BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

Use of cognitive-behavioural arthritis education programmes in newly diagnosed rheumatoid arthritis

Objective: To identify the effect of attending a cognitive-behavioural arthritis education programme on the health status of participants with newly diagnosed rheumatoid arthritis (RA) compared with a control group. Design: Randomized controlled trial. Setting: Hospital based. Subjects: Newly diagnosed with RA. Intervention: Participation in either a cognitive-behavioural arthritis education programme or a standard arthritis education programme (control group). Sessions for both groups lasted for 2 hours per week for four weeks. Subjects were examined at home by an assessor blinded to group allocation, prior to and three and six months following attendance. Outcome measures: The main outcome measure was the Physical Function subscale of the Arthritis Impact Measurement Scale Two. Other outcome measures included erythrocyte sedimentation rate (ESR), joint count scores, assessments of pain and psychological status. Results: Fifty-four subjects (mean time since diagnosis 4.5 months) took part. Baseline analysis revealed that the control group had significantly better levels of functional ability (U = 185; p = 0.009) and lower levels of helplessness (U = 168; p = 0.002) prior to intervention. This difference remained unchanged three months later. Six months following the intervention no signi�cant differences were noted between the groups for any measure of health status. There were no significant changes in health status over time in either group. Conclusion: Attending a cognitive-behavioural arthritis education programme had no significant effect on the health status of individuals newly diagnosed with RA. The move to early use of these programmes should be examined further, with a larger sample size and longer duration of follow-up

NETs generate structured antimicrobial peptide-nucleosome immune complexes with inter-DNA spacings optimal for TLR9 activation

The molecular pathogenesis of psoriasis is characterized in part by breakdown of immune tolerance to self-DNA. Recent work demonstrates that the human antimicrobial peptide (AMP) LL37 overexpressed in psoriasis organizes naked DNA into periodic nanocrystals to potently hyperactivate Toll-like receptor 9 (TLR9) in plasmacytoid dendritic cells (pDCs). Interestingly, a subset of self-DNA in psoriatic lesions remain bound to histones as histone-DNA nucleosome core particles (NCPs) released from neutrophil extracellular traps (NETs). At present, it is unknown how NET components like AMPs interact with NCPs, and whether AMP-NCP complexes form structures compatible with TLR9 activation in psoriasis. Here, we combine synchrotron X-ray scattering, cryo-electron microscopy, and computer simulations to demonstrate that under a broad range of conditions, NCPs stack into columns that present periodically arranged dsDNA ligands like threads on a screw, allowing for optimal interdigitation with clusters of TLR9. Remarkably, simulations and electron microscopy indicate that the superhelical pitch of DNA wrapped around the NCP column relaxes to a value that is well-matched with the steric size of TLR9, which predicts strong immune activation. Taken together, our results suggest that AMPs can remodel the structural organization of nucleosomes from NETs into potent amplifiers of inflammation. Preliminary immune activation experiments will be presented