Michael R. Backhouse

Concordance in diabetic foot ulcer infection

Introduction Accurate identification of pathogens, rather than colonising bacteria, is a prerequisite for targeted antibiotic therapy to ensure optimal patient outcome in wounds, such as diabetic foot ulcers. Wound swabs are the easiest and most commonly used sampling technique but most published guidelines recommend instead removal of a tissue sample from the wound bed, which is a more complex process. The aim of this study was to assess the concordance between culture results from wound swabs and tissue samples in patients with suspected diabetic foot infection. Methods and analysis Patients with a diabetic foot ulcer that is thought to be infected are being recruited from 25 sites across England in a cross-sectional study. The coprimary endpoints for the study are agreement between the two sampling techniques for three microbiological parameters: reported presence of likely isolates identified by the UK Health Protection Agency; resistance of isolates to usual antibiotic agents; and, the number of isolates reported per specimen. Secondary endpoints include appropriateness of the empiric antibiotic therapy prescribed and adverse events. Enrolling 400 patients will provide 80% power to detect a difference of 3% in the reported presence of an organism, assuming organism prevalence of 10%, discordance of 5% and a two-sided test at the 5% level of significance. Assumed overall prevalence is based on relatively uncommon organisms such as Pseudomonas. We will define acceptable agreement as κ>0.6. Ethics and dissemination Concordance in diabetic foot ulcer infection (CODIFI) will produce robust data to evaluate the two most commonly used sampling techniques employed for patients with a diabetic foot infection. This will help determine whether or not it is important that clinicians take tissue samples rather than swabs in infected ulcers. This study has been approved by the Sheffield NRES Committee (Ref: 11/YH/0078) and all sites have obtained local approvals prior starting recruitment. Study registration NRES Ref: 11/YH/0078, UKCRN ID: 10440, ISRCTN: 52608451

Use of conservative and surgical foot care in an inception cohort of patients with rheumatoid arthritis

Objectives. To describe conservative and surgical foot care in patients with RA in England and explore factors that predict the type of foot care received. Methods. Use of podiatry and type of foot surgery were outcomes recorded in an inception cohort involving nine rheumatology centres that recruited patients with RA between 1986 and 1998 across England. Associations between patient-specific factors and service use were identified using univariate logistic regression analyses. The independence of these associations was then verified through multiple binary logistic regression modelling. Results. Data were collected on 1237 patients with RA [66.9% females, mean (s.d.) age at disease onset = 54.36 (14.18) years, median DAS = 4.09 (1st quartile = 3.04, 3rd quartile = 5.26), median HAQ = 1 (0.50, 1.63)]. Interventions involving the feet in the cohort were low with only 364 (30%) out of 1218 receiving podiatry and 47 (4%) out of 1237 patients having surgery. At baseline, female gender, increasing age at onset, being RF positive and higher DAS scores were each independently associated with increased odds of seeing a podiatrist. Gender, age of onset and baseline DAS were independently associated with the odds of having foot surgery. Conclusions. Despite the known high prevalence of foot pathologies in RA, only one-third of this cohort accessed podiatry. While older females were more likely to access podiatry care and younger patients surgery, the majority of the RA population did not access any foot care.

Concurrent validation of activity monitors in patients with rheumatoid arthritis.

Background Physical activity is frequently reported in rheumatology but it is difficult to measure objectively outside the gait laboratory. A new generation of activity monitors offers this potential but it has not yet been evaluated in patients with rheumatoid arthritis. This study aimed to evaluate three types of activity monitors in patients with rheumatoid arthritis. Methods The Step-N-Tune, Activ4Life Pro V3.8, and the Intelligent Device for Energy Expenditure and Activity activity monitors were tested concurrently in 12 patients with rheumatoid arthritis as well as in a healthy control group of 12 volunteers. Participants walked at a self selected speed for two minutes and were filmed for later review. Temporal and spatial gait parameters were also validated against the GAITRite walkway and the total number of steps recorded by each activity monitor was compared to a gold standard derived from half speed video replays. Findings Activity monitor performance varied between devices but all showed poorer performance when used in the group with rheumatoid arthritis. Bland–Altman plots demonstrated wider 95% limits of agreement in the group with rheumatoid arthritis and a systematic decrease in agreement between activity monitors and the gold standard with decreasing functional ability. Interpretation Despite some variation between devices, all the activity monitors tested performed reasonably well in healthy young volunteers. All except the Activ4Life showed a marked decrease in performance in patients with rheumatoid arthritis, suggesting Activ4Life could be the most suitable for use in this patient group. The marked between group difference in functional ability, and systematic decrease in device performance with deteriorating gait, indicate that activity monitors require specific validation in target clinical populations.

Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study

To determine clinical outcomes and explore prognostic factors related to ulcer healing in people with a clinically infected diabetic foot ulcer.

Joint Orthopaedic and Rheumatology Clinics: Evidence to Support the Guidelines

Joint Orthopaedic and Rheumatology Clinics: Evidence to Support the Guidelines Heidi J. Siddle* Bsc (Hons), MSc, Michael R. Backhouse BSc (Hons), PGCert, Ray Monkhouse MB ChB, FRCS (Tr. & Orth), FRCS (Ed), Nick J. Harris FRCS (Tr. & Orth) & Philip S. Helliwell MA, FRCP, PhD Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK Foot Health Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, UK

National variation in the composition of rheumatology multidisciplinary teams: a cross-sectional study

The objective of this study is to describe the composition of multidisciplinary teams (MDT) working within rheumatology departments across the UK. All rheumatology departments in the United Kingdom (UK) were invited to participate in a national electronic survey between February 2014 and April 2015 as a part of a national audit for the management of rheumatoid and early inflammatory arthritis commissioned by Healthcare Quality Improvement Partnership. Rheumatology departments were asked to report their MDT composition; defined as a rheumatologist (consultant or specialist trainee), specialist nurse, occupational therapist physiotherapist, and podiatrist. The data were collected as Whole Time Equivalent (WTE) of each professional group at each department adjusted to 100,000 population. The data were grouped according to British Society for Rheumatology regions to study regional variations. The survey was completed by 164/167 departments (98% response rate). All departments reported an MDT comprising a rheumatologist (consultant or specialist trainee) and almost all included a specialist nurse but only 28 (17%) of the departments had MDTs comprising all the professional groups. There was a high degree of regional variation in the provision of Allied Health Professionals (physiotherapists, occupational therapists, and podiatrists) in the UK. MDT care is recommended for the management of inflammatory arthritis, but few UK rheumatology departments have a full complement of healthcare professionals within their MDT. There is a high degree of regional variation in the composition and staffing levels of the rheumatology MDT across the UK; the impact of which warrants further investigation.

Diurnal variation of gait in patients with rheumatoid arthritis: The DIVIGN study

Background Circadian variation of joint stiffness (morning stiffness) and its impact on functional ability are widely recognised in rheumatoid arthritis. Subsequent within-day variation of walking ability is important due to the increased availability of instrumented gait analysis. This study aimed to quantify diurnal variation of gait in patients with rheumatoid arthritis, and explore associations with disease characteristics. Methods Thirty one inpatients with rheumatoid arthritis walked at a self-selected speed along a GAITRite instrumented walkway 5 times during a single day. Findings Participants showed marked diurnal variation in gait, leading to a systematic variation throughout the day (F = 19.56, P = < 0.001). Gait velocity and stride length both increased, whereas the proportion of each gait cycle spent in stance phase or double support decreased, consistent with improving function throughout the day. Although absolute gait velocity correlated with disease characteristics, the magnitude of diurnal variation appeared to be independent of disease activity (rho = 0.26, P = 0.15), disease duration (rho = − 0.19, P = 0.324), and underlying functional ability (rho = 0.09, P = 0.65). Interpretation Although morning stiffness is well recognised in rheumatoid arthritis, this is the first time that its effect on gait has been quantified. Patients with rheumatoid arthritis exhibited a systematic change in walking ability throughout the day, which was independent of disease characteristics. These findings have important implications for the interpretation of existing data and the design of future studies. Repeat measures should be conducted at the same time of day to exclude the effects of diurnal variation.

Interpreting outcome following foot surgery in people with rheumatoid arthritis

BackgroundFoot surgery is common in RA but the current lack of understanding of how patients interpret outcomes inhibits evaluation of procedures in clinical and research settings. This study aimed to explore which factors are important to people with RA when they evaluate the outcome of foot and ankle surgery.Methods and ResultsSemi structured interviews with 11 RA participants who had mixed experiences of foot surgery were conducted and analysed using thematic analysis. Responses showed that while participants interpreted surgical outcome in respect to a multitude of factors, five major themes emerged: functional ability, participation, appearance of feet and footwear, surgeons’ opinion, and pain. Participants interpreted levels of physical function in light of other aspects of their disease, reflecting on relative change from their preoperative state more than absolute levels of ability. Appearance was important to almost all participants: physical appearance, foot shape, and footwear were closely interlinked, yet participants saw these as distinct concepts and frequently entered into a defensive repertoire, feeling the need to justify that their perception of outcome was not about cosmesis.Surgeons’ post-operative evaluation of the procedure was highly influential and made a lasting impression, irrespective of how the outcome compared to the participants’ initial goals. Whilst pain was important to almost all participants, it had the greatest impact upon them when it interfered with their ability to undertake valued activities.ConclusionsPeople with RA interpret the outcome of foot surgery using multiple interrelated factors, particularly functional ability, appearance and surgeons’ appraisal of the procedure. While pain was often noted, this appeared less important than anticipated. These factors can help clinicians in discussing surgical options in patients.

An audit of a combined rheumatology and orthopaedic foot and ankle surgery clinic

Failure of conservative care is often followed by orthopaedic intervention with foot surgery accounting for 1/3 of lower limb surgery in Rheumatoid Arthritis (RA). National guidelines encourage combined rheumatology & orthopaedic care.

Preliminary concurrent validity of the Fitbit-Zip and ActiGraph activity monitors for measuring steps in people with polymyalgia rheumatica

BACKGROUND Activity monitors provide objective measurements of physical activity, however, the accuracy of these devices in people with polymyalgia rheumatica (PMR) is unknown. Therefore, this study aimed to obtain preliminary evidence of the accuracy of two activity monitors and explore if clinical and gait-related factors altered device accuracy in people with PMR. METHODS The ActiGraph with low frequency extension (+LFE) and standard (-LFE) algorithms, Fitbit-Zip (waist) and Fitbit-Zip (shirt) were concurrently tested using a two-minute walk test (2MWT) and stairs test in 27 people with PMR currently treated with prednisolone. To determine accuracy, activity monitor step-count was compared to a gold-standard step-count (GSSC; calculated from video recording) using Bland-Altman plots. RESULTS The Fitbit-Zip (waist) achieved closest agreement to the GSSC for the 2MWT (mean bias (95%CI): 10 (-3, 23); 95%LOA: -55, 74). The ActiGraph (+LFE) achieved closest agreement to the GSSC for the stairs test (mean bias (95%CI): 0 (-1, 1); 95%LOA: -5, 5). The ActiGraph (-LFE) performed poorly in both tests. All devices demonstrated reduced accuracy in participants with lower gait velocity, reduced stride length, longer double-limb support phase and greater self-reported functional impairment. CONCLUSION Our preliminary results suggest that in controlled conditions, the Fitbit-Zip fairly accurately measures step-count during walking in people with PMR receiving treatment. However, device error was greater than data published in healthy people. The ActiGraph may not be recommended without activation of the LFE. We identified clinical and gait-related factors associated with higher levels of functional impairment that reduced device accuracy. Further work is required to evaluate the validity of the activity monitors in field conditions.