A team of experts in the field of reconstructive surgery for leprosy-affected people was identified. Using the Delphi method, an exercise was undertaken to ascertain whether a consensus on essential criteria and indicators for Tibialis Posterior Transfer (TPT) could be reached among the team. This paper describes the Delphi Exercise, giving results at each stage of consensus development. The final outcome was that essential criteria, including contraindications for surgery, pre- and post- operative assessments and expected outcomes, were agreed. The criteria are presented with recommendations.
Evidence-Based Practice does head the "hierarchy of evidence" upon which developments in clinical practice should be based. There are, however, situations where evidence is either unavailable, unclear, or results between studies are at variance. Consensus is a reliable contingency, and approaches to reaching consensus have acceptable construct validity (Nominal Group Technique, Delphi, and Consensus Development Conference).Consensus is reached when: (i) the method of investigation tightly controls communication to reduce the obscuring "noise" of divergent discussion; (ii) statistical measures of agreement or dissent screen out the bias that would otherwise be produced by the dictate of vociferous minorities or coalitions that may represent vested interests; (iii) all participants contribute equally to the product of the investigation.
colleagues report data from a long term seroprevalence study to evaluate the association of HIV infection and leprosy among patients seen at their clinic in Agra, India (). In the period from 1989 to 1993, 5 of 4025 leprosy patients (0.12%) were HIV positive, whereas in the period from 1999 to 2004, 5 of 2125 (0.38%) were HIV positive. This increase is not significant despite the apparent major increase in HIV infections among subjects screened at the same clinic. In 2004, among 387 persons who were “voluntarily” screened at their request, the HIV prevalence was 40.3%, and it was 43.4% among 106 persons referred for screening (). From this it appears that the prevalence of HIV infection has not increased in patients with leprosy despite evidence of a substantial HIV epidemic among the population served by the clinic. So why hasn’t the HIV prevalence increased in a comparable fashion among leprosy patients? Are they resistant or immune to HIV infection? In the past few years some individuals have been identified who are immune to HIV infection despite repeated exposure to the virus. One such group are persons who are homozygous for a 32 base pair deletion in the CCR5 gene that renders them completely resistant to infection with HIV-1 viruses that require attachment to the CCR5 co-receptor to enter the target CD4+ lymphocyte and replicate ( ). Individuals who are heterozygous for the CCR5 deletion are partially resistant to HIV-1 infection and progress more slowly after infection (). Also persons with genetic mutations in the CCR2 and SDF-1 genes progress more slowly after acquiring an HIV-1 infection (). These critically important discoveries have had major ramifications in our understanding of the biology of HIV-1 infections in humans. Another group of individuals who are partially resistant to HIV-1 infection are those who are heterozygous for HLA alleles (). Also, subjects who are heterozygous for HLA-B or DR alleles when compared to their HIV-1 positive sex partner appear to be less readily infected than persons who are homozygous with their partner for these genetic loci. However, this resistance to transmission is only relative, not absolute like homozygozity for the 32 base pair deletion in the CCR5 receptor ( ). In addition, some patients appear to acquire relative resistance to HIV infection or progression of HIV. Persons who are coinfected with GB virus C, a retrovirus that also infects macrophages and lymphocytes, appear to have slower progression of HIV, and lower HIV viral loads during their GB virus viremia, which is often chronic ( 19, ). Whether or not they are resistant to HIV-1 transmission, as well, has not been determined. Other infections, which have been reported to slow or delay the progression of HIV, and decrease the HIV-1 viral load in infected individuals, include scrub typhus (O. tsutsugamushi), Dengue, and measles ( 17, ). The proposed mechanism for the negative interaction between these infections and HIV-1 also involve the CCR5 coreceptor, which is also the receptor for the Beta chemokines, MIP-1 alpha, MIP-1 beta, SDF-1 and RANTES. These chemokines regulate the immune response and attach to receptors on CD4+ lymphocytes blocking the ability of HIV-1 to attach to and enter CD4+ lymphocytes to produce more viral copies. Could M. leprae infection also interfere with HIV-1 attachment and entry into CD4+ lymphocytes by attaching to the chemokine receptor? This seems very doubtful for a number of reasons. Whereas untreated patients with polar or borderline lepromatous COMMENTARY
Leprosy prevalence has reportedly declined all over the world, but six countries, including India, are still endemic for the disease. India alone contributes about 60% to the world's leprosy case load, with the major share from its northern states. The present study done in Agra district was based on a randomly-selected sample of over 10% of the population, spread across 300 villages and 16 urban units of the district. A house-to-house survey was conducted from July 2001 to July 2003 in all the 26 selected panchayats (300 villages), all the 11 block headquarters which have an urban component, and 5 (out of 20) localities in Agra city.A population of 361,321 persons was examined for leprosy. A total of 592 leprosy cases [new and cases yet to complete a full course of multi-drug therapy(M.D.T.)] were found, giving a prevalence rate of 16.4/10,000 population. Although the overall prevalence was found to be similar in both rural and urban areas, there were pockets with high prevalence. More cases were detected in the eastern side of Agra (31.4/10,000 in Fatehabad and 28.5/10,000 in Bah Tahsils). Overall, the multibacillary (MB) leprosy rate was 22.3% and the child leprosy rate 8.4%.Of the 592 cases, 523 (88.3%) were new untreated cases, giving a new case detection rate of 14.5/10,000. The MB rate was 17% (89/523), and the child leprosy rate was 8.4% (44/523) among the new patients. The grade 2 deformity rate was found to be 4.8% (25/523) among these cases. The duration of disease among new cases was 32.3 months as compared to 48.1 months among prevalent (registered) cases (i.e., patients who had been diagnosed earlier and had yet to complete a full course of M.D.T.). The large number of undetected cases found in this survey suggests the need for continued intensive health education campaigns and case detection activities.This study highlights the fact that a large number of leprosy cases go undetected in the present integrated system which is mainly based on voluntary reporting of cases.
feet on each point, three score is given to that site for face and foot. Four score is given to that site in hand as four filaments are used for the pa1mar surface: two for not feeling that fi1ament in face and foot and so forth. Thus, tota1 loss of sensation at a point will be scored as zero for the face, hand, and feet; i.e., since there are 3 testing points for trigemina1, the maximum sensory loss per this nerve is scored, as O + O + O, which is 0. Norma1 sensation will be scored as 3 + 3 + 3 = 9. The maximum score for norma1 sensation of the following nerves are stated below and these are indicated as denorninators in the first Table. -Ramaswamy Premkumar, PhD., Pichaimuthu Rajan, BOT, Ebenezer Daniel, MS, MPH
The clinical and histologic experience with 30 patients who had Lucio's phenomenon, and pure and primitive diffuse lepromatosis (Latapi's lepromatosis) has been reviewed. The unanticipated clinical findings were a male to female ratio of nearly 1:1, a 21 month median time of onset of erythema nodosum leprosum (Type 2 reaction) after starting antibacterial treatment, and an absence of a stocking-glove pattern of anesthesia in 7 patients. The only unanticipated histologic finding was a lepromatous-granulomatous vasculitis, occurring in comparatively large vessels, or in vessels made large by pathologic changes, located near the dermal-subcutaneous interface. This finding was present in 6 of the 22 patients with histologic material available for review. In 2 of these 6 this vasculitis was identified before the onset of Lucio's phenomenon. With one conspicuous exception, the onset of treatment with a microbicidal agent was associated with a cessation of new lesions of Lucio's phenomenon within one week. Long-term morbidity, other than Type 2 reaction, was found in 22 of the 25 patients followed for more than 1.3 years. Usually this was the consequence of Latapi's lepromatosis, specifically venous insufficiency and/or loss of protective sensation, and only rarely from Lucio's phenomenon, specifically scar formation. Briefly summarized are the seven patients who had had a skin biopsy before the onset of Lucio's phenomenon, as well as the two patients who were considered to be atypical. Criteria for the diagnosis of Latapi's lepromatosis, in the absence of Lucio's phenomenon, are also considered.
In Iran, there have been a few cases of leprosy in several provinces, however, native physicians believe that leprosy is not present primarily in an Isfahan endemic area. We performed an investigation either to approve or rule out this idea.We found 25 lepra patients who were registered and followed in Isfahan Leprosy Health Registeration Center, all of whom were infected in other regions and migrated to Isfahan city at a later time.Final analysis proved that there are not any cases of leprosy by itself in Isfahan as an endemic region at the time of this study (1975 to 2002).
BACKGROUND:Leprosy is a chronic infectious disease that is considered to be declining, though it still remains prevalent in many parts of the world. A study was made to explore the health and socioeconomic factors that most influenced the trend of the disease in a typical Mediterranean country.MATERIALS AND METHODS:An ecological study was conducted, investigating possible social, economic and health factors related to the evolution of leprosy incidence. The time period considered was 50 years--the second half of the twentieth century in Spain.RESULTS:The variables showing the strongest correlation to evolution of the incidence of the disease were employment, the number of physicians, and the gross domestic product (GDP), with negative coefficients--while tuberculosis showed a positive coefficient. However, the GDP showed the highest coefficient (0.5). The model that best explained the evolution of leprosy over the last 50 years comprised a 6-year lag period between the socioeconomic factors and the incidence of leprosy--explaining 57% of the data obtained. The annual decrease in leprosy incidence was 1.6%.CONCLUSIONS:Socioeconomic development, assessed in terms of the GDP, was the most important factor in explaining the evolution of leprosy incidence.
