Diabetes in Patients from the Indian Subcontinent

(Great Britain— The Practitioner, May 2001, p. 445.) Insulin resistance and type 2 diabetes are highly prevalent in people from the Indian subcontinent who reside in Western countries. Of Indo-Asian people who have immigrated to the United Kingdom, it is estimated that about 10 percent have diabetes by age 45 years and 20 percent by age 60 years. Compared with white patients who have diabetes, Indo-Asian patients have rapid transition from impaired glucose tolerance to overt diabetes, presentation of type 2 diabetes at a younger age, less success with oral and combined antiglycemic therapy, earlier initiation of insulin therapy, and higher dosage requirements (units per kg per 24 hours) of insulin. These patients also differ from Western populations in their vulnerability to the complications of diabetes. Renal disease is particularly common among Indo-Asian patients, but neuropathy and amputation risk are reduced compared with other patients who have diabetes. Cataracts are also more common in Indo-Asian patients with diabetes, but other eye complications appear to occur at about the same rate as in white patients. Having diabetes doubles the risk of myocardial infarction and this may be exacerbated by obesity, hypertension, and other risk factors. Effective management of diabetes in Indo-Asian patients requires significant patient and community education to develop practical methods of exercise, weight control, and compliance with medications. Every effort should be made to include family members in patient education. Management must involve attention to the use of herbs and unconventional medicine, periods of fasting, and arrangements for accommodating travel.

Diabetic Dermopathy

(Canada— Canadian Family Physician, April 2001, p. 725.) Men with diabetes commonly develop “shin spots” (diabetic dermopathy), which appear as irregularly shaped, light brown patches of skin with depressed surfaces. Patients may attribute the lesions to trauma and, in some patients, the initial lesions are erythematous and scaly; however, shin spots are most likely to be related to the underlying diabetes. Similar lesions can occur in nondia-betic patients with circulatory compromise and are probably related to the degree of microangiography. Histologic examination of the lesions shows thickened dermal arterioles and capillaries with deposition of fibrillar material. No effective treatment exists, but lesions tend to remit and recur spontaneously with new “crops” of lesions arising over time.

Managing Minor Wounds in Children

(Canada— Canadian Family Physician, April 2001, p. 769.) Although minor wounds are common in children, few controlled trials have addressed the optimal management of such wounds. A recent review concludes that cleansing and debridement are the most important initial steps. Because antiseptic and other agents may cause tissue damage, sterile saline is the best agent to use for irrigation. Most wounds should be covered with a dry, nonadherent dressing for the first 24 to 48 hours after cleaning to prevent contamination and permit epithelialization. Systemic antibiotics are indicated only in contaminated wounds and when there has been a lapse of more than three hours since the injury, but they also may be considered in immuno-compromised patients. The efficacy of topical antibiotics has not been adequately investigated. Skin tapes are good for closure of low-tension wounds once bleeding has been contained, the wound is clean, and the surrounding skin is dry. Skin adhesives have become very popular for wound management in children, but are not suitable for lesions on the lips, mucosal surfaces, or areas of the hands and feet that receive heavy use.

Tibialis Posterior Tendon Insufficiency

(Great Britain— The Practitioner, May 2001, p. 452.) Tibialis posterior tendon insufficiency is a common but under-recognized cause of leg and foot pain, especially in elderly women. Up to 8 percent of female residents of nursing homes have this condition. Patients complain of an ache behind the medial malleolus that is exacerbated by walking and by attempting to stand on tiptoe while standing on one leg (the single heel-raise test). Slight swelling of the ankle may be present. Treatment involves the use of insoles plus anti-inflammatory medication. If the condition progresses, the weakened tendon can permanently stretch or rupture, resulting in flat foot, a valgus heel, and an abducted forefoot. At this stage, patients have difficulty standing on tiptoe on both legs. Early recognition of this condition is very important because surgery is usually required for more advanced cases.