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Foot ulceration in diabetes mellitus is common. Foot problems remain the commonest cause of hospital admission amongst patients with diabetes in Western countries. The lifetime risk of a patient with diabetes developing an ulcer is 25%, and up to 85% of all lower limb amputations in diabetes are preceded by foot ulcers. As many as 50% of older patients with type 2 diabetes have risk factors for foot problems and regular screening by careful clinical examination is essential; those found to be at risk should attend more regular follow-up together with education in foot self-care. The key to management of diabetic neuropathic foot ulceration is aggressive debridement with removal of callus and dead tissue, followed by application of some form of cast to offload the ulcer area. Most ulcers will heal if pressure is removed from the ulcer site, if the arterial circulation is sufficient and if infection is managed and treated aggressively. Any patient with a warm swollen foot without ulceration should be presumed to have acute Charcot neuroarthropathy (CN) until proven otherwise. The optimal approach to reducing ulceration requires regular screening, patient education and a team approach to management, both in the community and in hospital.

COVID-19 outbreak is currently being concerned for managing patients with immunological disorders nowadays, including SLE. Lupus is a complex autoimmune disease characterized by the presence of autoantibodies that against cell nucleus involved many organs in the body. Patients with SLE will increase risk of severe infection because the intrinsic respond attack with their immune respond though immunosuppressive drugs consumption, and will potentially damage some organs target associated with their disease. Lupus have multiple clinical manifestations with a fluctuating symptom. Patient who come with the symptom ofbreathlessness will getworse day by day. The symptom could be felt in the same time as fatigue, joint pain, hair loss, malar rash, oral ulcer, pleural effusion and swollen feet. There's a patient with antinuclear antibody positive for anti-smith and anti-Ro/SS-A. She was diagnosed with COVID-19, SLE with nephritis, haemolytic anemia, vasculitis and pleural effusions. The clinical manifestations of this patient indicate a COVID-19 with lupus nephritis that has severe disease. She was being treated with methylprednisolone and hydroxychloroquine for SLE and azithromycin plus oseltamivir as a therapy for COVID-19. The effect of hydroxychloroquine on SARS-CoV-2 was better seen in patients with SLE who gotthe medication regularly. Patients went home after 24 days of hospitalization after negative RT-PCR results and clinical improvement of LES.

Introduction: Tuberculosis (TB), one of the oldest diseases known to affect humans, is caused by the bacteria Mycobacterium tuberculosis. The disease usually affects the lungs, although, in up to one-third of cases, other organs are involved. TB of the bone mimics other clinical conditions such as chronic osteomyelitis, Madura mycosis and actinomycosis. Case Report: A fifth child and last-born girl, in a family of living four children, aged 9 years, consulted Kigali University Teaching Hospital (CHUK) on December 7, 2017, from Kibuye Referral Hospital (Western of Rwanda) for ulcerated, infected left heel with swollen foot 4 months before our consultation. Physical examination revealed a patient with swollen and tender foot discharging serous bloody fluids accompanied by inability to stand with a painful right hip. Small left inguinal lymph nodes were present. Blood work-up, computed tomography scan of the left foot, and an incisional biopsy at the level of the left calcaneus were performed and revealed extrapulmonary TB. The histopathological features for TB were scanty, but the high index suspicion of possible extrapulmonary TB led to the confirmation of the diagnosis using auramine-rhodamine special stain. Anti-TB therapy for 12 months course was initiated and the monthly follow-up for 11 months was done. Conclusion: Although calcaneal TB is very rare, in countries with high incidence of TB, clinicians must have a high suspicion index and skeletal TB must be included in differential diagnosis of bone masses whenever possible bone mass biopsy and special staining technique in addition to most common diagnosis means should be done to rule out the possibility of bone TB. Keywords: Calcaneus, tuberculosis, Rwanda.

The risk of pregnancy is quite anxious for pregnant women, although it is known that physical and psychological changes will occur in the pregnancy process. These physical changes are in the form of increased hormones which can also affect a person's mood, back pain, leg cramps or tingling, and swollen feet that often occur at night and interfere with the quality of sleep of pregnant women. The purpose of this activity is to provide knowledge to pregnant women about edema and anxiety in the 3rd trimester and complementary therapies that can be done. This activity is carried out by the method of lectures, discussions and demonstrations. This activity was held on October 10, 2019 and was attended by 22 pregnant women. The results obtained were an increase in the knowledge, understanding, and ability of participants in understanding the material presented in this service activity. It was found that 80% of the audience present were able to mention the meaning of foot edema and anxiety, 75% of the audience present were able to mention and demonstrate how to soak feet in warm water. Health education can be carried out by health workers to increase the knowledge of pregnant women about edema and anxiety and its handling. Resiko kehamilan cukup membuat resah ibu hamil, meskipun diketahui dalam proses kehamilan akan terjadi perubahan-perubahan fisik maupun psikologis. Perubahan fisik tersebut berupa peningkatan hormon yang juga dapat mempengaruhi suasana hati seseorang, sakit punggung, kram atau kesemutan kaki, dan kaki bengkak yang sering terjadi di malam hari dan mengganggu kualitas tidur ibu hamil. Tujuan kegiatan ini adalah memberikan pengetahuan kepada ibu hamil tetang udem dan kecemasan pada trimester III dan terapi komplementer yang dapat dilakukan, Kegiatan ini dilakukan dengan metode ceramah, diskusi dan demonstrasi. Kegiatan ini dilaksanakan pada tanggal 10 oktober 2019 dan diikuti oleh 22 orang ibu hamil. Didapatkan hasil adanya peningkatan pengetahuan, pemahaman, dan kemampuan peserta dalam memahami materi yang disampaikan pada kegiatan pengabdian ini . Didapatkan 80% Audiens yang hadir mampu menyebutkan pengertian udem kaki dan kecemasan , 75% Audiens yang hadir mampu menyebutkan dan mendemonstrasikan cara rendam kaki air hangat . Pendidikan kesehatan ini dapat dilakukan oleh tenaga kesehatan untuk meningkatkan pengetahuan ibu hamil tentang udem dan kecemasan serta penanganannya. Kata Kunci : Udem, Kecemasan, Ibu Hamil, Trimester III ABSTRACT The risk of pregnancy is quite anxious for pregnant women, although it is known that physical and psychological changes will occur in the pregnancy process. These physical changes are in the form of increased hormones which can also affect a person's mood, back pain, leg cramps or tingling, and swollen feet that often occur at night and interfere with the quality of sleep of pregnant women. The purpose of this activity is to provide knowledge to pregnant women about edema and anxiety in the 3rd trimester and complementary therapies that can be done. This activity is carried out by the method of lectures, discussions and demonstrations. This activity was held on October 10, 2019 and was attended by 22 pregnant women. The results obtained were an increase in the knowledge, understanding, and ability of participants in understanding the material presented in this service activity. It was found that 80% of the audience present were able to mention the meaning of foot edema and anxiety, 75% of the audience present were able to mention and demonstrate how to soak feet in warm water. Health education can be carried out by health workers to increase the knowledge of pregnant women about edema and anxiety and its handling. Keywords : Udem, Anxiety, Pregnant Women, 3rd Trimester

This article describes the development of a nurse-led voluntary organisation that provides basic foot care to the homeless at street level in three Welsh cities. There is a large percentage of street sleepers who choose not to access professional health and care services for various reasons, and many of these individuals have foot health problems, such as sore, painful, swollen feet from continuous walking, calluses, dried skin, blisters that are often de-roofed and trench foot. Through support and education, however, several of these people have been able to take ownership of their identified problems, by building trusting relationships with Homeless Hope nurses. Through collaborative communication with professional services, Homeless Hope nurses provide an informal link between non-engaging rough sleepers and the services in place to help support them.

Beta-beta wood (Lunasia amara Blanco) is one of the Rutaceae plants. It has been used traditionally in Indonesia, both in the form of a single extract or in a mixture of several herbs, for the treatment of swollen feet, skin diseases and inflammation or irritation of the eyes. This study aims to examine the antioxidant activity and the phytochemical profile of beta-beta wood extract. The research methods include plant extraction by maceration, testing of antioxidant activity by 2,2-diphenyl-1-picrylhydrazyl (DPPH) method and phytochemical profiling with specific chemical reagents. The results showed that beta-beta wood extract (Lunasia amara Blanco) has antioxidant activity with IC50 was 69.46 μg/ml (0.069 mg/ml) and it contained steroid, phenolic, saponin, alkaloid and coumarin compounds.

We describe the use of Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) in the investigation and diagnosis of Charcot neuroarthropathy (CN) in patients with a hot swollen foot but normal radiographs and clinical suspicion of CN, usually termed Stage 0. This was a retrospective cohort review of 46 diabetes patients who underwent 3 phase bone scintigraphy with &ldquo, High Resolution&rdquo, SPECT/CT. The imaging demonstrated that Stage 0 Charcot foot has a distinct bone pathology, which can be classified into three groups: (1) fractures on Computed Tomography (CT) with accompanying focal uptake of tracer on SPECT, (2) bony abnormalities apart from fracture on CT with focal uptake of tracer on SPECT, and (3) normal CT but focal bony uptake of tracer on SPECT. The CT component of SPECT/CT detected bony fractures in 59% of patients. Early treatment with below knee cast and follow-up for 24 months showed only 4 patients who developed Stage 1 Eichenholtz Charcot foot. Our findings support the use of 3 phase bone scintigraphy with SPECT/CT in the characterization and early diagnosis of CN. Stage 0 Charcot foot has a distinct bone pathology which requires urgent treatment to prevent progression to Stage 1 Eichenholtz Charcot foot. If SPECT/CT is unavailable, CT alone will detect bone fracture in 59% patients.

10 weeks old infant presented to emergency with 9 days history of fever. He was seen by G.P twice during this illness, initially the impression of viral illness was made and on second time child had 9 days of fever and looked miserable and lethargic so was referred to padiatrics emergency. There was no significant past medical history. No history of sick contacts and no recent travel. At presentation the child was febrile and irritable with no obvious source for fever. He was started on IV Ceftriaxone and Aciclovir. Initial bloods revealed profound leucocytosis (Total WBC 76, neutrophils 50.1) and CRP of 236, with serial blood films showing a reactive picture and left shift. Chest x-ray was clear, urine/blood cultures were negative and LP showed 8 WCC with negative cultures. After 72 hours of inpatient care the child was referred to tertiary centre in view persistent fever and irritability. In the tertiary Hospital, parents told that child had bloodshot eyes, puffy swollen feet and red lips. Child was started on IVIG 2 gm/kg and high dose aspirin. Child had echocardiography which showed right coronary artery (RCA) dilatation maximal at distal segment measuring 3.58 mm with Z-score of 8.86. RCA at mid-point and proximal segment measured 3.06 and 2.93 respectively with Z-score of 6.31 and 5.14 respectively. Left anterior descending artery measured 2.42 with Z-score of 4.27. During in-patient child was having on-going mild fever and in view of significant coronary dilatation child was started on low molecular weight heparin and also second line treatment with infliximab to which he responded well. Repeat echocardiography showed stable coronary dilatation. Kawasaki is a mucocutaneous lymph node syndrome with specific diagnostic features, having said that it seems to be a rarity to find all the features consistent with diagnosis. The age presentation, less than 6 month is a very uncommon reported finding in UK and the lack of any diagnostic features initially for Kawasaki except fever lasting for more than 5 days makes this case an important academic and learning standpoint for paediatric trainees.

Charcot arthropathy is a progressive condition primarily affecting the lower limbs in patients with diabetes mellitus. It is a rare complication of diabetic neuropathy and if left untreated can lead to severe limb destruction necessitating major amputation. Here, we report the case of a 41-year-old female who presented with rapidly progressive Charcot foot over a 10-day period, necessitating open reduction and internal fixation of Lisfranc-type fracture dislocations. Her presentation with a rapidly progressing red, swollen foot with a blister on the plantar aspect prompted initial treatment on the basis of a diabetic foot infection. The report will therefore serve as a useful reminder to maintain a high index of suspicion for Charcot foot, which may present in an atypical manner.

Introduction Off period research in Parkinson's disease commonly relies on questionnaires. We aimed to investigate the breadth of off period experiences by interviewing persons with Parkinson's disease (PwP) and carepartners. Methods Investigators performed PwP and carepartner dyad interviews using a semi-structured questionnaire to describe off period experiences. Investigators analyzed interview transcripts using a qualitative descriptive approach to identify and compare themes between groups. Results Twenty PwP and their carepartners participated in interviews. PwP were on average 65.1 years-old (SD 8.3) and 7.8 years (SD 4.7) after their Parkinson's disease diagnosis. PwP and carepartners identified 13 motor symptoms, 5 of which (immobility, gait changes, freezing, trouble swallowing, and having to concentrate on movements) were not in the wearing off questionnaires recommended by the International Parkinson and Movement Disorders Society. PwP and carepartners identified 15 non-motor symptoms, 8 of which (behavior changes, irritability, fatigue, language difficulties, dizziness, dry mouth, urinary symptoms, and swollen feet) were not in recommended questionnaires. Certain symptoms were reported only by PwP (e.g. dizziness, urinary symptoms) or carepartners (e.g. behavioral changes), or were reported by dyad members to different degrees (e.g. fatigue, anxiety). Conclusion Wearing off questionnaires capture the presence of fluctuations and can facilitate patient-physician communication regarding off periods. However, they may miss the breadth of individual PwP experiences. PwP and carepartners also report different PwP experiences during off periods. To fully appreciate an individual's off experiences, clinicians likely need to use multiple approaches to gathering information including questionnaires and both PwP and carepartner report.

Aim The aim of this study was to assess the relationship between ultrasonographic features of tibialis posterior (TP) tendon in rheumatoid arthritis (RA) patients and associated pes planovalgus (PPV) foot deformity. Patients and methods This study included 20 (40 feet) RA patients with PPV and ultrasound-proven TP tenosynovitis. The following variables were recorded for patients: the number of tender and swollen foot joints count, foot posture index (FPI), Health Assessment Questionnaire, and Disease Activity Score 28 (DAS28). FPI is a clinical tool used to quantify the degree to which a foot is pronated, neutral, or supinated using the set criteria. Patients underwent high-resolution ultrasound of the TP tendon. Measurement of tendon diameter was recorded in the retromalleolar region. The presence of fluid around the TP tendon and levels of power Doppler signal (PDS) were assessed. Results High disease activity was detected in patients (mean DAS28 of 5.89). Eighteen (45%) feet had thickened transverse diameter and 15 (37.5%) feet had thickened longitudinal diameter. Twenty-three feet showed PDS. Nineteen feet had fluid around the tendon, detected only in the retromalleolar region. Regarding FPI, 14 feet were mild to moderate pronated feet and 26 feet were highly pronated feet. There were direct correlation between FPI and both DAS28 (p=0.05) and transverse diameter thickness (p=0.01). Highly pronated feet had higher DAS28 (p=0.03), increased transverse diameter thickness (p=0.04), more detection of fluid around the TP tendon (p=0.005) as well as higher incidence of PDS around the TP tendon (p=0.002). Conclusion Higher degree of pronation in RA feet with PPV is associated with ultrasonographic increased tendon thickness, PDS, and fluid around TP tendon. Early diagnosis and intervention for TP tenosynovitis may prevent progressive PPV foot deformity.

Diabetes is an increasing problem in the modern world. Along with the rise in prevalence of the disease the number of diabetic complications presenting is increasing and amongst these is diabetic foot issues. Foot infection and Charcot arthropathy are the two key pathologies that present acutely with a hot swollen foot. Both require timely diagnosis and management to prevent disastrous long-term sequelae. Acutely presenting foot infections are both limb and life threatening and require urgent intervention to improve the chance of limb salvage. The ability to recognize and acutely deal with a diabetic foot requiring urgent surgical drainage is relevant to all orthopaedic surgeons with an on-call commitment and not solely to the foot and ankle specialist. Charcot arthropathy results in foot deformity that increases the likelihood of future ulceration and infection. The differentiation and acute management of the two conditions will be discussed.

At least half of all amputations occur in people with diabetes, most commonly because of an infected diabetic foot ulcer. A thorough understanding of the causes and management of diabetic foot ulceration is essential to reducing lower-extremity amputation risk. This compendium elucidates the pathways leading to foot ulcers and enumerates multiple contributory risk factors. The authors emphasize the importance of appropriate screening and wound classification and explain when patients should be referred for specialist care, targeted education, or therapeutic shoes or insoles. They provide a comprehensive review of treatment approaches, including devices for foot lesion off-loading and aggressive wound debridement through mechanical, enzymatic, autolytic, biologic, and surgical means. Because infection and peripheral artery disease are key contributors to amputation risk, the authors discuss the diagnosis and management of these conditions in detail. They also review the expanding armamentarium of evidence-based adjunctive treatments for foot ulcers, including growth factors, skin substitutes, stem cells, and other biologics. Because Charcot neuroarthropathy is a serious but frequently missed condition in people with diabetic neuropathy, the authors explain the differential diagnosis of the hot, swollen foot that is a hallmark of this condition. The article ends with an overview of four strategies for maintaining a foot in remission, followed by a brief look at the future of diabetic foot care.

Diabetes mellitus is the most common cause of Charcot neuropathy affecting foot and ankle. Acute Charcot foot (CF) presents with a red and swollen foot in contrast to the painless deformed one of chronic CF. Enhanced osteoclastogenesis plays a central role in the pathogenesis of acute CF. Many studies have shown elevated levels of bone turnover markers in patients with acute CF confirming it. These findings have led clinicians to use anti-resorptive agents [bisphosphonates (BP), calcitonin, and denosumab] along with immobilization and offloading in acute CF patients. The maximum evidence among all anti-resorptive agents is available for BPs, although its quality is low. Pamidronate has been shown to reduce the markers of activity of CF like raised skin temperature, pain, edema, and bone turnover markers in the majority of studies. Intravenous BPs are known to cause acute phase reactions leading to flu-like illness following their first infusion, which can be ameliorated by oral acetaminophen. Alendronate is the only oral BP used in these patients. It needs to be taken on an empty stomach with a full glass of water to avoid esophagitis. The side-effects and contraindications to BPs should be kept in mind while treating acute CF patients with them.

Leprosy reaction contributes to disability due to peripheral nerve damage. Nerve conduction study (NCS) provides a profound physiological description of peripheral nerves. This study aims to report a case of polyneuropathy in leprosy with type 2 reactions (T2R) which is evaluated using NCS. A 33-year-old woman complain of painful bumps in her arms and legs, fever, swollen feet since 2 days ago, and history of leprosy. Dermatologic examination on the right superior palpebra, right and left arms and legs revealed multiple tenderness erythematous nodules; right claw hand; and both legs oedema. Slit skin smear revealed positive result. Histopathologic examination supported T2R description. The NCS examination concluded severe axonal demyelinating motoric sensoric polyneurophaty, with left worse. She was treated with MDT-MB, bed rest, orally methylprednisolone, vitamin B, paracetamol, ferrous sulfas, and topical olive oil. Clinical improvement was achieved after 2 weeks. The NCS is used to assess the nerve impuls conduction along the peripheral nerves. In this case, it was found that NCS could showed early neuropathy in nerves that were clinically undetectable. It can be concluded that the NCS examination is an important diagnostic modalities for early detection of neuropathy and confirmed the diagnosis of clinical neuropathy in leprosy.

Background. Dyspnea is the most frequent, but not specific manifestation of the chronic heart failure (CHF). The arterial hypertension (HTN) is one of the causes of CHF. Its verification requires an echocardiography with tissue Doppler, which is not always available in routine practice. Identification of easily estimable CHF predictors in hypertensive patients with dyspnea is an important task. Objective of our study was the identification of the predictors of CHF with preserved ejection fraction (EF) among hypertensive outpatients with dyspnea. Design and methods. We included 116 outpatients with HTN and dyspnea over 60 years old with EF ≥ 50 %. Exclusion criteria were concomitant diseases which might lead to CHF. All patients performed the 6-minute walk test and echocardiography with tissue Doppler. Results . CHF was confirmed in 52,6 % patients. Palpitations, right-sided heaviness below the ribs, swollen feet, as well as reduced tolerance to physical activity were more frequent in older patients with HTN and dyspnea and did not allow to confirm CHF. Patients with confirmed CHF showed higher levels of systolic blood pressure (SBP). They had longer disease anamnesis and lower financial resources. Conclusions. Among elderly hypertensive outpatients with dyspnea every second one has no echocardiographic signs of CHF. SBP ≥ 140 mm Hg according to home measurements is associated with the 6-fold higher probability of CHF with preserved ejection fraction. In the elderly hypertensive outpatients with dyspnea, the duration of HTN more than 20 years and limited financial resources for medications are associated with the increased probability of CHF.

Introduction: Hansen's disease (leprosy) most commonly presents with cutaneous and nerve involvement. Rheumatological manifestations occur commonly but are often under-recognized. Physicians and rheumatologists alike are often perplexed with the rheumatological manifestations, given that these may precede the diagnosis of leprosy or may suggest another disease, in addition to leprosy. We present our experience with patients of leprosy presenting with rheumatological manifestations. Methods: This was a retrospective study carried out in the Departments of Rheumatology and Medicine, King George's Medical University, Lucknow, a tertiary care hospital in North India. Those patients who had a confirmed diagnosis of leprosy were subsequently included. Demographic details and clinical presentations were documented. Results: Twenty-nine cases (19 males, mean age 38 ± 17.2 years) were included in the study. The mean duration of disease was 20.2 ± 18.4 months. Rheumatological manifestations seen included arthritis (n = 17), tenosynovitis (n = 5), swollen hands and feet syndrome (n = 6), painful swollen feet (n = 2), arthralgias (n = 3), and vasculitis (n = 1). The rheumatological diseases mimicked were rheumatoid arthritis (n = 10) and spondyloarthritis (n = 3), sarcoidosis (n = 2), relapsing polychondritis (n = 1), and vasculitis (n = 1). At some point in time, lepra reactions manifesting with arthritis, nodules, tenosynovitis and/or dactylitis were observed in 15 cases. Other classical clinical manifestations detected were paresthesia (n = 13) and anesthetic patches (n = 15). Thickened great auricular, ulnar and lateral popliteal nerve were seen in 20 cases. Five patients had pure neuritic leprosy with no cutaneous manifestations and had arthritis or tenosynovitis. Conclusion: Leprosy may mimic a number of common and uncommon rheumatological diseases, and these may be the presenting manifestation. Awareness and a high index of suspicion are required to arrive at a timely and accurate diagnosis.

Patients with diabetes and a painful, hot, swollen foot can sometimes present a diagnostic challenge. Gout can often present in a similar fashion to diabetic foot infections or acute Charcot neuro-osteoarthropathy, and cases have been described where patients with Charcot neuro-osteoarthropathy were misdiagnosed as having gout, leading to treatment delay. We describe a patient who presented with a painful, swollen, warm foot who did not respond to initial treatment with antibiotics. Improvement in his symptoms occurred following treatment for gout, however he then went on to develop Charcot neuro-osteoarthropathy. As far as we are aware, this is the first case described in the literature where acute gout may have triggered acute Charcot neuro-osteoarthropathy. It is important to bear in mind that more than one pathology may be present in a patient at the same time or may closely follow one another.

Cosmos caudatus Kunth. (Asteraceae), commonly known as ulam raja, is widely grown as an herbal aromatic shrub. In Malaysia, its young leaves are popularly eaten raw as salad with other greens and have been reported to possess extremely high antioxidant properties, which may be partly responsible for some of its believed medicinal functions. In early 2010, a suspected powdery mildew was observed on ulam raja plants at the Agricultural Park of Universiti Putra Malaysia. Initially, individual, white, superficial colonies were small and almost circular. Later, they enlarged and coalesced to cover the whole abaxial leaf surface. With development of the disease, all green parts (leaves, stems, and petioles) became covered with a continuous mat of mildew, giving a dusty appearance. Newly emerged leaves rapidly became infected. Diseased leaves ultimately senesced and dried up, making them aesthetically unattractive and unmarketable. The pathogen produced conidia in short chains (four to six conidia) on erect conidiophores. Conidiophores were unbranched, cylindrical, 125 to 240 μm long, with a slightly swollen foot cell. Individual conidia were hyaline, ellipsoid, and 25 to 30 (27.5) × 15 to 20 (17.5) μm with fibrosin inclusions. Morphological descriptions were consistent with those described for Sphaerotheca fuliginea or S. fusca, which has lately been reclassified as Podosphaera fusca (1). From extracted genomic DNA of P. fusca UPM UR1, the internal transcribed spacer (ITS) region was amplified with ITS1 (5′-TCCGTAGGTGAACCTGCGG-3′) and ITS4 (5′-TCCTCCGCTTATTGATATGC-3′). A BLAST search of GenBank with an ITS rDNA sequence of this fungus (GenBank Accession No. HQ589357) showed a maximum identity of 98% to the sequences of two P. fusca isolates (GenBank Accession Nos. AB525915.1 and AB525914.1). To satisfy Koch's postulates, the pathogenicity of fungal strain UPM UR1 was verified on 4-week-old plants. Inoculation was carried out by gently rubbing infected leaves onto healthy plants of C. caudatus. Ten pots of inoculated plants were kept under a plastic humid chamber and 10 pots of noninoculated plants, placed under another chamber, served as controls. After 48 h, the plants were then placed under natural conditions (25 to 28°C). Powdery mildew symptoms, similar to those on diseased field plants, appeared after 7 days on all inoculated plants. The white, superficial colonies enlarged and merged to cover large areas within 2 weeks. The infected leaf tissues became necrotic 6 to 8 days after the appearance of the first symptoms. Sporulation of P. fusca was observed on all infected leaves and stems. No symptoms were seen on the control plants. To our knowledge, this is the first report of P. fusca causing powdery mildew on C. caudatus in Malaysia. This pathogen has also been reported previously to be economically important on a number of other hosts. With ulam raja plants, more attention should be given to prevention and control measures to help manage this disease. Reference: (1) U. Braun and S. Takamatsu. Schlechtendalia 4:1, 2000.

Forefoot fractures are frequently accompanied by severe soft tissue damage. Therefore, treatment should focus not only on fractures but also on soft tissue damage, for which external fixation can be used as a surgical option. A 63-year-old woman presented to the emergency clinic of our hospital with forefoot pain after a motorcycle accident. Comminuted fracture of the proximal part of the metatarsal was diagnosed. Because of the swollen foot and fracture comminution, an operation using the Ilizarov mini external fixator was performed to prevent further damage to the soft tissue. Weight-bearing was permitted seven weeks after the operation, and the extraction of the apparatus was performed nine weeks postoperatively. One year later, the patient had no pain and had returned to ballroom dancing, a hobby which she performed five days a week, with no difficulties. Our results suggest that the Ilizarov mini external fixator should be considered not only for temporary treatment, but also for the entire duration of treatment of first metatarsal fractures associated with severe soft tissue damage.

Ethnopharmacological relevance The use of animals and plants as traditional remedies for both medical afflictions and social or cultural issues (symbolism) has a long history in South Africa and a reasonably large proportion of the population will consult a traditional healer during their life-time. Compared to plants, the use of animal parts in traditional medicine and folklore is poorly documented. Methods We interviewed 32 traders from South Africa's largest traditional medicine market, the Faraday Street market in Johannesburg, of which only 20 consented to supplying some species use information. Traders are particularly protective of the medicinal properties of their wares. Given the sensitive nature of this information (12 traders declined to be interviewed), we were only able to gather data on their perceived uses and no data on dosages, efficacy, or individual turn-over of products. We assessed the trade of animal parts from the perspective of consumer needs by analysing use-categories (e.g. headaches, strokes, skin problems, bad luck, etc.) and the degree of informant consensus in the selection of fauna to treat certain conditions. Results We documented 301 uses for animal parts from 52 species and 18 ‘morphospecies’ that we allocated to 122 broad-use categories. Overall, reptiles and mammals were the most frequently used taxa in traditional medicine and some species had multiple uses (i.e., appeared in multiple use-categories) including crocodiles, lizards generally, chameleons, striped polecats, elephants and jackals. Animals were mostly used for ‘strength’ (physical or overcoming fear), but also as love charms, warding off bad luck or bad spirits or improving one's luck. Only 36% of our categories were medicinal (e.g., headaches, skin problems, swollen feet, etc.). We also found a high rate of non-disclosure of uses per species (a mean 86% of traders did not reveal information on the use of a species), and a variable degree of consensus between the traders on what particular species are actually used for. Conclusions We suggest that traditional medicine markets provide a unique opportunity to gauge the health and symbolic or personal issues representative of a large sector of society. What’s more, we recommend that researchers be more mindful in the way that use information is reported. We also highlight the potentially serious threat of traditional medicine to species that may be particularly vulnerable by virtue of their restricted distribution or predictable behaviour.

Background Heart failure patients experience multiple concurrent symptoms called symptom clusters. Understanding the role and characteristics of symptom clusters in heart failure (HF) patients is limited. Illness uncertainty may lead to difficulty interpreting symptoms and timely treatment. Before person-centered interventions can be developed, more information about variations in HF symptom clusters and factors associated with them are needed. Purpose The purpose of this study was to describe HF symptom clusters and determine if illness uncertainty levels differed by symptom cluster. Methods A total of 129 HF patients (mean age 76.4 (12.4) years, education 10.6 (3.2) years and time with HF 3.6 (5.9) years, 54% male, 93% Caucasian, 46% widowed/divorced, NYHA class III) completed the Heart Failure Somatic Perception Scale (HFSPS, 0-90, higher score indicates more symptoms) and Mishel's Uncertainty in Illness Scale (MUIS, 23-115, higher score indicates more uncertainty) during hospitalization. Symptom clusters were determined by hierarchical agglomerative clustering techniques in SPSS 25. After controlling for differences in age, gender and length of time with HF, ANCOVA (post hoc LSD) analyses explored uncertainty levels by symptom cluster group. Results Three clusters were found: 1. Shortness of breath cluster (SOB), n = 43 (fatigue, hard to breathe, SOB when dressing, orthopnea, DOE, PND, rest during day, wake urinate at night), 2. Edema cluster, n = 47 (swollen feet, tight shoes, tight clothes, weight gain), 3. Cardiac symptom cluster, n = 39 (palpitations, chest pain, upset stomach, decreased appetite, cough). After adjusting for age, gender and length of time with HF, there was a significant difference in uncertainty levels by symptom cluster group (p = .000). Post hoc analysis demonstrated that cardiac cluster members reported less illness uncertainty than edema cluster members (69.7 vs 75, respectively, p = .033). Conclusions Results suggest that significant differences exist in illness uncertainty levels based on the symptom experience of patients with HF. Care and management of HF symptoms should include a complete assessment of unique symptom cluster profiles.

The usual presentation of Charcot neuropathic osteoarthropathy (CN) is of a hot red swollen foot but later presentations are characterised by deformity and ulceration, which may be complicated by infection. Having reached the stage of significant foot deformity and sometimes ulceration, patients with CN may also have peripheral arterial disease. It is unlikely that significant ischaemia was present at the onset of the CN but in the time interval from onset of the Charcot foot to acquiring deformity, it may have developed. Such patients can occasionally present with rest pain. Also, an association between Charcot foot, diabetic neuropathy, and medial arterial calcification has also been noted. The disease is usually infrapopoliteal but may be also femoro-popliteal. Arterial disease may compromise ulcer healing and surgical and orthopaedic interventions for the Charcot foot and thus all patients with this advanced presentation of CN should be investigated for vascular disease. A limited number of studies show the effectiveness of endovascular treatment in cases with Charcot foot and peripheral arterial disease. In a series of patients with ischaemic foot and also CN, the limb salvage rate was 90% and mean time to healing was 197 days after endovascular treatment. In conclusion, all Charcot foot patients with ulceration and those being considered for surgery should have vascular investigations. If surgery is planned for the Charcot foot, revascularisation, within a multidisciplinary approach, should be considered before surgery for limb preservation.

Background The prevalence of non-communicable diseases (NCDs) is increasing in rural sub-Saharan Africa. Implementation and adaptation of recommended self-care practices is crucial for successful management of NCDs to prevent complications. However, little is known about self-care practices in patients living in rural sub-Saharan Africa. In this study, we aimed to understand patients' adherence to self-care practices for hypertension, diabetes, or both, in rural Uganda and their reasons for non-adherence. Methods We conducted a mixed-methods study in adult patients previously diagnosed with diabetes or hypertension, or both, who attended outpatient NCD clinics at three health facilities in Nakaseke district. We concurrently collected quantitative data from a random sample of patients using pretested, structured questionnaires and held focus group discussions and in-depth interviews with a purposive sample of patients. Descriptive statistics were calculated for the quantitative data. Qualitative analysis was conducted using a thematic approach. Findings Between April and August, 2019, we administered questionnaires and carried out six focus group discussions and 19 in-depth interviews with 385 participants. Mean age was 54·0 years (SD 14·57) and most respondents, 257 (66·8%), were female. Of the 385 participants, 39·2% (151) had diabetes; 36·9% (142) had hypertension, and 23·9% (92) had both conditions. Most respondents reported daily adherence to medication for hypertension (79·5% [186/234]) and diabetes (84·8% [206/243]). Few participants (15·6% [60/385]) reported daily vigorous physical activity, but 63·1% (243/385) reported moderate physical activity at least once per week. Most respondents reported adherence to recommendations for dietary changes (75·6% [291/385]), non-smoking (98·7% [380/385]), alcohol abstinence (90·1% [347/385]), and weight management (75·6% [291/385]). From the interviews and discussions, patients reported that they tried to adhere to recommended medications but were limited by the inability to obtain them. Most patients reported irregular self-monitoring and many reported confusion about recommended practices due to mixed messages, mainly from their peers. Respondents also reported use of herbal remedies, soaking swollen feet in salt water, and coping with stress through prolonged sleep, social isolation, and alcohol use. Interpretation Varied self-care practices exist among rural Ugandan NCD patients. Patients inconsistently engage in recommended practices because of uncertain access to medicines, structural barriers, and inconsistent messaging. Locally adapted educational self-care programmes and consistent access to medicines could help improve self-care in these patients. As low-income countries like Uganda continue to advance their NCD policies, specific attention should be focused on strategies to ensure equitable access to essential NCD medicines. Additionally, the unique circumstances of people living in rural settings should be taken into account when developing programmes for management of NCDs. Funding Yale Institute of Global Health Hecht Global Health Faculty Network Award

Acute Charcot neuroarthropathy of the foot and ankle presents with the insidious onset of a unilateral acutely edematous, erythematous, and warm lower extremity. The acute stages are typically defined as Eichenholtz Stage 1, or Stage 0, which was first described by Shibata et al. in 1990. The ultimate goal of treatment is maintenance of a stable, plantigrade foot which can be easily shod, minimizing the risk of callus, ulceration, infection, and amputation. The gold standard of treatment is non-weight-bearing immobilization in a total contact cast. Surgical intervention remains controversial. A review of the literature was performed to provide an evidenced-based approach to the conservative and surgical management of acute Charcot neuroarthropathy of the foot and ankle.Keywords: foot collapse; neuroarthropathy; peripheral neuropathy; swollen foot; total contact cast(Published: 19 March 2015)Citation: Diabetic Foot & Ankle 2015, 6: 26627 - http://dx.doi.org/10.3402/dfa.v6.26627

Background: Sub-Saharan Africa has the highest maternal mortality ratio at 500 deaths per 100,000 live births. In Mozambique maternal mortality is estimated at 249-480 per 100,000 live births and eclampsia is the third leading cause of death. The objective of this study was to describe the community understanding of pre-eclampsia and eclampsia, as a crucial step to improve maternal and perinatal health in southern Mozambique. Methods: This qualitative study was conducted in Maputo and Gaza Provinces of southern Mozambique. Twenty focus groups were convened with pregnant women, partners and husbands, matrons and traditional birth attendants, and mothers and mothers-in-law. In addition, ten interviews were conducted with traditional healers, matrons, and a traditional birth attendant. All discussions were audio-recorded, translated from local language (Changana) to Portuguese and transcribed verbatim prior to analysis with QSR NVivo 10. A thematic analysis approach was taken. Results: The conditions of “pre-eclampsia” and “eclampsia” were not known in these communities; however, participants were familiar with hypertension and seizures in pregnancy. Terms linked with the biomedical concept of pre-eclampsia were high blood pressure, fainting disease and illness of the heart, whereas illness of the moon, snake illness, falling disease, childhood illness, illness of scaresand epilepsy were used to characterizeeclampsia. The causes of hypertension in pregnancy were thought to include mistreatment by in-laws, marital problems, and excessive worrying. Seizures in pregnancy were believed to be caused by a snake living inside the woman’s body. Warning signs thought to be common to both conditions were headache, chest pain, weakness, dizziness, fainting, sweating, and swollen feet. Conclusion: Local beliefs in southern Mozambique, regarding the causes, presentation, outcomes and treatment of pre-eclampsia and eclampsia were not aligned with the biomedical perspective. The community was often unaware of the link between hypertension and seizures in pregnancy. The numerous widespread myths and misconceptions concerning pre-eclampsia and eclampsiamay induceinappropriatetreatment-seeking and demonstrate a need for increased community education regarding pregnancy and associated complications. Trial Registration NCT01911494

Charcot neuropathic osteoarthropathy (CN) is one of the most debilitating complications of diabetic neuropathy. It classically presents as a red hot swollen foot, precipitated by trauma. The latter le

Bien que plusieurs fruitiers sauvages aient été étudiés au Bénin, d’autres, dont Cola millenii K. Schum., y demeurent peu documentés. Cette étude avait pour objectif d’inventorier les connaissances ethnobotaniques de C. millenii par les groupes socioculturels béninois. Des entretiens individuels structurés ont été menés auprès de 1 009 personnes. La fréquence relative de citation et l’indice d’efficacité ont été utilisés pour apprécier respectivement l’importance relative de chaque utilisation et le niveau d’efficacité de la plante dans le traitement d’une maladie donnée. C. millenii relève de huit catégories d’usage. L’usage alimentaire de la pulpe du fruit est le plus pratiqué. Le paludisme est la maladie la plus citée. Globalement, l’espèce serait très efficace dans le traitement du paludisme, de l’ictère, des maux de ventre, de l’hypertension, des courbatures, de la fatigue, de la fièvre et du vertige ; moyennement efficace dans le traitement de l’asthme, des troubles liés à la grossesse et de l’enflure des pieds ; mais peu efficace contre l’oligospermie. La feuille est la partie la plus utilisée et la décoction est le mode de préparation le plus employé dans le traitement des maladies. Les Anii et Chabè préfèrent l’usage alimentaire de l’espèce tandis que son usage à des fins magiques et comme brosse végétale ou bois de service est privilégié par les Adja et Kotafon. Par contre, les Aïzo l’utilisent plus à des fins médicinales, et son usage comme bois d’œuvre est plus important pour les Mahi. Les feuilles et les fruits sont les parties les plus commercialisées. Malgré son importance, l’espèce subit diverses pressions et bénéficie très peu de mesures de conservation. Des recherches futures devraient se pencher sur sa sylviculture pour assurer sa domestication.

A previously healthy 12-year-old girl presented to our outpatient pediatric dermatology clinic with a three-week history of an itchy, red raised rash on her lower extremities that had spread to her buttocks. She also reported abdominal pain, swollen feet and joint pain but could not recall seeing

Category: Diabetes Introduction/Purpose: Charcot osteooarthropathy (CN) is a debilitating condition afflicting the bone, soft tissue and joints of foot and ankle and is related to pain insensitivity. Its pathogenesis and natural progression is poorly understood. In patients with high clinical suspicion, treatment with immediate off-loading and immobilisation may halt and (help to) reverse or prevent deformity. We aim to establish the role of SPECT CT in the diagnosis of acute charcot osteoarthropathy of the red swollen foot prior to radiographic changes and assess its reliability in diagnostic accuracy and guiding treatment. Methods: A prospective, observational review of all patients presenting to the multidisciplinary diabetic foot clinic from 1st Jan 2009 to 1st Jan 2013 with clinically suspected acute active charcot arthropathy was performed. All patients with a high clinical suspicion of acute CN and normal radiographs, underwent SPECT-CT within 10 days of the assessment after emergency off-loading in a TCC. A positive SPECT CT scan for new onset acute CN was diagnosed if radioisotope uptake was seen in all 3 phases of scanning. Further CT fusion images provided localization of ongoing activity. All patients were followed up for 1-year or until treatment ceased and treated in concordance with clinical symptoms and SPECT CT imaging. Results: In total 137 patients were referred or self referred with a high suspicion of new onset acute CN. The majority being diabetic (98%), including 116 unilaterally symptomatic feet with normal radiographs; 86 were consequently positively confirmed on SPECT-CT CN; 15 new ‘diabetic’ fractures were diagnosed on the CT component. At 1 year – only 5 patients went on to develop radiological changes consistent with charcot arthropathy even with accepted off loading in TCC. Thirty negative scans were recorded where no triple phase trace response & localisation was uni-focal or not associated with skeletal structures. Differential diagnosis included cellulitis, degenerative changes, old fractures, and planter fasciitis were made. At 1-year none of the patients were found to have developed CN in neither in the form of foot deformity nor radiological evidence of fragmentation or loss of normal bone anatomy. Conclusion: A combination of symptoms including swelling, pain and/or heat, positive three phase tracer uptake and localisation on SPECT CT can identify and aid the management of acute active CN in radiographically normal feet. Positive scans seem to identify an intermediate grade of charcot arthropathy where cortical fractures have occurred with significant subchondral bone turnover. A negative scan excludes high-risk feet for CN confidently and thus can direct treatment. We find SPECT CT a valuable addition to the armamentarium of the treating physician in instituting off loading to prevent the possible progression and onset of deformity and avoiding unnecessary treatment.

Aim: Leprosy classically presents with cutaneous and neural involvement. Rheumatological manifestations arefrequent, although often under-recognized. At times, these may present to a rheumatology clinic prior to thediagnosis of leprosy. Herein, we present our experience with patients referred with various rheumatological dis-orders who were subsequently diagnosed as having leprosy.Methods: This retrospective study (January 2001–September 2010) was carried out at the Department of Clini-cal Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, in northern India.Patients who were confirmed as having leprosy were included. Details regarding demographic and clinical pre-sentations were collected.Results: Forty-four cases (30 male, mean age 40 ± 13.6 years and mean disease duration 18.7 ± 24.3 months)were identified. Musculoskeletal manifestations included arthritis ( n = 22), swollen hands and feet syndrome(SHFS) (n = 11), tenosynovitis (n = 9), painful swollen feet (n = 9), arthralgias (n = 7) and vasculitis ( n = 1).Distribution of joints mimicked rheumatoid arthritis ( n = 14) and spondyloarthropathy (n = 7). Arthritis and/or tenosynovitis were part of spontaneous onset lepra reaction in 28 cases. Other clinical manifestations were:paresthesias (n = 28), erythematous nodules (n = 25) and anesthetic patches ( n = 7). Thirty-one patients hadthickened nerves (ulnar n = 28, common peroneal n = 21). Eight patients did not have any cutaneous manifes-tations and had presented with SHFS and arthritis or tenosynovitis. These were labeled as pure neuritic leprosy.Most of the patients responded to multidrug anti-leprosy therapy and glucocorticoids.Conclusion: Rheumatological presentations of leprosy may mimic RA, spondyloarthropathy or vasculitis. Pureneuritic variety and spontaneous type 2 lepra reaction pose unique diagnostic challenges. Increased awarenessmay avoid delay in diagnosis.Key words: arthritis, lepra reaction, leprosy, pure neuritic leprosy, swollen hand foot syndrome, tenosynovitis.

The majority of urban informal sector workers lack basic health and social protection services and work in an unhealthy and unsafe environment. Women in cross-border trading are one such group. Even though they contribute significantly to and are an important component of many economies, they do so at their personal and economic risks. As these women travel, they experience health hazards which add to their existing occupational exposure. Using in-depth interviews and observation, this paper unravels the health-related risks that women in cross-border trading face. The most common physical health complaints were musculoskeletal problems such as body aches, back pains, waist pains and swollen feet as a result of long hours of travelling and poor road networks. In addition to the limited access to information on sexually transmitted diseases, women also go through psychosocial problems arising out of constant thinking and ‘worrying too much’ about their safety in the vehicles, the cash they carry along, the activities of gendarmes and armed robbers, untrustworthy clients as well as the safety of the children they leave behind. It is recommended that more attention should be paid to women’s work in the informal economy and cross-border trade in particular, so as to unravel the ways in which women’s work affects their physical and mental health. It is only through this that policies could be put in place to address the health-related challenges of women in the informal economy.

In patients with long-standing, poorly controlled diabetes and peripheral neuropathy, a red, hot, swollen foot without open ulceration should raise the suspicion of Charcot neuroarthropathy, an often-overlooked diabetic foot complication. The authors discuss key diagnostic features and how to differentiate this condition from cellulitis, osteomyelitis, and other conditions. They review key elements of the workup and emphasize the importance of early diagnosis and prompt treatment to preserve a functioning foot.

Microcirculation (2010) 17, 281–296. doi: 10.1111/j.1549-8719.2010.00030.x Abstract Objective: Milroy disease is an inherited autosomal dominant lymphoedema caused by mutations in the gene for vascular endothelial growth factor receptor-3 (VEGFR-3, also known as FLT4). The phenotype has to date been ascribed to lymphatic aplasia. We further investigated the structural and functional defects underlying the phenotype in humans. Methods: The skin of the swollen foot and the non-swollen forearm was examined by (i) fluorescence microlymphangiography, to quantify functional initial lymphatic density in vivo; and (ii) podoplanin and LYVE-1 immunohistochemistry of biopsies, to quantify structural lymphatic density. Leg vein function was assessed by colour Doppler duplex ultrasound. Results: Milroy patients exhibited profound (86–91%) functional failure of the initial lymphatics in the foot; the forearm was unimpaired. Dermal lymphatics were present in biopsies but density was reduced by 51–61% (foot) and 26–33% (forearm). Saphenous venous reflux was present in 9/10 individuals with VEGFR3 mutations, including two carriers. Conclusion: We propose that VEGFR3 mutations in humans cause lymphoedema through a failure of tissue protein and fluid absorption. This is due to a profound functional failure of initial lymphatics and is not explained by microlymphatic hypoplasia alone. The superficial venous valve reflux indicates the dual role of VEGFR-3 in lymphatic and venous development.

Background An isolated injury to the calcaneocuboid joint is frequently unrecognized clinically. The possibility of an injured dorsal calcaneocuboid ligament (DCC) should be considered in all acutely swollen feet after trauma involving supination. Despite its significance, there is much confusion in the literature regarding nomenclature, morphology, and location. Materials and methods To determine morphometric dimensions, dissection was performed on the feet of 30 adult preserved cadaveric limbs. Results The DCC was consistently present in all specimens in the form of either a solitary structure (66.6%) or 2 components (33.3%). For the solitary structures, the superior and inferior borders measured 18.6 +/- 2.8 mm and 17.3 +/- 2.5 mm, respectively. The widths of the calcaneal and cuboid sides were 13.8 +/- 2.2 mm and 12.4 +/- 2.1 mm, respectively. In the 2 component ligaments, the superior component had a superior and inferior length that averaged 16.9 +/- 2.1 mm and 16.4 +/- 2.8 mm, respectively. Its calcaneal and cuboid borders were 9.3 +/- 1.2 mm and 10.6 +/- 1.4 mm, respectively. The inferior component had superior and inferior sides that were 12.9 +/- 2.9 mm and 13.8 +/- 3.0 mm, respectively. The widths of the calcaneal and cuboid sides were 8.3 +/- 1.4 mm and 7.2 +/- 1.0 mm, respectively. Conclusion We have demonstrated variations in the morphology of the DCC along with its morphometric dimensions. Clinical relevance Knowledge of the morphologic variations and dimensions of the DCC can be of aid when planning for surgical management of the ruptured ligament.

In Catull. 69 Rufus has a goat living in his armpits. In Catull. 71 a nameless man is part of a love triangle that has afflicted the two male participants with “the goat” and gout. Critics have been hesitant to suggest that Catullus could really be making a joke about sexually transmitting body odor and swollen feet. By examining the literary and medical evidence, I conclude that his audience would have appreciated such a joke. The identification of “the goat” and gout in 69 and 71 as venereal afflictions leads to a direct and funny reading, which fits the dominant pattern of Catullus’ slanderous epigrams.

Objective To report the physical medicine and rehabilitation (PMR) conditions seen in the Astrodome Clinic after Hurricane Katrina. Design Retrospective chart analysis from the county hospital-sponsored disaster-relief clinic in large urban city, including a study of 239 patients with 292 PMR conditions. The total number of patients seen in the Astrodome Medical Clinic was 11,245. The Astrodome database was reviewed for PMR condition diagnostic codes. A retrospective chart analysis was conducted, including date of visit, age, gender, ethnicity, and PMR diagnosis category. Descriptive statistics were obtained for the entire sample. chi2 or t tests were used to determine gender, age, or date-of-service predominance for the most common diagnostic categories. Results Mean +/- SD age was 45.7 +/- 14.3 yrs; 56% were women, 43% were men (1% unspecified), and 76% were African American. The majority (75%) of PMR conditions presented in the first week. Most frequent were swollen feet and legs (22%), leg pain and cramps (17%), headache (12%), and neck and back pain (10%). Persons with headaches were younger than those without (41.3 vs. 46.3 yrs, P = 0.048). Persons with neck and/or back pain were older than those without those conditions (51.3 vs. 44.8 yrs, P = 0.004). Women had more headaches (20.9%) than did men (6.7%, P = 0.002). There were no Caucasians with leg pain/cramps, whereas 20.2% of African Americans had this condition (P = 0.028). Conclusions This study documents the time of clinic presentation and most frequent types of PMR conditions of patients treated in the Astrodome Clinic after a historic hurricane. Most PMR conditions were treated by PMR personnel during the first week. Thus, future disaster planning should include PMR professionals as early responders.

Heart failure is a common, clinical syndrome that results from any functional or structural cardiac disorder that impairs the pumping ability of the heart. According to the Department of Health patients with heart failure account for 5% of acute admissions to hospital. This group of patients have a poor quality of life, poor prognosis and high re-admission rates (35–43%). Common signs and symptoms include breathing difficulties, fatigue and swollen feet, ankles or legs. Diagnosis is made on the presence of symptoms of heart failure, objective evidence of cardiac dysfunction and often a clinical response to treatment. Once a diagnosis of heart failure is made there are many treatments available to help the heart function better.

"Man stands alone, because man alone stands." (Western La Barre)I. Swift Feet and Winged WordsFeet and fate seem to be curiously related in the ancient Greek tradition. The remark may strike us pedestrian at first (no pun intended), but I hope to show that this connection signified for the Greeks something of utmost importance: it signified what it is to be human-in other words, to be a mortal being, someone who is conscious of, and thus in relation to, his or her finitude. To speak of a human being's fate then is to speak of his or her standing; standing not merely in the sense of social status-though status is always bound up with the question of fate-but standing literally on one's feet as the proper mode of human existence.Our most noted example comes of course from the myth of Oedipus and its subsequent dramatization by Sophocles. The story is well-known: trying to avoid the fatal prophecy that he will be killed by his offspring, Oedipus's father, Laius, had the infant s feet first pierced and bound, and then instructed a shepherd to dispose of it in the wild. Rescued by the shepherd and raised by an adopted family, the limping foundling grew-of all things-into a peripatetic wanderer. First he wandered in search of his natural father, and after the accidental parricide, wandered in exile in expiation of his crime. Both myth and drama suggest that Oedipus's fate is inscribed bodily in the injury of his feet, an injury that in turn is inscribed in his very name: "Oedipus" means "swollen foot," and thus the proper name carries within itself the singular fate of the person. In his reading of Sophocles's Oedipus Tyrannus, Seth Benardete notes the intricacy of this connection between fatality and feet, and their co-inscription in the proper name. Benardete traces the marking of fate in the shape of the letter that "begins" Oedipus's Labdacid ancestry, the letter L1 and that looks like two uneven legs: "The name of Oedipus perhaps most clearly shows that the surface truth of Oedipus is the sign of his depths as well. To be crippled was considered to be a sign of tyrannical ambitions, and the very name of the royal family, Labdacidae, contains within it labda or lambda, the letter that resembles an uneven gait" (2000, 75).Although the Oedipal myth illustrates most emphatically this link between fate and feet, it is not unique. In less obvious but still evocative terms, this relation is expressed earlier on in Homer's Iliad as well.2 I am referring, in particular, to the repeated characterization of Achilles3 as a man of the swift feet [podas okus] and of an untimely [panaorion] (XXIV.540) and bad destiny [kakei aisei] (I.418). Physical quickness in this story goes hand in hand with the brevity of life. In her first appearance to Achilles in Book 1, his mother, Thetis, calls him okumoros-a word that contains the adjective okus of Achilles's feet-and that designates someone who is short-lived. When Thetis pleads to Zeus to grant due honor to her son, she appeals to the god by reminding him of the brevity of Achilles's life. This time she uses the superlative form of the same adjective, stressing how amongst all men he is the one doomed to this tragic destiny: "timeson moi huion has okumorotatos allon / eplet'" (1.505-06). Later on, in requesting Hephaestus to craft a shield for Achilles, Thetis again uses the regular form of the same adjective to refer to her son's speedy death [okutnoroi] (XVIII.458).Swiftness may indeed be the very essence of Achilles,4 since he is also a man of winged words [epea pteroenta]. Pteroenta derives from the verb pteroo, for which the Liddell-Scott lexicon gives two meanings, one literal, the other metaphorical: a) to furnish with feathers or wings; b) to excite, to agitate. Hence, "winged words" could refer both to a rapid but smooth and eloquent verbal exchange, as well as to an agitated, edgy speech. Although this formula of the winged words applies to other figures in the epic alongside Achilles, I think that it is more distinctively his characterization as is that of the swift feet. …

A cross-sectional survey of 68 integrated Irish pig farms was conducted to determine the prevalence and risk factors for foot and limb lesions in 2948 piglets from 272 litters. One litter was selected per age category; 3–7 days, 8–14 days, 15–21 days and 22–28 days per farm. All piglets were examined for sole bruising, sole erosion, coronary band injuries, limb abrasions, alopecia, swollen limbs and swollen feet and scored from 0 to 3 based on relative size. Environmental parameters were recorded for each litter examined. A questionnaire was completed on management, health and performance factors for each farm. The overall prevalence of each lesion was calculated and multilevel mixed effect logistic regression models were used to elucidate risk factors. The prevalence (farm range) of lesions were: sole bruising = 61.5% (7–100%), sole erosion = 34.1% (0–100%), coronary band injuries = 11.3% (0–46%), limb abrasions = 55.7% (11–98%), alopecia = 24.8% (0–83%), swollen limbs = 2.4% (0–11%) and swollen feet = 4.4% (0–14%). Age was negatively associated with sole bruising (OR 0.42; CI 0.37, 0.50) and coronary band injury (OR 0.69; CI 0.60, 0.81) and positively associated with limb abrasions (OR 1.54; CI 1.12, 2.14). There was a reduced risk of sole bruising in piglets in pens with plastic slats with oval voids in the piglet area of the pen with a plastic solid area for piglets and metal slats under the crate (OR 0.32; CI 0.15, 0.70) compared with plastic stats throughout and a plastic solid area for piglets. There was an increased risk of sole erosion (OR 1.81; CI 1.07, 3.09) and foot and limb swellings (OR 1.90; CI 1.01, 3.57) in pigs in pens with metal slats only and a solid plastic area for piglets compared with plastic stats throughout and a solid plastic area for piglets. There was an increased risk of coronary band injury in pens with metal slats throughout and a metal solid area for piglets (OR 4.25; CI 1.96, 3.57) compared with plastic stats throughout and a plastic solid area for piglets. We conclude no single floor type was ideal for piglet foot and limb health with all floors influencing different lesions in different ways, however, the positive association between sole erosions, coronary band injury and foot and limb swellings and metal slats suggest that this floor type was most detrimental and most likely to be associated with joint infections that lead to severe health and welfare concerns.

A case of Staphylococcus aureus infection causing osteomyelitis in young turkey poults is described. Mortality during the first week after hatching was 12.6%. Poults showed leg weakness, inflammation of all four toes, swelling of feet and hock joints, and osteomyelitis of the proximal tibiotarsus. Staphylococcus aureus was isolated from exudate in the hock joints and footpads. Granulocytic infiltration and colonies of gram-positive coccoid bacteria compatible with S. aureus were found on microscopic examination of the lesions. Toe trimming after hatching is believed to have provided a portal of entry for S. aureus, which resulted in infection of the toes and spread along tendons to joints and bones of the leg. Neonatal staphylococcal osteomyelitis should be considered when recently placed turkey flocks experience increased mortality, especially if they develop severe swelling and inflammation of toes following trimming and have enlarged swollen feet, tendons, or joints.

Little is known about the symptom experience throughout the trajectory of recovery for patients after coronary artery bypass surgery (CABS). This study investigates the preoperative and postoperative symptoms experienced by younger (< 65 years) and older (= 65 years) patients (N= 102) who had undergone CABS. Reported preoperative symptoms were angina, shortness of breath, dizziness, and sweating. At 1 week post-CABS, symptoms were incisional pain, wound drainage, chest congestion, shortness of breath, dizziness, sweating, swollen feet, and loss of appetite; incisional pain and swollen feet were reported by a few patients at 6 weeks after CABS. The incidence and frequency of postoperative symptoms declined over time. There were several age-related differences in symptom reports prior to and at 1 and 6 weeks after the procedure. Such information can be used to plan the care of patients undergoing CABS, to prepare them for normal recovery, and to determine the need for symptom management by health care providers.

The heavy metal lead is an environmental toxic material that can induce pathophysiological changes in many organ systems. Previous studies have shown the effects of lead exposure on immune cells in different experimental animals, however, the mechanism of their influence on the immune system is unclear. We reported that in vivo lead exposure inhibits phagocytosis, nitric oxide release, induces DNA fragmentation suggesting the apoptotic death of the target cell. We have also presented evidence that inhibition of macrophage functional responses implicated alteration of humoral and cell mediated immunity. In vivo exposure to lead acetate alters the phagocytic capacity of splenic macrophages as evident from the reduction of phagocytic index of control from 19,792+/-1385.69 to 8893+/-893 in the treated group. The amount of nitric oxide released by the control cell 2.25+/-0.125 microM is also reduced to 1.9375+/-0.0625 microM upon in vivo lead treatment. Functional integrity of the target cell is also decreased after lead exposure as obtained from the percentage of DNA fragmentation. Control group shows 33.29+/-0.11% of fragmented DNA, which is enhanced to 42.43+/-0.725% following the lead treatment. A greater percentage of DNA fragmentation upon lead treatment probably indicating that the heavy metal induces apoptosis. The humoral immune response is also altered after lead exposure as indicated by the decrease of the antibody titre in control group from 1:2048 to 1:128 in the treated group. From the DTH reaction, it was observed that the mean diameter of swollen foot pad of control mice is 0.329+/-0.15 cm and that of lead treated mice is 0.274+/-0.056 cm. It can, therefore, be suggested that lead inhibits normal functional activities of splenic leukocytes, particularly phagocytosis and also affects the functional integrity of cells by inducing DNA fragmentation. The study may demonstrate the usefulness of investigation of humoral immune system and leukocyte functions as sensitive parameters in detecting the effects of lead toxicity.

1. William M. Stauffer, MD, MSPH, DTM&H* 2. Angela D. Siwek, MD† 3. Deepak Kamat, MD, PhD‡ 4. Erika Kempler-Meyer, MD§ 1. *Center for International Health & International Travel Clinic, Regions Hospital, Pediatric Emergency Medicine, University of Minnesota, Minneapolis, MN 2. †Department of Pediatrics, University of Minnesota, Minneapolis, MN 3. ‡Director, Institute of Medical Education, Children’s Hospital of Michigan, Detroit, MI 4. §Doernbecher Children’s Hospital, Oregon Health & Science University, Portland, OR A 14-year-old boy presents with rash, fever, chills, and difficulty walking due to right hip pain. The patient had been healthy until 2 weeks ago when he developed muscle pain, headaches, sore throat, cough, and decreased appetite. Ten days ago, he was started on a course of azithromycin for “bronchitis.” Rapid streptococcal antigen and mononucleosis antibody tests were negative at that time. Three days later, the antibiotic regimen was changed to a second-generation cephalosporin for a presumed urinary tract infection after red blood cells appeared in the urine. Urine nitrite and leukocyte esterase were negative. Three days later (and 4 days prior to presentation), the patient developed right shoulder pain, fever, “sores” in his mouth, blood-streaked sputum, frequent episodes of nosebleeding, “pain with deep breaths,” a rash on his lower legs, and sore and swollen feet. At that time, his white blood cell (WBC) count was 5.2×103/mcL (5.2×109/L), with a normal differential count; findings on chest radiograph were normal. The patient currently has difficulty walking due to right hip pain. He denies any history of exposure to infectious diseases. The boy’s past medical history is remarkable for a ventricular septal defect (VSD) discovered during early infancy. He has received prophylaxis against bacterial endocarditis before every dental procedure. His growth and development are normal, and he has no allergies to food or medicine. His immunizations are up to date, and current medications include cefprozil, acetaminophen with codeine, and ibuprofen. He is in eighth grade, lives with his parents, and has no siblings. He denies sexual activity and use of tobacco, alcohol, or drugs. On physical examination, the patient appears pale and weak. His temperature is 101.3°F (38.5°C), blood pressure is 135/78 mm Hg, respiratory rate is 22 breaths/min, and heart rate is 104 beats/min. Raised, red-purple, nonblanching …

This review describes a decision pathway for the conservative management of foot problems in persons with diabetes mellitus. The decision pathway was developed by the Louisiana State University Health Sciences Center Diabetes Foot Program as part of the Statewide Diabetes Disease Management Initiative to standardize foot care in a medically underserved population. The pathway describes the prevention and/or management of foot problems through 5 clinical subpathways: injury prevention, warm swollen foot, ulcer, osteomyelitis, and remodeling. The pathway provides physiatrists and other rehabilitation practitioners with a framework to evaluate and manage neuropathic foot problems in a multidisciplinary setting.

We studied the clinical course of 5 patients (2 males and 3 females) with rheumatoid arthritis (RA) whose first symptoms were foot or ankle pain. To assess the changes in swollen feet and ankles, we examined them by fat-suppressed, gadolinium-enhanced magnetic resonance imaging (MRI). In each patient, the synovium or Achilles tendon sheath showed high signal intensity.It is difficult to diagnose early stage RA in patients complaining of pain and swelling of the foot or ankle.Fat-suppressed, gadolinium-enhanced MRI however proved useful for detecting tenosynovitis in the foot or ankle and for early diagnosis of RA.

Water is a skin irritant which deserves attention because of its ubiquity. During the Vietnam war, soldiers suffered from painful swollen feet, so-called tropical immersion foot. In occupational dermatology, the importance of water as a skin irritant is especially appreciated. The irritancy of water has been demonstrated by occlusion experiments; occlusion with either closed chambers or water-soaked patches has been shown to produce clinical and histopathological inflammation. Functional damage, as revealed by increased transepidermal water loss, has also been shown. Repeated water exposure without occlusion caused an increase in blood flow on irritated skin; however, clinical evaluation did not show a difference in dryness or scaling. Several mechanisms such as osmolarity, pH, hardness and temperature might account for the irritancy of water. Extraction or dilution of natural moisturizing factors in the stratum corneum is another possible explanation. Occlusion per se also changes the physiology of skin and may trigger the activation of potentially active substances. However, much remains to be done to clarify the risk factors and mechanisms of water-induced irritation.

Although numerous transgenic mouse models for atherosclerosis have been developed recently, little is known about their response to hypolipidaemic or anti-atherosclerotic agents. We investigated the effect of the known hypocholesterolaemic and anti-atherosclerotic drug probucol on serum lipids, lipoproteins and atherosclerosis in fat-fed low density lipoprotein (LDL) receptor deficient mice. Probucol at doses of 0.2 and 1% in the diet which are similar to those used in the mouse by other investigators reduced serum cholesterol by 26 and 37%, respectively. Probucol also reduced serum triglyceride levels by 33 and 47% at doses of 0.2 and 1%, respectively. The decrease in serum cholesterol and triglycerides was mainly due to a decrease of these lipids in VLDL and or chylomicrons. Despite these potentially beneficial changes in serum lipids atherosclerotic lesion areas in the aortic root were unchanged in the probucol treated mice. After 12 weeks treatment most of the mice receiving probucol had swollen feet and tails due to oedema. Histological examination of the base of the hearts from the probucol treated mice revealed lipid droplets within the reticuloendothelial and other interstitial cells. There was also an interstitial subacute inflammatory cell infiltration associated with the lipid deposition. The oedema induced by probucol could be the result of cardiac insufficiency due to interstitial lipidosis and inflammation in the base of the heart together with the extensive atherosclerotic lesions in the aortic sinus.