Plantar pressure distribution and altered postural control in multibacillary leprosy patients.

BACKGROUND: Leprosy is a chronic infectious disease caused by Mycobacterium leprae, predominantly affecting the peripheral nerves, resulting in sensory and motor deficits in the feet. Foot ulcers and imbalances are frequent manifestations in leprosy, often correlating with diminished sensitivity. While clinical scales and monofilament esthesiometers are conventionally utilized to evaluate foot sensitivity and balance in these patients, their discriminatory power is limited and their effectiveness is greatly dependent on the examiner's proficiency. In contrast, baropodometry and posturography offer a more comprehensive evaluation, aiming to preempt potential damage events. This study aimed was to assess the correlation between baropodometry and force plate measurements in leprosy patients and control participants, to improve the prevention and treatment of foot ulcers and complications associated with leprosy. METHODOLOGY: This cross-sectional study was conducted during 2022 and enrolled 39 participants (22 patients with multibacillary leprosy and 17 non-leprosy controls). Demographic data were collected, and a monofilament esthesiometer was used to assess sensory deficits. In addition, physical examinations and balance and plantar pressure tests were conducted. The Student's t-test was used to compare mean and maximum plantar pressures between groups. For most COP variables, a Mann-Whitney Wilcoxon test was used, except for AP amplitude which was analyzed with the Student's t-test due to its normal distribution. The relationship between foot pressure and balance control was assessed using Spearman's correlation, focusing on areas with significant pressure differences between groups. PRINCIPAL FINDINGS: Leprosy patients showed increased pressure in forefoot areas (T1, M1, T2-T5, and M2) and decreased pressure in hindfoot regions (MH and LH) compared to controls. These patients also displayed higher AP and ML amplitudes, suggesting poorer COP control. Correlation analyses between the two groups revealed that foot plantar pressures significantly impact balance control. Specifically, increased T1 region pressures correlated with greater sway in balance tasks, while decreased MH region pressures were linked to reduced COP control. CONCLUSIONS/SIGNIFICANCE: The findings suggest a joint disturbance of plantar pressure distribution and static balance control in leprosy patients. These alterations may increase the risk of tissue injuries, including calluses and deformities, as well as falls.

The Voice of the Lost Toe: Pseudo-Ainhum Beyond Skin.

An 11-year-old boy presented with serial autoamputations of the right 4th and 5th toes during the past 6 years. This was associated with sensory loss on the right leg and development of constriction bands around the right 2nd and 3rd digits for the past 5 months. For a year, the patient had been treated with paucibacillary, multi-drug therapy (PB-MDT) with a presumptive diagnosis of leprosy. He was born from a nonconsanguinous marriage and the birth was uneventful. The developmental milestones were normal, and no family history of any congenital anomalies was reported.

A qualitative process evaluation of a community conversation intervention to reduce stigma related to lower limb lymphoedema in Northern Ethiopia.

BACKGROUND: Lower limb lymphoedema (swelling of the lower leg) due to Neglected Tropical Diseases (NTDs) such as podoconiosis, lymphatic filariasis and leprosy is common in Ethiopia, imposing huge burdens on affected individuals and communities. Stigma significantly increases the disease burden and acts as a major barrier to accessing lymphoedema care services. A multi-component stigma reduction intervention was implemented in Northern Ethiopia. Community Conversation (CC) was one of the components implemented, and aimed to reduce stigma and enhance access to and uptake of integrated lymphoedema care services with the active engagement of community members. METHODS: A cross-sectional qualitative process evaluation was conducted to document lessons focusing on CC's relevance, outcomes and implementation challenges. Data were collected from a total of 55 purposively selected participants (26 from the CC intervention site and 29 from the control site) through key informant interviews, in-depth individual interviews and focus group discussions. RESULTS: Community Conversations increased acceptability of health messages about lymphoedema and created peer learning opportunities for unaffected community members. Improvement in the awareness of CC participants about the causes, prevention and treatment of lymphoedema contributed significantly to the reduction of stigmatizing attitudes and discriminatory behaviors, thereby improving access to and utilization of lymphoedema care services provided through primary health care facilities. However, a range of challenges affecting implementation of CC and outcome quality were identified, including perceived complexity of the facilitation guide among facilitators, expectation of incentives among CC participants, inadequate implementation of facilitation principles and procedures, inadequacy of supportive supervision, and low engagement of untrained health workers in CC. CONCLUSIONS: With these challenges addressed, the implementation of CC integrated with other lymphoedema care services shows potential to reduce stigma and promote access to lymphoedema care services.

Stakeholder perspectives on an integrated package of care for lower limb disorders caused by podoconiosis, lymphatic filariasis or leprosy: A qualitative study.

BACKGROUND: Lower limb disorders including lymphoedema create a huge burden for affected persons in their physical and mental health, as well as socioeconomic and psychosocial consequences for them, their families and communities. As routine health services for the integrated management and prevention of lower limb disorders are still lacking, the 'Excellence in Disability Prevention Integrated across Neglected Tropical Diseases' (EnDPoINT) study was implemented to assess the development and delivery of an integrated package of holistic care-including physical health, mental health and psychosocial care-within routine health services for persons with lower limb disorders caused by podoconiosis, lymphatic filariasis and leprosy. METHODOLOGY/PRINCIPAL FINDINGS: This study was part of the first of three phases within EnDPoINT, involving the development of the integrated care package. Focus group discussions and key informant interviews were undertaken with 34 participants between January-February 2019 in Awi zone, Ethiopia, in order to assess the draft care package's feasibility, acceptability and appropriateness. Persons affected by lower limb disorders such as lymphoedema experience stigma, exclusion from families, communities and work as well as physical and financial hardship. Beliefs in disease causation inhibit affected persons from accessing care. Ignorance was a barrier for health care providers as well as affected persons. Training and education of affected persons, communities and caregivers is important in improving care access. It also requires time, space, materials and financial resources. Both top-down and grass roots input into service development are key, as well as collaboration across stakeholders including charities, community leaders and "expert patients". CONCLUSIONS/SIGNIFICANCE: This study highlighted the need for the EnDPoINT integrated care package and provided suggestions for solutions according to its three aspects of integrated care (integration into routine care; integration of mental health and psychosocial care; and integration of care across the three diseases), thereby giving support for its feasibility, acceptability and appropriateness.

Development of an integrated, holistic care package for people with lymphoedema for use at the level of the Primary Health Care Unit in Ethiopia.

BACKGROUND: Neglected Tropical Diseases (NTDs) are a group of several communicable and non-communicable diseases prevalent in tropical and subtropical areas. The co-endemicity of these diseases, the similarity of their clinical signs, and the need to maximize limited financial and human resources suggest the importance of adoptingan integratedapproach to their prevention and treatment. AIMS: This study describes the development of a comprehensive package of physical, mental health and psychosocial care for people with lower-limb lymphoedema caused bypodoconiosis, lymphatic filariasis (LF)or leprosy as part of the EnDPoINT program in Ethiopia. METHOD: The care package was developed using a mixed-methods approach, consisting of a literature review, situational analysis, Theory of Change (ToC) workshops, qualitative research, and additional workshops to fine-tune the draft care package. The care package was developed between March 2018 and January 2020 in Addis Ababa and the implementation research site, Awi zone in the North-West of Ethiopia. RESULTS: The holistic care package includes components implemented at three levels of the health care system:health organization, facility, and community. Sections of the care package are directed at strengthening capacity building, program management, community engagement, awareness-raising, stigma-reduction, morbidity management, disability prevention, follow-up visits, referral linkage, community-based rehabilitation, and monitoring and evaluation. CONCLUSIONS: The study developed a holistic integrated care package for lower limb disorder and co-morbid mental health problems caused by podoconiosis, LF or leprosy. The approach has the potential to significantly reduce lower limb disorder-associated morbidity, disability, and psychosocial problems. It also standardizes a scalable approach appropriate for the Ethiopian setting and, most likely, other countries where these NTDs are present.

Economic assessment of a community-based care package for people with lower limb disorder caused by lymphatic filariasis, podoconiosis and leprosy in Ethiopia.

We conducted an implementation research study to integrate a holistic package of physical health, mental health and psychosocial care for podoconiosis, lymphatic filariasis and leprosy into routine healthcare in Gusha cluster, Guagusa Shikudad district, northwest Ethiopia. The healthcare package included training patients in lower limb hygiene and skin care and provision of shoes, hygiene supplies and medication. The implementation activities included training events, workshops, awareness raising, self-help groups, supportive supervision, staff secondments and advisory board meetings. The cost of implementing the care package in Gusha cluster, with a population of 30 558 people, was 802 655 Ethiopian birr (ETB) (£48 159) and the cost of delivering care to 235 participants was 204 388 ETB (£12 263), or 870 ETB (£52) per person. There was a 35% decrease in the mean disability scores (measured using the World Health Organization Disability Assessment Schedule 2.0) and a 45% improvement in the dermatology-specific quality of life (measured using the Dermatology Life Quality Index) at the 3-month follow-up compared with baseline. There were reductions in the number of days with symptoms, days off usual activities/work and days with reduced activity due to illness, all of which were statistically significant. Our pilot suggests that integration of the care package into routine healthcare in Ethiopia may be effective in improving health-related quality of life and disability and reducing time out of economic activity due to illness.

Lower Extremity Horizontal Work But Not Vertical Power Predicts Lower Extremity Injury in Female Collegiate Dancers.

Ambegaonkar, JP, Schock, CS, Caswell, SV, Cortes, N, Hansen-Honeycutt, J, and Wyon, MA. Lower extremity horizontal work but not vertical power predicts lower extremity injury in female collegiate dancers. J Strength Cond Res 32(7): 2018-2024, 2018-Dancers often perform powerful and explosive movements that require adequate lower extremity (LE) activity in horizontal and vertical directions. We examined whether these measures were interrelated and whether they predicted LE injury status in dancers using binary logistic regressions and receiver operator characteristic (ROC) curve analyses. Forty-three collegiate female dancers (18 ± 0.7 years; 162.6 ± 5.9 cm; 59.4 ± 7.1 kg) performed single leg hop (SLH, m) and vertical jump (VJ, cm) tests. Single leg hop and VJ distances were used to calculate SLH norm (as a % of body height) and vertical power (vPower, watts). Lower extremity injuries and dance exposure hours (DEhrs) were recorded for 16 weeks. Dancers had 51 injuries resulting in a 3.7/1,000 DEhr injury incidence rate (95% confidence interval [CI]: 2.7-4.7). Twenty dancers were injured, whereas 23 remained injury free. Injured dancers had significantly lower SLH norm than noninjured dancers (t = 2.7, p = 0.009, 85.2 ± 11.2% vs. 76.8 ± 8.4%, respectively), but vPower was similar (t = 0.6, p = 0.53, injured = 2,632.0 ± 442.9 watts, noninjured = 2,722.7 ± 480.0 watts). SLH norm, but not vPower significantly predicted injury status χ(1,43) = 5.9, p = 0.02. Specifically, an SLH norm cut-off value of 78.2% identified dancers at injury risk (area under the curve = 0.73, SE = 0.08, p = 0.01, 95% CI = 0.57-0.89, sensitivity = 0.75, specificity = 0.70). However, vPower was not able to identify dancers at risk (p = 0.36). vPower had moderate relationships with SLH norm (r = 0.31, p = 0.04). Compared with injured dancers, noninjured dancers had greater SLH norm but similar vPower. Only SLH norm predicted injury status in female collegiate dancers. Thus, the SLH test may possibly predict LE injury risk in dancers. Strength and conditioning coaches can prospectively use baseline SLH test screenings to identify dancers whose SLH is less than 78.2% of their height because these dancers may have increased probability of LE injury risk. Coaches can then include horizontal direction exercises when designing training programs and examine whether these programs reduce LE injury risk in female collegiate dancers.

Histoid leprosy: a retrospective clinicopathological study from central Nepal.

BACKGROUND: Histoid leprosy is a rare variant of lepromatous leprosy characterized by varied morphological and histopathological appearance while having a high bacillary load. These factors contribute to an ominous threat to the elimination status of leprosy, whereby these patients may act as a reservoir of infection. OBJECTIVE: To identify the clinicopathological characteristics of histoid leprosy in Chitwan, Nepal. METHODS: A retrospective hospital-based study spanning a period of 6 years was carried out at our department. All cases clinically and histopathologically suggestive of histoid leprosy were included in our study, and all relevant data were recorded and analyzed as per standard protocol. RESULTS: Histoid leprosy comprised 2.9% of all leprosy cases. Mean age of 39.45 years and male:female ratio of 1.75:1 were seen. Previous history of leprosy was obtained in 72.7%, and de novo development of histoid leprosy took place in 27.3%. Papules were the most common lesion seen, and upper limbs were the most frequent site of involvement, and the ulnar nerve was enlarged in most cases. Mean bacillary index was 5.39. Histopathology showed epidermal atrophy, positive Fite-Faraco stain for lepra bacilli, spindle-shaped histiocytes arranged in various patterns, and a well-circumscribed area of cells in the dermis in all cases. Grenz zone and pseudocapsule were seen in the majority of patients. All cases responded well to multibacillary multidrug therapy (MB-MDT) of 2 years. CONCLUSION: A high index of suspicion is essential for diagnosing histoid leprosy, both clinically and histopathologically.

Vitiligo on black skin: epidemiological and clinical aspects in dermatology, Cotonou (Benin).

BACKGROUND: Vitiligo is unsightly on darkly pigmented skin and leads important stigmatization because of the mix-up with leprosy. PATIENTS AND METHODS: We analyzed retrospectively the epidemiological and clinical patterns of vitiligo on darkly pigmented skin between 1988 and 2008 in the Department of Dermatology in Cotonou (Benin). The diagnosis was made based on the clinical characteristics of vitiligo. RESULTS: Two hundred and forty-six patients were seen, representing 0.9% of new consultations. The gender ratio was 1 : 1, and the mean age of patients was 25.9 years. The mean duration of the lesions was 30.9 months. Among the 246 patients, an associated pathology was found in 26% of cases. These included atopy (23.2%), diabetes (1.6%), thyroid disease (0.8%), and alopecia (0.4%). A family history of vitiligo was present in 1.2% of cases. The sites of the lesions were in descending order of frequency: head (60.6%), lower limbs (40.2%), upper limbs (33.3%), trunk (22.4%), genitals (13.0%), and neck (8.9%). On the head, the most common sites affected were the lips (65.1%), cheek (20.8%), and ears (16.8%). According to the different clinical forms, vitiligo was achromic (76%), speckled (12.6%), and trichromic (11.4%). Vitiligo vulgaris was the commonest form of the disease (52.4%), followed by localized vitiligo (36.2%), segmental vitiligo (9.8%), and vitiligo universalis (1.6%). Triggering factors were identified in 4.5% of patients. CONCLUSION: Our survey shows that the patterns of vitiligo are similar to that reported from other African countries with a few distinguishing particularities.

Livedoid vasculopathy: A review of pathogenesis and principles of management.

Livedoid vasculopathy is a rare cutaneous disease manifesting as recurrent ulcers on the lower extremities. The ulceration results in atrophic, porcelain white scars termed as atrophie blanche. The pathogenesis is yet to be understood with the main mechanism being hypercoagulability and inflammation playing a secondary role. The important procoagulant factors include protein C and S deficiency, factor V Leiden mutation, antithrombin III deficiency, prothrombin gene mutation and hyperhomocysteinemia. Histopathology of livedoid vasculopathy is characterized by intraluminal thrombosis, proliferation of the endothelium and segmental hyalinization of dermal vessels. The treatment is multipronged with anti-thrombotic measures such as anti-platelet drugs, systemic anticoagulants and fibrinolytic therapy taking precedence over anti-inflammatory agents. Colchicine, hydroxychloroquine, vasodilators, intravenous immunoglobulin, folic acid, immunosuppressive therapy and supportive measures are also of some benefit. A multidisciplinary approach would go a long way in the management of these patients resulting in relief from pain and physical as well as psychological scarring.

The diagnostic challenge of mapping elephantiasis in the Tigray region of northern Ethiopia.

BACKGROUND: In Ethiopia, lymphatic filariasis and podoconiosis are the two neglected tropical diseases planned to be mapped together within the recently launched Ethiopian neglected tropical diseases master plan (2013-2015). However, other disorders cause tropical lymphedema, and this report aims to identify clinical epidemiological aspects of limb swelling in northern Ethiopia and to provide an algorithm orienting the clinical diagnosis. METHODS: Medical records of patients with lower limb elephantiasis attending the Italian Dermatological Centre of Mekele, Tigray capital city, over a 4-year period (2005-2009) were retrospectively analyzed. Nine variables were collected from the charts comprising demographic data, job, origin, literacy, clinical, histopathologic, microscopic, and cultural findings. RESULTS: Over a total of 511 patients, lymphedema resulted from trauma (40.7%), chronic venous insufficiency (12.5%), deep mycoses (10.8%), lymphatic filariasis (9.2%), elephantiasis nostras verrucosa (7.0%), tropical ulcer (6.3%), leprosy (4.9%), recurrent infections (3.1%), podoconiosis (1.8%), tuberculosis (1.0%), malignancy (1.3%), Kaposi's sarcoma (1.0%), leishmaniasis (0.2%), and neurofibromatosis (0.2%). CONCLUSIONS: Advanced-stage elephantiasis, chronic osteomyelitis, and podoconiosis not previously reported in Tigray were observed. Further epidemiological investigation and training programs addressed to healthcare providers at the peripheral level are needed to detect elephantiasis early, prevent disabilities, and improve patients' quality of life.

¿Cuál es su diagnóstico? Lepra lepromatosa multibacilar / No disponible

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