Association of Foot Symptoms With Decreased Time to All-Cause Mortality: The Johnston County Osteoarthritis Project.

OBJECTIVE: Adults with foot symptoms (ie, pain, aching, or stiffness) may be at increased risk of reduced time to all-cause mortality. The purpose of this study was to evaluate whether foot symptoms are independently associated with all-cause mortality in older adults. METHODS: We analyzed longitudinal data from 2613 participants from the Johnston County Osteoarthritis Project, a longitudinal population-based cohort of adults 45 years of age and older. Participants completed questionnaires at baseline to determine presence of foot symptoms and covariable status. Baseline walking speed was measured via an 8-foot walk test. To examine the association of foot symptoms with time to mortality, hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox regression models, adjusted for potential confounders. RESULTS: We observed 813 deaths over 4 to 14.5 years of follow-up. At baseline, 37% of participants had foot symptoms, mean age was 63 years, mean body mass index was approximately 31 kg/m2 , 65% were women, and 33% were Black. Moderate to severe foot symptoms were associated with reduced time to mortality after adjustment for demographics, comorbidities, physical activity, and knee and hip symptoms (HR = 1.30, 95% CI 1.09-1.54). Importantly, this association was not modified by walking speed or diabetes. CONCLUSION: Individuals with foot symptoms had an increased hazard of all-cause mortality compared with those with no foot symptoms. These effects were independent of key confounders and were not moderated by walking speed. Effective interventions to identify and manage at least moderate foot symptoms may reduce the risk of decreased time to mortality.

The Impact of Diabetes in Intermittent Claudication: A Prospective Cohort Study.

The aim of this study was to determine the lower-limb outcome in patients with intermittent claudication (IC) and to identify predictors for deterioration. This study employed a prospective observational cohort single-centre design. One hundred fifty patients with IC attending a vascular surgery unit for the first time were recruited. Lower limb perfusion was assessed utilising ankle brachial index (ABI) measures, toe-brachial index (TBI) measures, Doppler waveform analysis and the walking impairment questionnaire. Follow-up was conducted after 1 year and 2 years following recruitment to assess haemodynamic parameters, symptom severity and outcome. Recruited participants had a mean age of 69.7 (±9.3) years, BMI 27.8(±4.2) and 79.3% were men. Significant haemodynamic decline (decline in ABPI by ≥0.15 and/or decline in TBPI by ≥0.1) occurred in 50.6% of the cohort within 2 years of whom 23.3% developed chronic limb threatening ischaemia (CLTI) with rest pain and/or tissue loss. Baseline ABPI, ABPI ≤ 0.5, TBPI ≤ 0.39, infrapopliteal artery (IPA) disease and high Haemoglobin A1c were identified as significant predictors for deterioration to CLI. (P < .05, binomial logistic regression). Patients with IC are at a high risk of developing CLTI within 2 years. Risk of lower limb adverse events is tripled in patients with IPA disease, low ankle and toe pressures and poorly controlled diabetes. Early identification of those at high risk for early deterioration may justify a paradigm shift in the management of this subgroup.

Predicting Forefoot-Orthosis Interactions in Rheumatoid Arthritis Using Computational Modelling.

Foot orthoses are prescribed to reduce forefoot plantar pressures and pain in people with rheumatoid arthritis. Computational modelling can assess how the orthoses affect internal tissue stresses, but previous studies have focused on a single healthy individual. This study aimed to ascertain whether simplified forefoot models would produce differing biomechanical predictions at the orthotic interface between people with rheumatoid arthritis of varying severity, and in comparison to a healthy control. The forefoot models were developed from magnetic resonance data of 13 participants with rheumatoid arthritis and one healthy individual. Measurements of bony morphology and soft tissue thickness were taken to assess deformity. These were compared to model predictions (99th% shear strain and plantar pressure, max. pressure gradient, volume of soft tissue over 10% shear strain), alongside clinical data including body mass index and Leeds Foot Impact Scale-Impairment/Footwear score (LFIS-IF). The predicted pressure and shear strain for the healthy participant fell at the lower end of the rheumatoid models' range. Medial first metatarsal head curvature moderately correlated to all model predicted outcomes (0.529 < r < 0.574, 0.040 < p < 0.063). BMI strongly correlated to all model predictions except pressure gradients (0.600 < r < 0.652, p < 0.05). There were no apparent relationships between model predictions and instances of bursae, erosion and synovial hypertrophy or LFIS-IF score. The forefoot models produced differing biomechanical predictions between a healthy individual and participants with rheumatoid arthritis, and between individuals with rheumatoid arthritis. Models capable of predicting subject specific biomechanical orthotic interactions could be used in the future to inform more personalised devices to protect skin and soft tissue health. While the model results did not clearly correlate with all clinical measures, there was a wide range in model predictions and morphological measures across the participants. Thus, the need for assessment of foot orthoses across a population, rather than for one individual, is clear.

Prevalence of Foot Pain Across an International Consortium of Population-Based Cohorts.

OBJECTIVE: Despite the potential burden of foot pain, some of the most fundamental epidemiologic questions surrounding the foot remain poorly explored. The prevalence of foot pain has proven to be difficult to compare across existing studies due to variations in case definitions. The objective of this study was to investigate the prevalence of foot pain in several international population-based cohorts using original data and to explore differences in the case definitions used. METHODS: Foot pain variables were examined in 5 cohorts: the Chingford 1000 Women Study, the Johnston County Osteoarthritis Project, the Framingham Foot Study, the Clinical Assessment Study of the Foot, and the North West Adelaide Health Study. One question about foot pain was chosen from each cohort based on its similarity to the American College of Rheumatology pain question. RESULTS: The precise definition of foot pain varied between the cohorts. The prevalence of foot pain ranged from 13% to 36% and was lowest in the cohort in which the case definition specific to pain was used, compared to the 4 remaining cohorts in which a definition included components of pain, aching, or stiffness. Foot pain was generally more prevalent in women and obese individuals and generally increased with age, with the prevalence being much lower in younger participants (ages 20-44 years). CONCLUSION: Foot pain is common and is associated with female sex, older age, and obesity. Estimates of the prevalence of foot pain are likely to be affected by the case definition used. Therefore, in future population studies, the use of consistent measures of data collection must be considered.

Journal of Foot and Ankle Research: the first ten years.

Journal of Foot and Ankle Research (JFAR) was launched in July 2008 as the official research publication of the Society of Chiropodists and Podiatrists (UK) and the Australasian Podiatry Council, replacing both the British Journal of Podiatry and the Australasian Journal of Podiatric Medicine. This editorial celebrates the 10 year anniversary of the journal.

UK podiatrists' experiences of podiatry services for people living with arthritis: a qualitative investigation.

BACKGROUND: Provision of podiatry services, like other therapies in the UK, is an area that lacks guidance by the National Institute for Health and Care Excellence. Many individuals living with arthritis in the UK are not eligible to access NHS podiatry services. The primary aim of this investigation was to understand the views of podiatry clinicians on their experiences of referral, access, provision and treatment for foot problems for patients who have arthritis. METHODS: Focus groups were undertaken to explore, in-depth, individual views of podiatrists working in the UK to gain feedback on experiences of barriers and facilitators to referral, access, provision and treatment for foot problems for individuals living with arthritis. A purposive sampling strategy was adopted and two, semi-structured, focus group interviews conducted, involving 12 podiatrists from both NHS and independent sectors. To account for geographical variations one focus group took place in each of 2 predetermined 'zones' of the UK; Yorkshire and Hampshire. Thematic analysis was employed to identify key meanings and report patterns within the data. RESULTS: The key themes derived from the podiatry clinician focus groups suggest a variety of factors influencing demand for, and burden of, foot pain within the UK. Participants expressed frustration on having a service that accepts and treats patients according to their condition, rather than their complaint. Additionally, concern was conveyed over variations in the understanding of stakeholders' views of what podiatry is and what podiatrists aim to achieve for patients. CONCLUSION: Podiatrists interviewed believed that many individuals living with arthritis in the UK are not eligible to access NHS podiatry services and that this may be, in part, due to confusion over what is known about podiatry and access criteria. Essentially, podiatrists interviewed called for a timely renaissance of current systems, to newer models of care that meet the foot care needs of individual patients' circumstances and incorporate national multi-disciplinary guidance. Through this project, we have formulated key recommendations that are directed towards improving what other stakeholders (including GPs, commissioners and users of podiatry services) know about the effectiveness of podiatry and also to futureproof the profession of podiatry.

Population prevalence and distribution of ankle pain and symptomatic radiographic ankle osteoarthritis in community dwelling older adults: A systematic review and cross-sectional study.

OBJECTIVES: To identify by systematic review published prevalence estimates of radiographic ankle osteoarthritis (OA) and to subsequently estimate the prevalence of ankle pain and symptomatic, radiographic ankle OA within community-dwelling older adults from North Staffordshire, UK. METHODS: Electronic databases were searched using terms for ankle, osteoarthritis and radiography. Data regarding population, radiographic methods, definitions and prevalence estimates of ankle OA were extracted from papers meeting predetermined selection criteria. Adults aged ≥50 years and registered with four general practices in North Staffordshire were mailed a health questionnaire. Ankle pain in the previous month was determined using a foot and ankle pain manikin. Respondents reporting pain in or around the foot in the last 12 months were invited to attend a research clinic where weight-bearing, antero-posterior and lateral ankle radiographs were obtained and scored for OA using a standardised atlas. Prevalence estimates for ankle pain and symptomatic, radiographic ankle OA were calculated using multiple imputation and weighted logistic regression, and stratified by age, gender and socioeconomic status. RESULTS: Eighteen studies were included in the systematic review. The methods of radiographic classification of ankle OA were poorly reported and showed heterogeneity. No true general population prevalence estimates of radiographic ankle OA were found, estimates in select sporting and medical community-dwelling populations ranged from 0.0-97.1%. 5109 participants responded to the health survey questionnaire (adjusted response 56%). Radiographs were obtained in 557 participants. The prevalence of ankle pain was 11.7% (10.8,12.6) and symptomatic, radiographic ankle OA grade≥2 was 3.4% (2.3, 4.5) (grade≥1: 8.8% (7.9,9.8); grade = 3: 1.9% (1.0,2.7). Prevalence was higher in females, younger adults (50-64 years) and those with routine/manual occupations. CONCLUSION: No general population prevalence estimates of radiographic ankle OA were identified in the published literature. Our prevalence study found that ankle pain was common in community-dwelling older adults, whereas moderate to severe symptomatic, radiographic ankle OA occurred less frequently. Further investigations of the prevalence of ankle OA using more sensitive imaging modalities are warranted.

Experiences of mobility for people living with rheumatoid arthritis who are receiving biologic drug therapy: implications for podiatry services.

BACKGROUND: Despite significant advancements in new treatment modalities for rheumatoid arthritis with biological therapies, foot complications remain a disabling and common feature of the disease. In this study the aim was to explore and describe the personal experiences of people with rheumatoid arthritis in receipt of biologic treatments in a bid to understand the impact of this form of medication on their mobility. METHODS: An interpretative phenomenological analysis (IPA) was undertaken to explore in depth the individual experience of rheumatoid disease through personal accounts of the patient journey spanning both 'before' and 'after' the instigation of biologic therapy. A purposive sampling strategy was adopted and in-depth semi structured interviews used to facilitate rich, detailed interview data exploring the lived experiences of individuals undertaking biological therapy and the changes to mobility experienced as a result. Thematic analysis was employed with an IPA framework to identify key meanings, and report patterns within the data. RESULTS: Five people with rheumatoid arthritis participated in the study. The mean disease duration was 20.2 years (range: 6 -32) and all were being treated with biologic therapies. Four key themes emerged from the data: 1) Life before biologic treatment, depicted in accounts as a negative experience characterised by painful and disabling symptoms and feelings of hopelessness. 2) Life with biologic treatment, often experienced as a life changing transition, restoring function and mobility and offering renewed hope. 3) Sense of self, in which the impact of rheumatoid disease and the subsequent changes arising from biologic therapy reveal a profound impact on feelings of personal identity both pre and post biologic therapy; an effect of footwear on self-image emerges as a dominant sub theme; 4) Unmet footcare needs were evident in the patient narrative, where the unrelenting if diminished impact of foot pain on mobility was viewed in the context of problematic access to foot health services. CONCLUSION: Whilst the findings from this study mirror those within the existing literature, which report improvements in physical function related to biological therapy, foot problems clearly remained an unremitting feature of life for patients with rheumatoid disease, even when in receipt of biologics.

Associations between body mass index and foot joint pain in middle-aged and older women: a longitudinal population-based cohort study.

OBJECTIVE: To investigate the relationship between body mass index (BMI) and foot joint pain (FJP) over a 5-year period in a community-based cohort. METHODS: We examined a subset of women from the Chingford Women's Study, a community cohort followed up for 20 years. From a baseline of 1,003 female participants, we reviewed data from 639 women (64%) for whom complete data sets for FJP and BMI were obtained over a 5-year period between year 10 (Y10) and year 15 (Y15). Descriptive statistics, binary regression modeling, and odds ratios (ORs) were used to examine the longitudinal relationship between BMI and FJP. RESULTS: For Y10 and Y15, the median age was 61 years (interquartile range [IQR] 57-67) and 66 years (IQR 62-72), respectively, and the mean ± SD BMI was 26.7 ± 4.6 kg/m(2) and 27.2 ± 4.8 kg/m(2) , respectively. FJP prevalence was 21.6% at Y10 and 26.6% at Y15. Longitudinal analyses showed that both BMI and FJP increased significantly from Y10 to Y15 (P < 0.001). The odds of having FJP after a 5-year period increased by 4.9% for each BMI unit increase 5 years earlier (OR 1.049 [95% confidence interval (95% CI) 1.011-1.089], P = 0.012). This remained significant when adjusted for age, diabetes mellitus, and rheumatoid arthritis (OR 1.051 [95% CI 1.011-1.091], P = 0.012). CONCLUSION: This is the first large longitudinal cohort study demonstrating that, in middle-aged women, a high BMI precedes and is predictive of FJP independent of age. Evidence from our findings can be used to identify those individuals at risk of developing FJP.

The reliability of a novel magnetic resonance imaging-based tool for the evaluation of forefoot bursae in patients with rheumatoid arthritis: the FFB score.

OBJECTIVE: The aim of this study was to determine the reliability of an MRI-based score that evaluates forefoot bursae (FFBs) in patients with RA. METHODS: Items for inclusion, grading criteria and MRI sequences were determined iteratively. The score was evaluated in 30 patients with established RA. Reader agreement was evaluated using the percentage of exact/close agreement, Bland-Altman plots, kappa and intraclass correlation coefficient analyses. RESULTS: The FFB score assesses nine forefoot regions and contains four items: presence, shape, enhancement and magnetic resonance characteristics. The FFB score showed moderate to good intra- and interreader agreement (κ range = 0.5-0.9 and 0.47-0.87, respectively). CONCLUSION: The FFB score is adequately reliable in the evaluation of bursa-like lesions of the forefoot in patients with RA.

Guidelines for the management of people with foot health problems related to rheumatoid arthritis: a survey of their use in podiatry practice.

BACKGROUND: In the last decade there has been a significant expansion in the body of knowledge on the effects of rheumatoid arthritis (RA) on the foot and the management of these problems. Aligned with this has been the development of specialist clinical roles for podiatrists. However, despite being recommended by national guidelines, specialist podiatrists are scarce. In order to inform non-specialist podiatrists of the appropriate interventions for these foot problems, management guidelines have been developed and disseminated by a group of specialist podiatrists. The aim of this survey was to investigate the use of these guidelines in clinical practice. METHOD: Following ethical approval an online questionnaire survey was carried out. The questions were formulated from a focus group and comprised fixed response and open response questions. The survey underwent cognitive testing with two podiatrists before being finalised. An inductive approach using thematic analysis was used with the qualitative data. RESULTS: 245 questionnaires were completed (128-non-specialist working in the private sector, 101 non-specialists working in the NHS and 16 specialist podiatrists). Overall, 97% of the non-specialists (n = 222) had not heard of the guidelines. The non-specialists identified other influences on their management of people with RA, such as their undergraduate training and professional body branch meetings. Three main themes emerged from the qualitative data: (i) the benefits of the foot health management guidelines, (ii) the barriers to the use of guidelines generally and (iii) the features of useable clinical guidelines. CONCLUSIONS: This study has revealed some crucial information about podiatrists' level of engagement with the foot health management guidelines and the use of guidelines in general. Specifically, the non-specialist podiatrists were less likely to use the foot health management guidelines than the specialist podiatrists. The positive aspects were that for the specialist practitioners, the guidelines helped them to identify their professional development needs and for the few non-specialists that did use them, they enabled appropriate referral to the rheumatology team for foot health management. The barriers to their use included a lack of understanding of the risk associated with managing people with RA and that guidelines can be too long and detailed for use in clinical practice. Suggestions are made for improving the implementation of foot health guidelines.

Prognostic indicators of foot-related disability in patients with rheumatoid arthritis: results of a prospective three-year study.

OBJECTIVE: To determine the prevalence and natural history of foot-related disability in patients with rheumatoid arthritis (RA). A secondary aim was to identify explanatory variables, including forefoot bursae, that are either associated with or predictive of disabling foot complications in patients with RA. METHODS: A longitudinal prospective cohort study recruited patients with RA from a rheumatology outpatient clinic. Data were collected at baseline (n = 149) and 1-year (n = 120) and 3-year followup (n = 60). Patient-reported disabling foot complications were evaluated using the subscales of the Foot Impairment Score (FIS): foot impairment/footwear restriction (FIS(IF)) and activity limitation/participation restriction (FIS(AP)). Explanatory variables investigated included ultrasound-detectable forefoot pathology and markers of disease activity. RESULTS: Disabling foot complications were highly prevalent on all occasions. Changes in foot impairment and activity limitation were significantly associated with fluctuations in disease activity (Disease Activity Score in 28 joints using the erythrocyte sedimentation rate [DAS28-ESR]: r = 0.455, P < 0.0001; ESR: r = -0.356, P = 0.008 and DAS28-ESR: r = 0.433, P = 0.001; ESR: r = -0.439, P = 0.001 for the FIS(IF) and FIS(AP), respectively), and approaching a significant association with changes in forefoot bursae (FIS(IF): r = 0.255, P = 0.063 and FIS(AP): r = 0.255, P = 0.063). The presence of disease duration and forefoot bursae was a significant prognostic indicator of foot impairment (P = 0.009 and P = 0.012, respectively), explaining 16% of score variability in the final regression model. Disease duration, forefoot bursae, and erosion presence were identified as significant prognostic indicators of activity limitation (P = 0.002, P = 0.006, and P = 0.019, respectively), explaining 35% of score variability in the final regression model. CONCLUSION: Despite advances in disease management, patients report disability associated with foot problems. Forefoot bursae should be considered for targeted therapy.

Forefoot pathology in rheumatoid arthritis identified with ultrasound may not localise to areas of highest pressure: cohort observations at baseline and twelve months.

BACKGROUND: Plantar pressures are commonly used as clinical measures, especially to determine optimum foot orthotic design. In rheumatoid arthritis (RA) high plantar foot pressures have been linked to metatarsophalangeal (MTP) joint radiological erosion scores. However, the sensitivity of foot pressure measurement to soft tissue pathology within the foot is unknown. The aim of this study was to observe plantar foot pressures and forefoot soft tissue pathology in patients who have RA. METHODS: A total of 114 patients with established RA (1987 ACR criteria) and 50 healthy volunteers were assessed at baseline. All RA participants returned for reassessment at twelve months. Interface foot-shoe plantar pressures were recorded using an F-Scan® system. The presence of forefoot soft tissue pathology was assessed using a DIASUS musculoskeletal ultrasound (US) system. Chi-square analyses and independent t-tests were used to determine statistical differences between baseline and twelve months. Pearson's correlation coefficient was used to determine interrelationships between soft tissue pathology and foot pressures. RESULTS: At baseline, RA patients had a significantly higher peak foot pressures compared to healthy participants and peak pressures were located in the medial aspect of the forefoot in both groups. In contrast, RA participants had US detectable soft tissue pathology in the lateral aspect of the forefoot. Analysis of person specific data suggests that there are considerable variations over time with more than half the RA cohort having unstable presence of US detectable forefoot soft tissue pathology. Findings also indicated that, over time, changes in US detectable soft tissue pathology are out of phase with changes in foot-shoe interface pressures both temporally and spatially. CONCLUSIONS: We found that US detectable forefoot soft tissue pathology may be unrelated to peak forefoot pressures and suggest that patients with RA may biomechanically adapt to soft tissue forefoot pathology. In addition, we have observed that, in patients with RA, interface foot-shoe pressures and the presence of US detectable forefoot pathology may vary substantially over time. This has implications for clinical strategies that aim to offload peak plantar pressures.

Assessment of the natural history of forefoot bursae using ultrasonography in patients with rheumatoid arthritis: a twelve-month investigation.

OBJECTIVE: To determine the natural history and clinical significance of forefoot bursae over a 12-month period in patients with rheumatoid arthritis (RA). METHODS: Patients with RA (n=149) attending rheumatology outpatient clinics were assessed at baseline. A total of 120 participants, mean±SD age 60.7±12.1 years and mean±SD disease duration 12.99±10.4 years, completed the 12-month followup (98 women, 22 men, 93 rheumatoid factor positive, 24 rheumatoid factor negative, and 3 unknown). Musculoskeletal ultrasound (US) was used to identify forefoot bursae in all of the participants. Clinical markers of disease activity (well-being visual analog scale [VAS], erythrocyte sedimentation rate [ESR], C-reactive protein [CRP] level, and Disease Activity Score in 28 joints [DAS28]) and foot symptoms on the Leeds Foot Impact Scale (LFIS) Questionnaire were recorded on both occasions. RESULTS: Presence of US-detectable forefoot bursae was identified in 93.3% of returnee (n=120) participants (individual mean 3.7, range 0-11) at baseline. Significant associations were identified between bursae presence and patient-reported foot impact for impairment/footwear (LFISIF ; baseline: r=0.226, P=0.013 and 12 months: r=0.236, P=0.009) and activity limitation/participation restriction (LFISAP; baseline: r=0.254, P=0.005 and 12 months: r=0.235, P=0.010). After 12 months, 42.5% of participants had an increase in the number of US-detectable forefoot bursae and 45% of participants had a decrease. Changes in bursae number significantly correlated with changes in LFISIF (r=0.216, P=0.018) and LFISAP (r=0.193, P=0.036). No significant associations were identified between changes in bursae and changes in global well-being VAS, ESR, CRP level, or DAS28. CONCLUSION: The findings of this study suggest that forefoot bursae may regress or hypertrophy over time in patients with RA, and that these changes may be associated with self-reported foot impairment and activity restriction.

Improvement in symptoms and signs in the forefoot of patients with rheumatoid arthritis treated with anti-TNF therapy.

BACKGROUND: Inhibition of tumour necrosis factor (TNF) is an effective way of reducing synovitis and preventing joint damage in rheumatoid arthritis (RA), yet very little is known about its specific effect on foot pain and disability. The aim of this study was to evaluate whether anti-TNF therapy alters the presence of forefoot pathology and/or reduces foot pain and disability. METHODS: Consecutive RA patients starting anti-TNF therapy (infliximab, etanercept, adalimumab) were assessed for presence of synovial hypertrophy and synovitis in the 2nd and 5th metatarso-phalangeal (MTP) joints and plantar forefoot bursal hypertrophy before and 12 weeks after therapy. Tender MTP joints and swollen bursae were established clinically by an experienced podiatrist and ultrasound (US) images were acquired and interpreted by a radiologist. Assessment of patient reported disease impact on the foot was performed using the Manchester Foot Pain and Disability Index (MFPDI). RESULTS: 31 patients (24 female, 7 male) with RA (12 seronegative, 19 seropositive) completed the study: mean age 59.6 (SD 10.1) years, disease duration 11.1 (SD 10.5) years, and previous number of Disease Modifying Anti Rheumatic Drugs 3.0 (1.6). Significant differences after therapy were found for Erythrocyte Sedimentation Rate (t = 4.014, p < 0.001), C-reactive protein (t = 3.889, p = 0.001), 28 joint Disease Activity Score (t = 3.712, p = 0.0001), Visual Analog Scale (t = 2.735, p = 0.011) and Manchester Foot Pain and Disability Index (t = 3.712, p = 0.001).Presence of MTP joint synovial hypertrophy on US was noted in 67.5% of joints at baseline and 54.8% of joints at twelve weeks. Presence of plantar forefoot bursal hypertrophy on US was noted in 83.3% of feet at baseline and 75% at twelve weeks. Although there was a trend for reduction in observed presence of person specific forefoot pathology, when the frequencies were analysed (McNemar) this was not significant. CONCLUSIONS: Significant improvements were seen in patient reported foot pain and disability 12 weeks after commencing TNF inhibition in RA, but this may not be enough time to detect changes in forefoot pathology.

Musculoskeletal ultrasound imaging of the plantar forefoot in patients with rheumatoid arthritis: inter-observer agreement between a podiatrist and a radiologist.

BACKGROUND: The use of musculoskeletal ultrasound (MSUS) in the diagnosis and management of foot and ankle musculoskeletal pathology is increasing. Due to the wide use of MSUS and the depth and breadth of training required new proposals advocate tailored learning of the technique to discrete fields of practice. The aims of the study were to evaluate the inter-observer agreement between a MSUS radiologist and a podiatrist, who had completed basic skills training in MSUS, in the MSUS assessment of the forefoot of patients with Rheumatoid Arthritis. METHODS: A consecutive sample of thirty-two patients with rheumatoid arthritis was assessed for presence of synovitis, erosions and bursitis within the forefoot using MSUS. All MSUS assessments were performed independently on the same day by a podiatrist and one of two Consultant Radiologists experienced in MSUS. RESULTS: Moderate agreement on image acquisition and interpretation was achieved for bursitis (kappa 0.522; p < 0.01) and erosions (kappa 0.636; p < 0.01) and fair agreement for synovitis (kappa 0.216; p < 0.05) during the primary assessments. Following a further training session, substantial agreement (kappa 0.702) between the two investigators was recorded. The sensitivity of the podiatrist using MSUS was 82.4% for detection of bursitis, 83.0% for detection of erosion and 84.0% for detection of synovitis. Specificity of the podiatrist using MSUS was 88.9% for detection of bursitis, 80.7% for detection of erosion and 35.9% for detection of synovitis. CONCLUSION: This study demonstrated good inter-observer agreement between a podiatrist and radiologist on MSUS assessment of the forefoot, particularly for bursitis and erosions, in patients with rheumatoid arthritis. There is scope to further evaluate and consider the role of podiatrists in the MSUS imaging of the foot following appropriate training and also in the development of reliable protocols for MSUS assessment of the foot.

Use of quantitative ultrasound scans of the calcaneus to diagnose osteoporosis in patients with rheumatoid arthritis.

BACKGROUND: Patients with rheumatoid arthritis are recognized as being at risk for osteoporosis as a result of the disease process as well as the medication used to treat it. This study was conducted to consider the use of calcaneal scanning with quantitative ultrasound-contact ultrasound bone analysis (CUBA)-to diagnose osteoporosis in patients with rheumatoid arthritis. METHODS: Forty-six patients (11 men and 35 women) with established rheumatoid arthritis underwent dual-energy x-ray absorptiometry (DEXA) of the nondominant wrist and CUBA of the nondominant heel. Sensitivity, specificity, and positive and negative predictive values were used to determine the correlation between osteoporosis as diagnosed by the CUBA heel scan compared with the DEXA wrist scan given that DEXA is widely seen as the gold standard for the diagnosis of osteoporosis. RESULTS: The CUBA heel scan revealed a sensitivity of 90% and a specificity of 44% for a diagnosis of osteoporosis compared with DEXA. The positive predictive value of the CUBA scan was 31%, and the negative predictive value was 94%. Therefore, if normal bone density is found using CUBA, there is 94% certainty this is correct. However, if osteoporosis is diagnosed using CUBA, there is only 31% certainty this is correct. In such instances a secondary scan using a different method (eg, DEXA) would be required. Future work should consider the effect of minor alterations to the equipment or scanning protocol, because this may improve diagnosis. CONCLUSIONS: The CUBA unit could be used as a primary screening device. Given the cost and accessibility issues associated with DEXA, quantitative ultrasound may have a role in screening for osteoporosis in the primary-care setting to determine the most appropriate routes of referral for patients requiring further investigations.

Context and cue cards in young children's testimony: a comparison of brief narrative elaboration and context reinstatement.

In a comparison of interview procedures that aimed to assist retrieval strategies in children's event recall, 72 children aged 4-6 years were questioned about a witnessed event. Context reinstatement and brief narrative elaboration (an abbreviated version of K. J. Saywitz and L. Snyder's [1996] procedure) produced similar levels of correct recall, and both elicited more correct recall than did a control condition, with no increase in errors. Combining these procedures did not further improve performance. The superiority of narrative elaboration over the control group was evident in free recall and did not depend on explicit prompting with cue cards. These findings suggest that incorporating brief narrative elaboration training in investigative interviews with children may, like context reinstatement, be a valuable mnemonic aid.