Veterinary student competence in equine lameness recognition and assessment: a mixed methods study

The development of perceptual skills is an important aspect of veterinary education. The authors investigated veterinary student competency in lameness evaluation at two stages, before (third year) and during (fourth/fifth year) clinical rotations. Students evaluated horses in videos, where horses were presented during trot on a straight line and in circles. Eye-tracking data were recorded during assessment on the straight line to follow student gaze. On completing the task, students filled in a structured questionnaire. Results showed that the experienced students outperformed inexperienced students, although even experienced students may classify one in four horses incorrectly. Mistakes largely arose from classifying an incorrect limb as lame. The correct detection of sound horses was at chance level. While the experienced student cohort primarily looked at upper body movement (head and sacrum) during lameness assessment, the inexperienced cohort focused on limb movement. Student self-assessment of performance was realistic, and task difficulty was most commonly rated between 3 and 4 out of 5. The inexperienced students named a considerably greater number of visual lameness features than the experienced students. Future dedicated training based on the findings presented here may help students to develop more reliable lameness assessment skills

O16 A study examining the reliability of digital ulcer definitions as proposed by the UK Scleroderma Study Group: challenges and insights for future clinical trial design

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The Keele community knee pain forum: action research to engage with stakeholders about the prevention of knee pain and disability

<p>Abstract</p> <p>Background</p> <p>Involvement of users in health care research is central to UK health care policy, and guidelines for involvement exist. However, there are limited examples in rheumatology research. The aim of this study was to establish a community knee pain forum aimed at engaging stakeholders in design, dissemination and prioritisation of knee pain research.</p> <p>Methods</p> <p>Ten people were recruited to the forum representing a wide range of agencies. These included Weight Watchers, the leisure industry, Beth Johnson Foundation, health and social care professionals and the public. Three two-hour meetings over a two-year period were held. Experienced qualitative researchers facilitated each meeting. Written feedback after each meeting was elicited, and a short evaluation form was mailed to all members after the final meeting.</p> <p>Results</p> <p>Establishing and maintaining a forum of mixed members required careful preparation and ongoing support. Meetings had to be well-structured in order to allow for balanced participation of lay and professional users. Users contributed to the design of methods, provided ideas for dissemination and set priorities for further research. Clear documentation of meetings ensured that users' contributions to the research cycle were transparent.</p> <p>Conclusion</p> <p>Our knee pain forum illustrates that community engagement can have a positive impact on the development, dissemination and implementation of health research. Engaging with non-academic partners enables mutual learning and this enhances the quality of NHS research.</p

Untersuchungen zum Einfluss von thrombozytären Wachstumsfaktoren auf den zellvermittelten Abbau eines nanopartikulären Knochenersatzstoffes auf Hydroxylapatitbasis : eine experimentelle Studie am Miniaturschwein

Ziel der vorliegenden tierexperimentellen Studie am Miniaturschwein war es, den Einfluss von plättchenreichem Plasma (PRP) auf den zellvermittelten Abbau eines nanopartikulären Hydroxylapatits (HA) in der Frühphase der Knochendefektheilung zu untersuchen. Hierzu wurden 26 männliche Miniaturschweine der Rasse Mini-Lewe in drei Versuchsgruppen eingeteilt und jeweils ein standardisierter Knochendefekt in der Intercondylarregion des rechten Femurs angelegt. Die Defekte wurden entweder mit dem Knochenersatzstoff (Gruppe I/PRP-,n = 11) oder dem Knochenersatzstoff kombiniert mit PRP (Gruppe II/PRP+, n = 11) befüllt. In einer Kontrollgruppe (n = 4) blieben die Defekte unbefüllt. Während der Implantationsoperation wurden bei sechs Tieren jeweils 250 ml Vollblut entnommen, aus dem anschließend durch fraktionierte Zentrifugation plättchenreiches Plasma gewonnen wurde. Die enthaltenen Thrombozyten wurden durch den Zusatz von Thrombin und Kalziumglukonat zur Degranulation angeregt, wodurch die enthaltenen Wachstumsfaktoren aus den alpha-Granula freigesetzt wurden. Zu diesen Wachstumsfaktoren gehören Platelet Derived Growth Factor AB und BB (PDGF AB, BB), Transforming Growth Factor ß 1 (TGF beta1), Vascular Endothelial Growth Factor (VEGF) und basic Fibroblast Growth Factor (bFGF). Die Konzentration der genannten Wachstumsfaktoren wurde mit Hilfe der ELISA-Technik bestimmt. Sie lagen zwischen Faktor 1,6 für TGF-beta1 und Faktor 24,4 für bFGF. 20 Tage post operationem fand die Explantation der operierten distalen Femura statt. Zur lichtmikroskopischen Untersuchung fanden die Knochen-Implantat-Proben Eingang in unterschiedliche Techniken der Einbettung (Paraffin-, Kunststoffeinbettungen), Präparation (Paraffinschnitte, Kunststoffschnitte und Schliffpräparationen), Färbung (Toluidinblau, Haematoxylin-Eosin, Safranin) und Histochemie (Enzym-, Immunhistochemie). Darüber hinaus wurden transmissionselektronenmikroskopische und computergestützte histomorphometrische Untersuchungen durchgeführt. Wie die Ergebnisse der Licht- und Transmissionselektronenmikroskopie aufgezeigt haben, erfolgt in den mit Knochenersatzmaterial behandelten Versuchsgruppen, unabhängig von der PRP-Applikation, die HA-Degradation hydrolytisch und Makrophagen-vermittelt. Die Makrophagen-Population wird durch Riesenzellen vom Langhans-Typ repräsentiert. Diese polarisierten Polykaryen adhärieren über ihre apikale Membrandomäne an den Implantatoberflächen. Das subplasmalemmale Zytoplasma ist immunhistochemisch durch Vimentin-Kondensationen gekennzeichnet. Nicht-adhärente, frei im Granulationsgewebe lokalisierte Polykaryen zeigen dagegen ein homogenes Vimentin-Verteilungsmuster im Zytoplasma. Der zelluläre Abbau des HA erfolgt mittels Phagozytose, indem die Polykaryen den "Fremdkörper" mit pseudopodienartigen Zytoplasmaausläufern umschließen und in ihr Zytoplasma inkorporieren. Diese Art der Degradation wird durch den post implantationem stattfindenden Zerfall des Knochenersatzmaterials in zahlreiche kleine Partikel unterstützt. Die hieraus resultierende Vergrößerung der Implantatoberfläche bietet einer Vielzahl von Zellen die Möglichkeit zur Haftung. Die festgestellten Expressionsmuster des CD44- Membranglykoproteins verweisen auf dessen funktionelle Rolle im Rahmen der Fusion mononukleärer Makrophagen zu multinukleären Riesenzellen. Die darüber hinaus beobachtete Umverteilung von CD44 von der apikalen zur basalen Membrandomäne bei Implantatassoziierten Polykaryen ist als transientes Geschehen im Zuge der Adhäsion zu interpretieren. Der hohe Aktivitätsstatus der adhärenten Polykaryen ist immunhistochemisch durch eine intensive Kathepsin K-Expression gekennzeichnet. Die vergleichende histomorphometrische Auswertung der mit HA aufgefüllten Defekte dokumentiert eine Verdopplung der Anzahl von Polykaryen in der Gruppe "Knochenersatzstoff mit PRP". Ein auf Basis der Messergebnisse durchgeführter Wilcoxon-Rangsummentest verweist auf den hochsignifikanten Einfluss (p < 0,01) des Faktors PRP auf die Ausdehnung Tartrat-resistenter saurer Phosphatase-positiver Areale in den Präparaten. Diese Effekte können sowohl auf den im PRP angereicherten Wachstumsfaktoren als auch auf dem homologen Charakter der PRP-Zubereitung beruhen. Die beobachteten Polykaryen – sogenannte "Fremdkörperriesenzellen" – sind auch immer Indikatoren einer stattfindenden Entzündungsreaktion. Die histomorphometrisch dargestellte, deutlich verstärkte Fremdkörperreaktion in Gruppe II/PRP+ kann auf die PRP-Applikation zurückgeführt werden. Im weiteren Heilungsverlauf kann dies zu einer Verzögerung der knöchernen Konsolidierung der Defekte führen.Aim of the current experimental study in Minipigs was to examine the effects of homologous platelet-rich plasma (PRP) on the cell-mediated degradation of a nanoparticulate hydroxyapatite (HA) during the early phase of bone defect healing. Twenty-six male "Lewe" minipigs were divided into three groups. Standardized bone defects were created in the intercondylar region of the right femur of each pig and were filled with HA (Group I/PRP-, n = 11) or HA + PRP (Group II/PRP+, n = 11). The defects of the control group (n = 4) were left empty. During the implantation procedure blood was drawn from six minipigs (250 ml each). PRP was isolated from these blood samples after several centrifugation steps. After the addition of thrombin and calcium gluconate growth factors were released from the alpha-granules of the thrombocytes which were enriched within the PRP. Some of these growth factors are Platelet Derived Growth Factor AB and BB (PDGF AB, BB), Transforming Growth Factor ß 1 (TGF beta1), Vascular Endothelial Growth Factor (VEGF) and basic Fibroblast Growth Factor (bFGF). The level of enrichment of these growth factors was controlled by the ELISA technique. Growth factor enrichment within the PRP ranged from 1.6 fold (TGF-beta1) to 24.4 fold (bFGF). After 20 days the treated distal femura were explanted. For light microscopical examination different tissue embedding methods (paraffine, plastic, resin), sectioning techniques (paraffine sections, plastic and resin sections, sawing and grinding sections), staining procedures (toluidine blue, hematoxylin eosin, safranin) and histochemical methods (enzyme- and immunohistochemistry) were performed. Additionally transmission electron microscopy and computer-assisted histomorphometry were used. The results of light microscopy and transmission electron microscopy showed that regardless of the addition of PRP, the HA is degraded by hydrolysis and macrophages. The population of macrophages consists of Langhans-type giant cells. The adhesion of the polarized polykaryons at the surfaces of the implant is mediated by the apical domain of the plasmamembranes. Vimentin condensations of the cytoplasm are attached to the apical plasmalemma. In contrast, non-adherent polykaryons of the granulation tissue reveal a homogeneous Vimentin distribution pattern within their cytoplasma. As shown ultrastructurally, the implant is degraded by means of phagocytosis. The implant particles are encircled by pseudopodia of the polykaryons and become incorporated into the cytoplasma. The degradation process is supported by disintegration of the bone substitute into numerous small particles after implantation. This disintegration causes enlargement of the implant surface and increases the probability of phagocyte adhesion. The pattern of CD44 expression points towards a functional role of the molecule during fusion of mononucleated macrophages into multinucleated giant cells. Implant-associated polykaryons show CD44 immunoreactivity only along the basal domains of the cytomembrane. This pattern can be interpreted as a temporal event during adhesion. Adherent polykaryons are further characterized by strong cathepsin K expression. The histomorphometric examination demonstrates twice as much foreign body giant cells in "Group II/PRP+" as in "Group I/PRP-". Based on these results, a Wilcoxon-signed-rank test was performed and a highly significant effect (p < 0.01) of PRP on the expansion of tartrate resistent acid phophatase (TRAP)-positive areas within bone defects could be demonstrated. This effect could be a result of the substution of PRP or of its homologous character. The polykaryons descibed in this work - so-called Foreign Body Giant Cells - are also indicators of inflammation. The enhanced cellular reaction observed in Group II/PRP+ must be interpreted as a strong foreign body reaction, triggered by the addition of PRP. It cannot be excluded that the strong inflammation reaction will lead to delayed bone formation in the course of healing

"Well, it's nobody's responsibility but my own." A qualitative study to explore views about the determinants of health and prevention of knee pain in older adults

Dahlgren and Whitehead's 'rainbow' outlines key determinants of health and has been widely adopted within public health policy and research. Public understanding regarding the determinants of health is, however, relatively unknown, particularly in relation to common chronic joint problems like knee pain. We aimed to explore individual attitudes to the prevention of knee pain, and assess how people make sense of their lives by using the rainbow model to explore social determinants of health

Reliability of digital ulcer definitions as proposed by the UK Scleroderma Study Group:A challenge for clinical trial design

INTRODUCTION: The reliability of clinician grading of systemic sclerosis–related digital ulcers has been reported to be poor to moderate at best, which has important implications for clinical trial design. The aim of this study was to examine the reliability of new proposed UK Scleroderma Study Group digital ulcer definitions among UK clinicians with an interest in systemic sclerosis. METHODS: Raters graded (through a custom-built interface) 90 images (80 unique and 10 repeat) of a range of digital lesions collected from patients with systemic sclerosis. Lesions were graded on an ordinal scale of severity: ‘no ulcer’, ‘healed ulcer’ or ‘digital ulcer’. RESULTS: A total of 23 clinicians – 18 rheumatologists, 3 dermatologists, 1 hand surgeon and 1 specialist rheumatology nurse – completed the study. A total of 2070 (1840 unique + 230 repeat) image gradings were obtained. For intra-rater reliability, across all images, the overall weighted kappa coefficient was high (0.71) and was moderate (0.55) when averaged across individual raters. Overall inter-rater reliability was poor (0.15). CONCLUSION: Although our proposed digital ulcer definitions had high intra-rater reliability, the overall inter-rater reliability was poor. Our study highlights the challenges of digital ulcer assessment by clinicians with an interest in systemic sclerosis and provides a number of useful insights for future clinical trial design. Further research is warranted to improve the reliability of digital ulcer definition/rating as an outcome measure in clinical trials, including examining the role for objective measurement techniques, and the development of digital ulcer patient–reported outcome measures

Monoamines as Drug Targets in Chronic Pain: Focusing on Neuropathic Pain

Monoamines are involved in regulating the endogenous pain system and indeed, peripheral and central monoaminergic dysfunction has been demonstrated in certain types of pain, particularly in neuropathic pain. Accordingly, drugs that modulate the monaminergic system and that were originally designed to treat depression are now considered to be first line treatments for certain types of neuropathic pain (e.g., serotonin and noradrenaline (and also dopamine) reuptake inhibitors). The analgesia induced by these drugs seems to be mediated by inhibiting the reuptake of these monoamines, thereby reinforcing the descending inhibitory pain pathways. Hence, it is of particular interest to study the monoaminergic mechanisms involved in the development and maintenance of chronic pain. Other analgesic drugs may also be used in combination with monoamines to facilitate descending pain inhibition (e.g., gabapentinoids and opioids) and such combinations are often also used to alleviate certain types of chronic pain. By contrast, while NSAIDs are thought to influence the monoaminergic system, they just produce consistent analgesia in inflammatory pain. Thus, in this review we will provide preclinical and clinical evidence of the role of monoamines in the modulation of chronic pain, reviewing how this system is implicated in the analgesic mechanism of action of antidepressants, gabapentinoids, atypical opioids, NSAIDs and histaminergic drug

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

Adjunctive rifampicin for Staphylococcus aureus bacteraemia (ARREST): a multicentre, randomised, double-blind, placebo-controlled trial.

BACKGROUND: Staphylococcus aureus bacteraemia is a common cause of severe community-acquired and hospital-acquired infection worldwide. We tested the hypothesis that adjunctive rifampicin would reduce bacteriologically confirmed treatment failure or disease recurrence, or death, by enhancing early S aureus killing, sterilising infected foci and blood faster, and reducing risks of dissemination and metastatic infection. METHODS: In this multicentre, randomised, double-blind, placebo-controlled trial, adults (≥18 years) with S aureus bacteraemia who had received ≤96 h of active antibiotic therapy were recruited from 29 UK hospitals. Patients were randomly assigned (1:1) via a computer-generated sequential randomisation list to receive 2 weeks of adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) versus identical placebo, together with standard antibiotic therapy. Randomisation was stratified by centre. Patients, investigators, and those caring for the patients were masked to group allocation. The primary outcome was time to bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomisation to 12 weeks, adjudicated by an independent review committee masked to the treatment. Analysis was intention to treat. This trial was registered, number ISRCTN37666216, and is closed to new participants. FINDINGS: Between Dec 10, 2012, and Oct 25, 2016, 758 eligible participants were randomly assigned: 370 to rifampicin and 388 to placebo. 485 (64%) participants had community-acquired S aureus infections, and 132 (17%) had nosocomial S aureus infections. 47 (6%) had meticillin-resistant infections. 301 (40%) participants had an initial deep infection focus. Standard antibiotics were given for 29 (IQR 18-45) days; 619 (82%) participants received flucloxacillin. By week 12, 62 (17%) of participants who received rifampicin versus 71 (18%) who received placebo experienced treatment failure or disease recurrence, or died (absolute risk difference -1·4%, 95% CI -7·0 to 4·3; hazard ratio 0·96, 0·68-1·35, p=0·81). From randomisation to 12 weeks, no evidence of differences in serious (p=0·17) or grade 3-4 (p=0·36) adverse events were observed; however, 63 (17%) participants in the rifampicin group versus 39 (10%) in the placebo group had antibiotic or trial drug-modifying adverse events (p=0·004), and 24 (6%) versus six (2%) had drug interactions (p=0·0005). INTERPRETATION: Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S aureus bacteraemia. FUNDING: UK National Institute for Health Research Health Technology Assessment