The diabetic foot : cavoid or not?

Diabetic peripheral neuropathy has been found to lead to a cavoid-type foot with a high arch and prominent metatarsal heads developing in some cases. In this study, it was discovered that patients with advanced peripheral neuropathy may develop a severely pronated foot type, which may result in increased risk of shear and pressure under the hallux (Nubé et al, 2006). This emphasises the importance of biomechanical assessment in patients with diabetic peripheral neuropathy. Furthermore, this study highlights that when treating patients with diabetic peripheral neuropathy, clinicians must assess patients in weight-bearing and nonweight-bearing positions to aid in decision-making regarding footwear and treatment.peer-reviewe

Atypical cavitary lung lesions : a case report and review of radiologic manifestations

A 68-year-old woman presented to our emergency department with a 15 day history of epigastric discomfort radiating to the back. She had undergone a hysterectomy with bilateral salpingo-oophorectomy ten years before, for a FIGO stage 1 endometrioid adenocarcinoma. While abdominal examination was unremarkable, her liver function tests showed a cholestatic picture. An ultrasound scan of the abdomen revealed several gallstones as to the cause of this pain. Incidentally on chest radiograph, several lung lesions were noted bilaterally (Figure 1). On further questioning, the lady admitted to a one-year history of asthma with cough during the day and exertional dyspnoea. Inhaled corticosteroids prescribed for her ‘asthma’ proved to be ineffective. She was a non-smoker. She denied other respiratory symptoms, night sweats, chills, rigors or weight loss. She managed a good appetite and a good exercise tolerance for her age. There was no history of old TB, recurrent chest infections, recent travel or the presence of any mould at home.peer-reviewe

A rare case of pulmonary alveolar microlithiasis

A 47-year-old asymptomatic man with no significant family history was referred to our faculty because of an abnormal chest X-ray (CXR). The CXR, similar to his CXR 10 years previously, showed bilaterally increased interstitial markings suggestive of pulmonary fibrosis. High-resolution CT (HRCT) showed multiple bilateral branching calcifications, mostly in the lung bases (figures 1 and 2), with ground-glass opacities in the lingula, and no enlarged mediastinal lymph nodes. A repeat HRCT after 4 months remained similar. After discussion at a multidisciplinary team meeting, a diagnosis of pulmonary alveolar microlithiasis (PAM) was reached.peer-reviewe

Atherosclerotic Cardiovascular Disease

Peripheral Arterial Disease [PAD] is a significant public-health problem. It has been estimated that only approximately 25% of patients living with PAD receive treatment since most people are not aware that they are living with this condition. Despite the lack of symptoms such patients still share the same prognosis as symptomatic patients showing a risk profile comparable to patients with symptomatic lower extremity PAD or with chronic heart disease. It is imperative that this condition is diagnosed as early as possible in order to avoid devastating further complications including atherosclerotic cardiovascular complications. The aim of this chapter is to report studies evaluating the occurrence and diagnosis of peripheral arterial disease using different non-invasive modalities in specific diverse populations namely patients living with Type 2 diabetes mellitus, smokers and non-smokers. A further aim is to compare these modalities in order to determine whether a correlation between them exists. Although large clinical randomized studies on arterial disease are limited, this chapter provides evidence from recently published studies on the importance of using different non-invasive modalities when assessing patients with arterial disease and when results do not concur, further extensive evaluations should be performed. These findings reported in this chapter have important implications for both clinical practice and future research. The findings from our present studies suggest that use of ABPI alone in patients with Type 2 diabetes mellitus or smokers is likely to yield high false negative results. We recommend that peripheral arterial perfusion in patients with diabetes or smokers should be assessed utilizing ABPIs, Doppler waveforms and toe pressures and toe brachial pressure indices. When the findings from these modalities do not correlate these patients should be monitored or further evaluated accordingly. One possible alternative when inconsistencies occur between modalities could include further physiological testing including duplex scanning, high resolution CT and magnetic resonance imaging to establish whether PAD is actually present.peer-reviewe

The influence of blood flow on skin surface temperature in the lower-limbs : a research article

Background: Peripheral arterial disease (PAD) tends to be associated with lower foot skin temperatures, however it is dubious whether there is enough evidence to support this claim. Skin temperature monitoring, and its ability to be an independent diagnostic modality for PAD, particularly in diabetes, has gained remarkable interest in recent years, but its ability to detect and diagnose PAD is not yet clear.Methods: A systematic literature search was conducted in: Academic Search Ultimate, CINAHL, Cochrane Library, LISTA, and MEDLINE Complete until February 2022.Results: A total of nine studies were eligible for review. For the purpose of this review, the inclusion studies were grouped according to the type of investigation analysed: those investigating lower-limb thermal patterns in various populations and those investigating comparisons between various outcome measures to assess blood flow to the feet, including skin temperature measurement. Findings suggest that higher foot skin temperatures were found in PAD patients with Diabetes Mellitus (DM). Foot skin temperature measurements also showed a clear correlation with blood flow to the feet, evaluated by ABI.Conclusions: Variations in foot skin temperature play an important role in the diagnosis of PAD. Current evidence shows that the influence of blood flow on surface skin temperature is complex. The interpretation of thermography as a diagnostic modality for PAD and its severity needs to be considered within the context of the overall medical condition of the individual patient.peer-reviewe

Inter-rater reliability of Doppler waveform analysis amongst health care professionals

Hand-held Doppler ultrasound examinations of pedal arteries is today one of the most frequently used non-invasive assessment methods employed by health care professionals for the diagnosis and ongoing monitoring of people who are at risk of developing, or are living with, peripheral arterial disease. The aim of this study was to determine the inter-rater reliability of the interpretation of this testing method. An inter-rater reliability study was conducted amongst five experienced qualified podiatrists at a University of Malta Research Laboratory.peer-reviewe

The effects of skin temperature changes on the integrity of skin tissue : a systematic review

OBJECTIVE To determine whether changes in skin temperature can affect the integrity of skin.METHODOLOGY The authors conducted a systematic literature search as per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. They searched the CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, MEDLINE Complete, Academic Search Ultimate, and HyDi databases for articles examining the effects of skin temperature on skin integrity published through April 2020. Two independent reviewers scored the methodologic quality of the 13 included studies.RESULTS Only 11 studies were included in the qualitative analysis, as the other two articles had a critical risk of bias. There is strong evidence to indicate that an increase in skin temperature leads to changes in skin structure and function. However, ulcer formation was more affected by intrinsic and extrinsic factors, rather than by temperature alone.CONCLUSION Further high-quality randomized controlled trials are required to investigate the direct effect of skin temperature on ulceration.peer-reviewe

Medical students’ knowledge of doctors’ working conditions in Malta

Aims: To determine the level of knowledge of medical students at different stages of the medical degree course regarding working conditions of junior doctors in Malta and postgraduate training. Methods: All students from the Malta Medical School were asked to fill in an online questionnaire containing questions about being a junior doctor in Malta. Results: A sample of 173 students was collected from the 5 years of Maltese medical school. 80⋅35% noted passion for the science as the reason for their chosen career path. Other notable choices included diversity in work (48⋅55%), pay (20⋅23%), job security (35⋅26%), notoriety (17⋅34%) and altruism (16⋅18%), lifestyle (14⋅45%), colleagues/friends (10⋅4%). When asked from where they got their knowledge about the career, responders noted doctors (53⋅18%), friends (43⋅93%), family (42⋅77%) and media (34⋅68%). 36⋅99% believe a junior doctor works 50–60 hours/week and 30⋅06% believe they work 60–70 hours/week. On being asked how much a junior doctor in Malta was paid; 33⋅53% responded 1500–2000 euros/month; 31⋅79% answered 1000–1500 euros/month and 26⋅59% answered 2000–2500 euros/month. 10⋅98% of students believe that postgraduate training lasts 1–2 years. 31⋅21% of individuals believed post-graduate training lasts between 6–8 years and 22⋅54% believe it lasts >8 years. 83⋅82% of students said that there is not enough awareness about the lifestyle and specifics of a career in the medical field and most respondents noted younger senior trainees (40⋅46%) or junior doctors (33⋅53%) as the ideal sources of this information. 35⋅84% of the students believe that this information should be given before entering medical school with another 34⋅68% believing it should come within the first 2 years of medical school. Conclusions: This study shows that a significant proportion of students don’t know important specifics about the career and lifestyle awaiting them once they graduate highlighting the importance of some form of education on these topics.peer-reviewe

Thermographic patterns of the upper and lower limbs : baseline data

This study was supported by an internal University of Malta Research Grant PODRP01-1. The study sponsor had no involvement in the execution and analysis of this study.To collect normative baseline data and identify any significant differences between hand and foot thermographic distribution patterns in a healthy adult population. Design. A single-centre, randomized, prospective study. Methods. Thermographic data was acquired using a FLIR camera for the data acquisition of both plantar and dorsal aspects of the feet, volar aspects of the hands, and anterior aspects of the lower limbs under controlled climate conditions. Results. There is general symmetry in skin temperature between the same regions in contralateral limbs, in terms of both magnitude and pattern. There was also minimal intersubject temperature variation with a consistent temperature pattern in toes and fingers. The thumb is the warmest digit with the temperature falling gradually between the 2nd and the 5th fingers. The big toe and the 5th toe are the warmest digits with the 2nd to the 4th toes being cooler. Conclusion. Measurement of skin temperature of the limbs using a thermal camera is feasible and reproducible. Temperature patterns in fingers and toes are consistent with similar temperatures in contralateral limbs in healthy subjects. This study provides the basis for further research to assess the clinical usefulness of thermography in the diagnosis of vascular insufficiency.peer-reviewe

Thermographic patterns of the upper and lower limbs: baseline data.

Objectives. To collect normative baseline data and identify any significant differences between hand and foot thermographic distribution patterns in a healthy adult population. Design. A single-centre, randomized, prospective study. Methods. Thermographic data was acquired using a FLIR camera for the data acquisition of both plantar and dorsal aspects of the feet, volar aspects of the hands, and anterior aspects of the lower limbs under controlled climate conditions. Results. There is general symmetry in skin temperature between the same regions in contralateral limbs, in terms of both magnitude and pattern. There was also minimal intersubject temperature variation with a consistent temperature pattern in toes and fingers. The thumb is the warmest digit with the temperature falling gradually between the 2nd and the 5th fingers. The big toe and the 5th toe are the warmest digits with the 2nd to the 4th toes being cooler. Conclusion. Measurement of skin temperature of the limbs using a thermal camera is feasible and reproducible. Temperature patterns in fingers and toes are consistent with similar temperatures in contralateral limbs in healthy subjects. This study provides the basis for further research to assess the clinical usefulness of thermography in the diagnosis of vascular insufficiency