Morbidity management and disability prevention: An agenda for developing nations initiated in India.

Treatment of patients with lymphedema focuses on reducing limb volume with more recent recognition of the importance of qualityof- life issues. Perhaps due to the incidence of filariasis-related lymphedema compared to breast cancer-related lymphedema in the western world, the Institute of Applied Dermatology (IAD) in Kerala, India has developed a low-cost and culturally acceptable treatment with quality-of-life focus that works well in that area. Worldwide, there is also recognition of chronic edema as a potential co-morbidity and the recent advances in genetic analysis continue to shed light on lymphedema development that may be important in filariasisrelated lymphedema. Although improvement in treatment outcomes by surgical means has been shown, there is often conventional treatment mixed in the therapy and no randomized controls of any therapy exist. In addition, these techniques require supermicrosurgical skill not available in many areas of the world. The WHO has documented the need in filariasis for both universal health care and innovative care for chronic conditions. The IAD has addressed these issues with its integrative model of treatment with patient quality-of-life at the forefront to incorporate traditional practice to involve the patient more fully in family and community support for an additional therapeutic tool.

Veterans with post-traumatic stress disorder exhibit altered emotional processing and attentional control during an emotional Stroop task.

BACKGROUND: Post-traumatic stress disorder (PTSD) is often associated with attention allocation and emotional regulation difficulties, but the brain dynamics underlying these deficits are unknown. The emotional Stroop task (EST) is an ideal means to monitor these difficulties, because participants are asked to attend to non-emotional aspects of the stimuli. In this study, we used magnetoencephalography (MEG) and the EST to monitor attention allocation and emotional regulation during the processing of emotionally charged stimuli in combat veterans with and without PTSD. METHOD: A total of 31 veterans with PTSD and 20 without PTSD performed the EST during MEG. Three categories of stimuli were used, including combat-related, generally threatening and neutral words. MEG data were imaged in the time-frequency domain and the network dynamics were probed for differences in processing threatening and non-threatening words. RESULTS: Behaviorally, veterans with PTSD were significantly slower in responding to combat-related relative to neutral and generally threatening words. Veterans without PTSD exhibited no significant differences in responding to the three different word types. Neurophysiologically, we found a significant three-way interaction between group, word type and time period across multiple brain regions. Follow-up testing indicated stronger theta-frequency (4-8 Hz) responses in the right ventral prefrontal (0.4-0.8 s) and superior temporal cortices (0.6-0.8 s) of veterans without PTSD compared with those with PTSD during the processing of combat-related words. CONCLUSIONS: Our data indicated that veterans with PTSD exhibited deficits in attention allocation and emotional regulation when processing trauma cues, while those without PTSD were able to regulate emotion by directing attention away from threat.

Future Research Priorities for Morbidity Control of Lymphedema.

BACKGROUND: Innovation in the treatment of lower extremity lymphedema has received low priority from the governments and pharmaceutical industry. Advancing lymphedema is irreversible and initiates fibrosis in the dermis, reactive changes in the epidermis and subcutis. Most medical treatments offered for lymphedema are either too demanding with a less than satisfactory response or patients have low concordance due to complex schedules. A priority setting partnership (PSP) was established to decide on the future priorities in lymphedema research. METHODS: A table of abstracts following a literature search was published in workshop website. Stake holders were requested to upload their priorities. Their questions were listed, randomized, and sent to lymphologists for ranking. High ranked ten research priorities, obtained through median score, were presented in final prioritization work shop attended by invited stake holders. A free medical camp was organized during workshop to understand patients' priorities. RESULTS: One hundred research priorities were selected from priorities uploaded to website. Ten priorities were short listed through a peer review process involving 12 lymphologists, for final discussion. They were related to simplification of integrative treatment for lymphedema, cellular changes in lymphedema and mechanisms of its reversal, eliminating bacterial entry lesions to reduce cellulitis episodes, exploring evidence for therapies in traditional medicine, improving patient concordance to compression therapy, epidemiology of lymphatic filariasis (LF), and economic benefit of integrative treatments of lymphedema. CONCLUSION: A robust research priority setting process, organized as described in James Lind Alliance guidebook, identified seven priority areas to achieve effective morbidity control of lymphedema including LF. All stake holders including Department of Health Research, Government of India, participated in the PSP.

Elephantiasis, elastin, and chronic wound healing: 19th century and contemporary viewpoints relevant to hypotheses concerning lymphedema, leprosy, erysipelas, and psoriasis--review and reflections.

Both wound healing and lymphedema have fibrosis of the skin in common. They also share destruction of elastin by elastases from neutrophils as a significant feature. These are not new observations, and the writings of Unna and Kaposi are recalled. The contemporary observations on elastin by Gerli and his team are discussed in the light of these much earlier opinions.

Integrated management of filarial lymphedema for rural communities.

The Global Alliance for the Elimination of Lymphatic Filariasis (GAELF) has recommended exploring local health traditions of skin care and a low cost treatment paradigm for rural communities has been proposed by Vaqas and Ryan. Our case study incorporates these promising treatments for use in treating filariasis in rural communities. Patients having lymphedema of one or both lower limbs (skin: normal, thickened or with trophic/warty changes) received treatment components from ayurveda, yoga and biomedicine simultaneously: including soap wash, phanta soaking, Indian manual lymph drainage (IMLD), pre- and post-IMLD yoga exercises, and compression using bandages for 194 days, along with diet restrictions and oral herbal medicines indicated for "elephantiasis" in Ayurveda. Entry points when infected were treated with biomedical drugs. The study was conducted in the reverse pharmacology design. 112 patients and 149 lower limbs completed 194 days of treatment during 2003-2006. Significant improvements were observed in the limb circumference measurements and the frequency of acute dermatolymphangioadenitis, use of preventive antibiotics, and reduction in the number of entry points were also improved. The objective to obtain significant benefit for a common problem using locally available, sustainable and affordable means has been achieved. It has not been our purpose to show that the regimen employed is better than another but the results do pose the question--"Are there components of Ayurvedic medicine that deserve further study?" It is important to understand that the regimen has been delivered mostly at home and that participants we have treated, representing a population suffering from a common problem, have not had access to effective conservative therapy that is culturally acceptable, safe, and efficacious.

A public health approach for leprosy detection based on a very short term-training of primary health care workers in basic dermatology.

INTRODUCTION: In countries where leprosy control is integrated to general heath services, health workers, at primary health care level, often manage a large number of patients with skin diseases including leprosy. The distinction of leprosy from others skin diseases requires more skill and attention. Basic dermatological knowledge will help these staff to provide a better quality of care. A few years ago, a short term training programme focussed on leprosy and some common skin diseases was set up in Mali through a pilot project. This study will evaluate the impact of this training on the detection of leprosy at primary health care level. METHODS: health care workers from two health districts were invited to participate in the training. Trainee was submitted to an anonymous written test before training, immediately after and 12-18 months post-training using a standardized scoring system. The suspected or referred leprosy cases before and after training were compared. Data were recorded and analysed with the software Epi info version 6.04. RESULTS: Overall, 495 HCW attended the three anonymous written tests (before training, just after and 12-18 months later). The proportion of participants who gave correct answers before training, just after were respectively: 33 and 57% for correct diagnosis, 5 and 39% for test of sensation and 28 and 47% for referral. Eight patients suspected of leprosy were referred for further examination; in these, five cases of leprosy were detected. DISCUSSION: The training showed a huge improvement in the skill of the participants in managing leprosy patients. This study addresses how leprosy control can be improved by involving primary health care staff and by the implementation of only a single day's training on basic dermatology. CONCLUSION: The role of the dermatologist in this post-elimination era of leprosy needs to be reconsidered and adapted to the increasing need to take multiple programmes, inclusive of dermatology and leprosy, into primary health care services and those interested in leprosy control should fund these programmes.

What are subcutaneous adipocytes really good for?

Our acute awareness of the cosmetic, psychosocial and sexual importance of subcutaneous adipose tissue contrasts dramatically with how poorly we have understood the biology of this massive, enigmatic, often ignored and much-abused skin compartment. Therefore, it is timely to recall the exciting, steadily growing, yet underappreciated body of evidence that subcutaneous adipocytes are so much more than just 'fat guys', hanging around passively to conspire, at most, against your desperate attempts to maintain ideal weight. Although the subcutis, quantitatively, tends to represent the dominant architectural component of human skin, conventional wisdom confines its biological key functions to those of energy storage, physical buffer, thermoregulation and thermoinsulation. However, already the distribution of human superficial adipose tissue, by itself, questions how justified the popular belief is that 'skin fat' (which actually may be more diverse than often assumed) serves primarily thermoinsulatory purposes. And although the metabolic complications of obesity are well appreciated, our understanding of how exactly subcutaneous adipocytes contribute to extracutaneous disease - and even influence important immune and brain functions! - is far from complete. The increasing insights recently won into subcutaneous adipose tissue as a cytokine depot that regulates innate immunity and cell growth exemplarily serve to illustrate the vast open research expanses that remain to be fully explored in the subcutis. The following public debate carries you from the evolutionary origins and the key functional purposes of adipose tissue, via adipose-derived stem cells and adipokines straight to the neuroendocrine, immunomodulatory and central nervous effects of signals that originate in the subcutis - perhaps, the most underestimated tissue of the human body. The editors are confident that, at the end, you shall agree: No basic scientist and no doctor with a serious interest in skin, and hardly anyone else in the life sciences, can afford to ignore the subcutaneous adipocyte - beyond its ample impact on beauty, benessence and body mass.

Advances in understanding disease epidemiology and implications for control and eradication of tuberculosis in livestock: the experience from New Zealand.

A deteriorating tuberculosis problem in cattle and deer in New Zealand has been halted and then reversed over the last decade. Mycobacterium bovis infection in both wild and domestic animal populations has been controlled. This has been achieved by applying a multi-faceted science-based programme. Key features of this have been a comprehensive understanding of the epidemiology of tuberculosis in animals, confidence in sampling wild animal populations, effective application of diagnostic tests in cattle and deer, and the ability to map M. bovis genotypes.

Regionalization: a strategy that will assist with bovine tuberculosis control and facilitate trade.

It is expected that the revised chapter on bovine tuberculosis in the Terrestrial Animal Health Code of the Office Internationale des Epizooties (OIE) will embrace regionalization as a functional means of assisting countries, states or regions to meet the requirements for freedom from tuberculosis and to facilitate trade. The benefits and applications of regionalization, which comprises zoning and compartmentalisation, are discussed. Regionalization requires that a country's veterinary administration is able to implement transparent and auditable biosecurity measures that will ensure that the tuberculosis-free status of a subpopulation of cattle is maintained despite the presence of infection in another cattle subpopulation, or in other domestic or wild animal species. Zoning, which requires cattle subpopulations to be separated by geographic boundaries, provides a practical basis whereby countries, states or regions, can progress towards freedom from tuberculosis, regardless of the source of infection for defined cattle subpopulations. Compartmentalisation however, requires that husbandry or management practices will be used to prevent a tuberculosis-free cattle subpopulation from contacting interspecific and intraspecific sources of infection. This will be difficult to achieve except for specialised cases such as artificial breeding centers.

An analysis of nursing activity in a day care and inpatient dermatology service.

The nursing context within which dermatological treatments are provided has received limited investigation. This activity analysis survey examined how nursing time is organized (n=17 nurses) within in- and out-patient day care services in a hospital teaching dermatology department, using a newly developed standardized tool over a 24-week period. The setting was a day care and inpatient facility in a UK dermatology department. Patients (n=108) referred to these services for day care or inpatient care over 24 weeks, excluding emergencies, were recruited consecutively; 76% (n=82) were seen during this time. Most patients (>95%) were referred for clearance of an acute episode of a chronic skin condition and specifically education. The total mean time in contact with the nursing service (mean hours/case) was 43.1 for inpatient and 6.6 for day care. Time in day care was mainly spent (mean hours/case) on direct care (living activities and dermatological treatments) (4.3), followed by teaching (2) and support (1.6). The pattern of inpatient care was similar. A profile has been derived that is indicative of how dermatology nurses spend their time in day and inpatient care. There may be scope for day care nursing to make more effective use of education opportunities to support patient self-management.

Using cycloidal vibration to heal venous leg ulcers: a cost-analysis based on retrospective data.

Using cycloidal vibration to stimulate the circulation to enhance healing can significantly reduce treatment costs. For the patient, the benefits include faster healing times, a better quality of life and a marked reduction in pain.

How echographic image analysis of venous oedema reveals the benefits of leg elevation.

OBJECTIVE: Venous insufficiency, leading to venous oedema, is a key pathogenic factor for the non-healing of venous leg ulcers. This study aimed to evaluate the effects of leg elevation on venous oedema. METHOD: Ten patients aged 44-89 years (median: 61) with leg oedema had high-frequency B-mode ultrasound scanning and digital image analysis before and after three to four hours of leg elevation. The echographic image analysis system was used, where oedema is represented by the hypoechogenic part of the image--that is, the total number or density of low echogenic pixels (LEPs) in a particular area. RESULTS: Compared with pre-elevation, the volume of the lower leg decreased by 2.9% +/- 0.6 (138 cm3 +/- 39) after three to four hours' elevation (p < 0.05). After elevation, the LEPs in the upper, middle and lower sites of the limb decreased by 8.8%, 15.6% and 17.3% respectively, reaching statistical significance (p < 0.05) in the lower site. The ratio of LEPs in the upper and lower dermis in the upper, middle and lower sites decreased by 30.3%, 45.8% and 22.5% respectively. This was significant in both the middle and lower sites (p < 0.01). After elevation dermal thickness increased by 0.047 mm, 0.194 mm and 0.232 mm respectively. This change was statistically significant in the middle (p < 0.05) and lower sites of the limb (p < 0.01). CONCLUSION: LEPs are a sensitive marker of dermal oedema and its effects. Leg elevation is extremely effective in reducing oedema, even if only for three to four hours.

Nurse-led education sets out to improve patient concordance and prevent recurrence of leg ulcers.

OBJECTIVE: This study evaluated the effects of a structured nurse-led education programme that aimed to improve patient concordance and prevent venous leg ulcer recurrence. METHOD: The design was quasi-experimental. Subjects (average age: 80) had venous leg ulceration that had healed within the previous two years, and were cared for at home by a district nurse. Data were available on 49 patients with 97 legs, 72 of which had had venous leg ulcers. Patients were divided into two groups: a control group, which received 'usual' care, and experimental group, which was exposed to the education programme. Recurrence rates, the effects of the education on patient behaviour and the effect on recurrence of having both ankle movement and general mobility were measured over one year. RESULTS: Patients in the experimental group experienced significantly less recurrence over the year (log rank test = 8.28, p = 0.004). To control for differences in mobility and ankle movement in the control and experimental groups at baseline, simultaneous logistic regression analysis was undertaken. This revealed a significant advantage for patients in the experimental group (p = 0.035; OR = 4.45, 95% CI = 1.11-17.74), who spent more time with their legs elevated each day. This difference was sustained throughout the 52 weeks (f = 2.88, p = 0.015). Those who had both full ankle movement (> 60 degrees) and full mobility (without aid) had significantly less recurrence (p = 0.042). Education had no significant effect on the amount of time patients wore compression hosiery (f = 2.1). CONCLUSION: A structured nurse-led patient concordance programme is effective in preventing venous leg ulcer recurrence and increasing the time patients spend with their legs elevated at heart level. Having both full ankle movement and full mobility reduces the risk of recurrence.

Use of mycobacterial peptides and recombinant proteins for the diagnosis of bovine tuberculosis in skin test-positive cattle.

More accurate tests are required to test cattle which have reacted positively in the tuberculin skin test. For this purpose, a range of mycobacterial antigens, MPB59, MPB64, MPB70, MPB83, ESAT-6 and CFP10, were used either as recombinant proteins or as synthetic peptides in the whole blood interferon-gamma (IFN-gamma) test. Groups of uninfected cattle with typical 'non-specificity' problems were targeted, in particular animals with skin tuberculosis, animals vaccinated against Johne's disease and animals that were positive in the standard purified protein derivative (PPD)-based IFN-gamma test. The two study groups consisted of 74 Mycobacterium bovis-culture positive animals and 72 uninfected animals, all of which tested positive in the caudal fold tuberculin skin test eight to 28 days before the blood test. The use of combinations of ESAT-6 and CFP10 antigens, either as recombinant proteins or peptides, detected similar percentages of M bovis-infected animals as the PPD-based IFN-gamma test, but produced significantly fewer false positive reactions. The PPD-based IFN-gamma test was very effective in differentiating animals vaccinated against Johne's disease that were skin-test positive from those with bovine tuberculosis, and the use of PPD or specific mycobacterial antigens minimised the number of false positive reactions in animals with skin tuberculosis.

Lymphatics in leprosy: relationship to elastic fibres and observations following intra-lesional injections of colloidal carbon.

An investigation of skin lymphatics in leprosy has been undertaken. Examination of 62 skin biopsies from 31 patients with various classifications of leprosy has revealed dilated initial lymphatics within granulomas of lepromatous leprosy, but no significant abnormalities in non-lepromatous disease or in non-granulomatous skin. Colloidal carbon injected intra-lesionally failed to appear within granulomas, but could be seen in lymphatics in non-granulomatous dermis. Elastic fibres were also absent within granulomas. AFB were clearly identified within endothelial cells of initial lymphatics. We suggest lymphatic malfunction may be compartmental, existing only within the granulomas and not in the surrounding normal appearing dermis.