in 12 diabetic patients with a palpable popliteal pulse, no distal pulses and limb-threatening ischaemia in the foot. Bypasses were done to the dorsalis pedis, plantar arteries or posterior tibial at the ankle using the popliteal or posterior tibial as the inflow source. Eleven of the 12 limbs were salvaged in the immediate post-operative period and another graft occlusion at 18 months resulted in below-knee amputation. We recommended that diabetics with limb-threatening foot ischaemiaand a palpable popliteal pulse should be carefully investigated by arteriography and Doppler, and distal bypass should be performed whenever possible. Because of the large diabetic population in the Caribbean and because of the morbidity and mortality of major amputations we feel that, wherever possible, limb salvage efforts should be made. Infrapopliteal vascular reconstruction in the diabetic can certainly save many limbs currently amputated because of tibial artery disease. (AU)

Infrapopliteal and distal bypass for limb salvage - abstract

Because the majority of our patients with lower limb ischemia present with femora popliteal disease, bypass surgery must be done to tibial and distal vessels for limb salvage. In 71 such bypasses done on 66 patients the indications were gangrene, 41, non healing ulcer 12, rest pain 18. Sixty-six bypasses were in situ saphenous vein while five were reversed vein grafts. Fourteen bypasses were done to the ankle or distally (5 dorsalis pedis, 7 posterior tibial, 2 plantar) while 57 were carried to infrapopliteal leg vessels (35 peroneal, 14 posterior tibial, 6 anterior tibial, 3 tibio-peroneal trunk). In the ankle/distal group 1 bypass occluded and 1 limb was lost. In the tibial group 8 bypasses occluded and 7 limbs were amputated. Although bypasses to the tibial and foot vessels are technically more demanding, they do carry a good limb salvage rate and patients should be given the benefit of this treatment (AU)

Computed tomography of the calves: a screening procedure in the diagnosis of unilateral thrombosis of the deep veins of the lower limbs

A prospective study of twelve patients, referred to the Department of Radiology of the University Hospital of the West Indies between March, 1990 and November, 1991 with a clinical diagnosis of deep vein thrombosis, was undertaken. All patients had computed tomography of the calves, as well as venography of the affected limb. Six patients (50 percent) had positive venographs. Of these, five had a difference of greater than 10 percent between the areas of the muscular compartments of the two limbs. Six patients had negative venograms but only three demonstrated a defference of a similar magnitude. The ratios of the area of the muscular compartment to the total limb area were also compared. Two of the six patients with negative venograms showed a greater ratio in the affected limb. In this study, 83.3 percent of patients who did not have thrombosis of the deep veins of the calves had a ratio of muscular area to total limb area that was less than or equal to that of the unaffected side. This latter finding provides a potentially useful means of screening patients referred for venograms (AU)

What to do in children's bowleg? - abstract

If idiopathic bowleg is common, rachitic bowleg must be recognized and cured with vitamin D therapy. Apart from these two conditions, there occurs very frequently another condition known as Blount's disease in the black population in the Caribbean. There is partial dystrophy of the medial part of the upper growth-plate of the tibia. Seventy-five cases were treated in 12 years and the different stages in the pathology of the condition are shown. Young children with this condition are treated with a small tibial osteotomy which prevents bowing of the legs (AU)

HTLV-I and tropical spastic paraparesis. 2. The human T-cell lymphotropic virus type 1

Human T-lymphotropic viruses (HTLV) are casually associated with adult T-cell leukaemia and with a progressive form of lower limb paralysis known as tropical spastic paraparesis. HTLV-I is endemic in parts of Japan, the Caribbean, West Africa and probably South America, and is associated with disease in these areas. Horizontal transmission is probably most common through sexual intercourse which, it is postulated, must be more prevalent in women in endemic areas. Vertical transmission appears to be principally through breast milk. Poor housing and hygiene may facilitate transmission. (AU)

Fasciocutaneous flaps for lower extremity salvage - abstract

Compound injuries to the lower limb with substantial soft tissue loss are traditionally resurfaced with distant jump flaps, cross-leg flaps or local random flaps. They have a high incidence of flap necrosis, limited flap size, and involve prolonged immobilization and multiple procedures. The use of muscle flaps has a better prognosis but are technically difficult: they detach functioning muscle and require expensive equipment. Fasciocutaneous flaps offer a solution as they provide soft tissue padding, have a rich vascular supply, are simple to perform with an avascular plane of dissection, lead to less contour defect and do not require rigid plaster immobilisation postoperatively. Over the past 12 months, we have used fasciocutaneous flaps in seven cases with exposed tibiae due to compound fractures and in an eighth case with an exposed calcaneus. Two of the patients had local transposition flaps while five had cross-leg flap, probably due to rinking of the flap postoperatively; the flap was sufficient to allow for excision and advancement. The immobilisation and length of hospital stay were significantly reduced. The value of the fasciocutaneous flap as a simple, safe method of providing well-vascularised, soft tissue coverage of defects of the leg has been demonstrated (AU)

Some observations on the biting habits of S. incrustatum and S. Amazonicum complex in the Lethem area, Rupununi district, Guyana, South America

Two species complexes: S. incrustatum and S. amazonicum form the Lethem area, Rupununi district, Guyana have been observed to show simmilar biting habits to African species mainly the damnosum complex but unlike those in the Americas. The observations are significant since it indicated that these potential vectors of onchocerciasis, "River Blindness", have the capacity for optimum trasmission of microfilariae of Onchocerca volvulus in the Rupununi,Guyana (AU)

Low leg tourniquet

Low leg tourniquet at a site between the calf and the malleloi was routinely used during various elective surgical procedures on 106 non-ischaemic feet of seventy-four consecutive patients in the age group 2 - 65 years. The period of ischaemic lasted up to 75 minutes. Using appropriate arm-size pneumatic cuff and suitable arm inflation pressure, a completely bloodless field was achieved in 104 surgical procedures without any local distal complications. The technique of application of the low leg tourniquet is safe, satisfactory and avoids unnecessary ischaemia to a relatively large segment of the lower limb. Its routine use in all suitable cases of surgery on the foot merits further trial and is recommended (AU)

Beta-thalassaemia of clinical significance in adult Jamaican negroes

Over a 9-year period, three adult Negro patients with á-thalassaemia of clinical significance were recognized out of approximately 185,000 new adult patients attending the University Hospital. These patients, ages 15-58 years, have clinical and haematological characteristics within the spectrum of á-thalassaemia intermedia; which in this paper refers to phenotypes resulting from defects in á-chain synthesis clinically intermediate between classical Cooley's anaemia and á-thalassaemia trait, genetic classification being dependent on family study. Family studies established the presence of two á-thalassaemia genes conclusively in one case (proposita, family A); presumptively in another(propositus, family C); while in the remaining subject (proposita, famaily B), who has two similarly affected siblings, homozygosity is suspected, but not proven by family study. In simultaneous Fe and Cr studies, estimates of effective erythropoiesis are in reasonable agreement with measurements of red cell destruction.(Summary)

XYY Sex chromosomes in a Jamaican with orthopaedic abnormalities

A male Jamaican patient is described with a bilateral deformities of the knee, mental retardation, and hypogonadism. He was found to have retarded bone age, varicose ulceration, a height of 227 cm (89 1/2in.) and a XYY sex chromosome constitution. The relation of these features to the presence of 2 Y chromosomes is discussed, and a paternal age effect is suggested in the origin of the condition. (Summary)

The relationship between Blount's disease and bow legs

The radiological appearances of the infantile form of Blount's disease (tibia vara) are described. These consist of a various deformity of the upper end of the tibia, torsion of the tibial shaft, irregularity and fragmentation of the medial part of the tibial metaphysis and gross thickening of the cortex on the medial side of the tibial shaft. This condition is very common in Jamaica and presents clinically as severe as bow legs. A study of the knees of 75 Jamaican children who presented with severe bow legs was carried out. Radiological examination revealed three different appearances. I. Severe simple (physiological) bow legs. 111. Early Blount's disease, due to a defect in the medial part of the metaphyseal beak, the metaphyseal "tear". III. Typical Blount's disease. Thirty cases showed transition from I to II or III and II to III. Evidence from the present study suggests that the development of the changes of Blount's disease in children with severe but simple bow legs is due to the increased proportion of the body weight which is supported by the medial part of the tibial metaphysis. This is described as eccentric pressure. The Jamaican child walks at an earlier age than the British child which results in the Jamaican child walking on the physiological bow legs. The British child walks on legs which are straight or show physiological knock knees. This is the racial factor. It is suggested that because of the normal plasticity of bone the child who walks on physiological bow legs will develop severe bow legs. This would explain the high incidence of severe bow legs in Jamaican children and hence the fact that Blount's disease may develop. Therefore, the three factors, eccentric pressure (due to severe bow legs), racial factors (early walking) and natural plasticity of bone are thought to be responsible for the persistence of physiological bow legs, the high incidence of severe bow legs and the development of Blount'd disease in the Jamaican child.(AU)

The long-term prognosis of severe infantile malnutrition

65 Jamaican children who had been treated for severe malnutrition in hospital were traced and examined 2-8 years after their discharge from hospital. They were found to be small by North American standards, but not when they were compared with Jamaican children, similar genetically and from the same economic background. When 56 of the previously malnourished children were matched with siblings or close relatives as controls they were slightly taller and heavier, broader in the chest, and had thicker bone and muscle in the leg than the sibling who had never been severely malnourished. There is no clear evidence that a period of severe malnutrition in infancy per se causes stunting of growth in children as it does in some animals. On the contrary, children who have been successfully treated for malnutrition tend to outgrow their siblings when they return home; this may have a genetic basis.(Summary)