Derek Santos

Foot orthoses in children with juvenile idiopathic arthritis: a randomised controlled trial

Introduction There is limited evidence supporting the podiatric treatment of children with juvenile idiopathic arthritis (JIA). This multicentre randomised controlled trial aimed to determine whether preformed foot orthoses (FOs) impacted on pain and quality of life (QoL) in children with JIA. Methods Eligible children were randomised to receive either ‘fitted’ FOs with customised chair-side corrections or ‘control’ FOs made without corrections. Changes in pain and QoL were measured using a visual analogue scale and Paediatric Quality of Life questionnaire, respectively. JIA children were assessed at baseline, 3 months and 6 months. Results 60 children were recruited. 179 out of a possible 180 assessments (99.4%) were completed. A statistically significant greater difference in pain reduction (baseline—6 months) was seen between the two groups favouring fitted FOs (p=0.029). The reduction in pain in the fitted FOs group was clinically important (8 mm). Significant differences in QoL favouring fitted FOs were also identified as measured by the children and independently by their parents/carers. Conclusions Fitted FOs may reduce pain and improve QoL in selected children with JIA. Trial registration number NCT02001844.

A systematic review of the sensitivity and specificity of the toe–brachial index for detecting peripheral artery disease:

The toe–brachial index (TBI) is used as an adjunct to the ankle–brachial index (ABI) for non-invasive lower limb vascular screening. With increasing evidence suggesting limitations of the ABI for diagnosis of vascular complications, particularly in specific populations including diabetes cohorts, the TBI is being used more widely. The aim of this review was to determine the sensitivity and specificity of the TBI for detecting peripheral artery disease (PAD) in populations at risk of this disease. A database search was conducted to identify current work relating to the sensitivity and specificity of toe–brachial indices up to July 2015. Only studies using valid diagnostic imaging as a reference standard were included. The QUADAS-2 tool was used to critically appraise included articles. Seven studies met the inclusion criteria. Sensitivity of the TBI for PAD was reported in all seven studies and ranged from 45% to 100%; specificity was reported by five studies only and ranged from 16% to 100%. In conclusion, this review suggests that the TBI has variable diagnostic accuracy for the presence of PAD in specific populations at risk of developing the disease. There was a notable lack of large-scale diagnostic accuracy studies determining the diagnostic accuracy of the TBI in detecting PAD in different at-risk cohorts. However, standardised normal values need to be established for the TBI to conclusively determine the diagnostic accuracy of this test.

Diabetic peripheral neuropathy, is it an autoimmune disease?

BACKGROUND Autoimmunity has been identified in a significant number of neuropathies, such as, proximal neuropathies, and autonomic neuropathies associated with diabetes mellitus. However, possible correlations between diabetic peripheral neuropathy and autoimmunity have not yet been fully investigated. OBJECTIVES This study was conducted to investigate whether autoimmunity is associated with the pathogenesis of human diabetic peripheral neuropathy. RESEARCH DESIGN AND METHODS A case-control analysis included three groups: 30 patients with diabetic peripheral neuropathy, 30 diabetic control patients without neuropathy, and 30 healthy controls. Blood analysis was conducted to compare the percentages of positive antinuclear antibodies (ANA) between the three groups. Secondary analysis investigated the correlations between the presence of autoimmune antibodies and sample demographics and neurological manifestations. This research was considered as a pilot study encouraging further investigations to take place in the near future. RESULTS Antinuclear antibodies were significantly present in the blood serum of patients with diabetic peripheral neuropathy in comparison to the control groups (p<0.001). The odds of positive values of ANA in the neuropathy group were 50 times higher when compared to control groups. Secondary analysis showed a significant correlation between the presence of ANA and the neurological manifestation of neuropathy (Neuropathy symptom score, Neuropathy disability score and Vibration Perception Threshold). CONCLUSION The study demonstrated for the first time that human peripheral diabetic neuropathy may have an autoimmune aetiology. The new pathogenic factors may lead to the consideration of new management plans involving new therapeutic approaches and disease markers.

The use of ‘off-the-shelf’ foot orthoses in the reduction of foot symptoms in patients with early rheumatoid arthritis

BACKGROUND Foot pain in patients diagnosed with early rheumatoid arthritis is common. OBJECTIVES To investigate effects of off-the-shelf foot orthoses on outcomes of swollen and tender joints, and pain, in patients with early rheumatoid arthritis. METHODS Thirty-five patients with painful and swollen foot joints were recruited. None had previously used foot orthoses or had contraindications to their use. Any patients with concomitant musculoskeletal disease, endocrine disorders, and neurological disease, were excluded. At baseline, participants were prescribed a customised off-the-shelf foot orthosis with chair-side modifications. Data was collected at baseline, three and six months. Foot pain (using Visual Analogue Scale) and the number of tender and swollen foot joints was measured. RESULTS There was a trend towards a reduction in the number of swollen and tender joints by 3 months with a further improvement by 6 months. Statistically (p<0.05) and clinically significant reductions in pain levels were also noted. CONCLUSION Patients diagnosed with early RA may benefit from using off-the-shelf foot orthoses with the majority of their pain reduction occurring within the first 3 months of use, but with some small further symptomatic improvement up to 6 months. There was a tendency to a reduction in swollen and tender joints although more studies are required to substantiate these findings.

A modular device to measure the effects of plantar foot pressure on the microcirculation of the heel

Abstract Background : Past research has concentrated on foot function and plantar foot pressure, with many devices developed for this purpose. However, little is known of how cutaneous blood flow compensates for ambulatory repetitive circulatory insults and how ulceration occurs. Objectives : To develop a system to measure the effects of plantar foot pressure on cutaneous blood flow in the supine and semi-weight bearing positions. Method : A system was developed that integrated a laser Doppler fluxmeter with a pressure probe, allowing plantar foot pressure and skin blood flow to be recorded simultaneously. The system was tested using four volunteers (28±8.6 years). Results : A significant difference existed between baseline laser Doppler flowmetry (LDF) in the supine and semi-weight bearing positions ( P =0.023). Differences between both positions also existed in the reduction in LDF levels following application of pressure ( P =0.015), the maximum hyperaemic response ( P =0.034) and time taken to reach maximum hyperaemic response ( P =0.019). Conclusion : The device has shown that with current technology it is now possible not only to investigate plantar foot pressure but also how it affects skin blood flow, which in some cases can lead to ulceration. The effect of plantar foot pressure on cutaneous blood flow differs depending on whether the subject is supine or semi-weight bearing. Thus, to understand the effects of plantar foot pressure on skin blood flow future researchers must ensure that subjects are in an upright position when recording.

Prevalence, presentation and treatment of lower limb pathologies in juvenile idiopathic arthritis: A narrative review

Juvenile idiopathic arthritis is a chronic, autoimmune, inflammatory joint disease. It is the most common arthritis in children and adolescents. This paper reviews the presentation and treatment of lower limb pathologies in juvenile idiopathic arthritis from an allied health perspective. Common lower limb pathologies include: synovitis causing swelling, tenderness and pain; persistent inflammation leading to flexion contractures; limb length discrepancies; muscle atrophy; enthesopathies such as plantar fasciitis and Achilles tendonitis; and tenosynovitis. Allied health professionals may use a range of non‐invasive therapies, including hydrotherapy, strengthening and stretching exercises, massaging, taping and foot orthoses to manage lower limb pathologies in juvenile idiopathic arthritis. Early detection and treatment of these common and potentially disabling lower limb pathologies are fundamental to achieving gold standard care for children with juvenile idiopathic arthritis.

Predictive parameters of arteriovenous fistula maturation in patients with end-stage renal disease.

Background The objevctive of the present study was to explore the potential influence of blood markers and patient factors such as risk factors, kidney function profile, coagulation profile, lipid profile, body mass index, blood pressure, and vein diameter on the maturation of arteriovenous fistula (AVF) in patients with end-stage renal disease. Methods Retrospective data from 300 patients who had undergone AVF creation at the Royal Infirmary of Edinburgh were examined. A predictive logistic regression model was developed using a backward stepwise procedure. Model performance, discrimination, and calibration were assessed using the receiver operating characteristic (ROC) curve and Hosmer–Lemeshow goodness-of-fit test. The final model was externally validated by 100 prospective patients who received a new fistula at the Royal Infirmary of Edinburgh. Results A total of 400 (300 retrospective and 100 prospective) patients were recruited for this study, with a mean age of 60.14 ± 15.9 years (development set) and 58 ± 15 years (validation set), respectively (P = 0.208). Study results showed that males were twice as likely to undergo fistula maturation as females, while patients with no evidence of peripheral vascular disease (PVD) were three times more likely to mature their fistula and a preoperative vein diameter > 2.5 mm resulted in a fivefold increase in fistula maturation as compared with a vein size of less than 2.5 mm. The model for fistula maturation had fair discrimination, as indicated by the area under the ROC curve (0.68), but good calibration as indicated by the Hosmer–Lemeshow test (P = 0.79). The area under the receiver operating curve for the validation model in the validation set was 0.59. Similarly, in the validation set, the Hosmer–Lemeshow statistic indicated an agreement between the observed and predicted probabilities of maturation (P > 0.05). Conclusion Gender, PVD, and vein size are independent predictors of AVF maturation. The clinical utility of these risk categories in the maturation of AVF requires further evaluation in longer follow-up.

Exploring the Effectiveness of Smart Technologies in the Management of Type 2 Diabetes Mellitus

The global epidemic of diabetes, with increasing prevalence of type 2 diabetes (T2D), is placing a huge burden on health care management and financial systems. Unless new strategic solutions are developed, the increasing prevalence of T2D will result in a significant rise in morbidity, health care costs, and complications associated with diabetes. The introduction of smart devices in diabetes management may provide meaningful improvements in clinical outcomes, patient engagement, as well as potential cost reductions for the health care system. Future research may be capable of providing new smart and interactive solutions to the growing multidisciplinary diabetes team and, most important, to reduce the morbidity associated with T2D.

Physical Examination Tools Used to Identify Swollen and Tender Lower Limb Joints in Juvenile Idiopathic Arthritis: A Scoping Review

Background Juvenile idiopathic arthritis (JIA) is the most common form of rheumatic disease in childhood and adolescents, affecting between 16 and 150 per 100,000 young persons below the age of 16. The lower limb is commonly affected in JIA, with joint swelling and tenderness often observed as a result of active synovitis. Objective The objective of this scoping review is to identify the existence of physical examination (PE) tools to identify and record swollen and tender lower limb joints in children with JIA. Methods Two reviewers individually screened the eligibility of titles and abstracts retrieved from the following online databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL. Studies that proposed and validated a comprehensive lower limb PE tool were included in this scoping review. Results After removal of duplicates, 1232 citations were retrieved, in which twelve were identified as potentially eligible. No studies met the set criteria for inclusion. Conclusion Further research is needed in developing and validating specific PE tools for clinicians such as podiatrists and other allied health professionals involved in the management of pathological lower limb joints in children diagnosed with JIA. These lower limb PE tools may be useful in conjunction with existing disease activity scores to optimise screening of the lower extremity and monitoring the efficacy of targeted interventions.

Sclerosing alcohol injections for the management of intermetatarsal neuromas: A systematic review

An intermetatarsal neuroma is a plantar digital neuritis causing metatarsalgia of the affected inter-metatarsal space. At present the evidence to support the management of the condition is poor with only some quality evidence supporting the short-term management of intermetatarsal neuromas using steroid injections. Some authors have supported the use of alcohol sclerosing intra-lesional injections to treat intermetatarsal neuromas. Following a search of the evidence 11 articles were identified. The systematic review found that alcohol injections appear to be safe although some papers report a short-term side effect of a flogistic reaction and there are variances in the alcohol concentration used and guiding verses not guiding the injection using ultrasound imaging. Some of the evidence may suggest a sclerosing histological effect of the nerve. However, all the studies reviewed present a research design offering a low level of evidence that is open to methodological biases and interpretation. Thus, this review found insufficient high-quality research evidence to afford conclusions on the management of intermetatarsal neuromas with alcohol sclerosing agent injections.