Podiatrists’ perspectives of the provision of foot health education for people with Rheumatoid Arthritis

IntroductionPatient education is considered to be a key role for podiatrists in the management of patients with Rheumatoid Arthritis (RA). However there is no evidence that identifies or supports the most appropriate strategies and content for its delivery. The aim of this study was to identify the nature and content of the current provision by podiatrists in relation to foot health education for people with RA. Any potential barriers to its provision were explored.MethodTwelve members (all female) of the Northwest Podiatry Clinical Effectiveness Group for Rheumatology volunteered to take part in a Focus Group, ranging from newly qualified podiatrists with an interest in working within rheumatology to those with extensive years of experience managing patients with RA (working within Primary and Secondary care). The dialogue was recorded digitally, transcribed verbatim and analysed using a structured, thematic approach by the lead author. The full transcription was verified as accurate by the focus group to ensure trustworthiness of the data.ResultsFive overarching themes emerged from the data, each with it’s own set of sub-themes, these were, 1. The Essence of Patient Education [information provision & empowerment,] 2. The content [what, why, when & by whom], 3. Barriers to Provision [external, psychosocial, educational, concordance & professional experience], 4. The therapeutic relationship [patient/practitioner knowledge & attitudes, influence of age & gender, role/title confusion, taboo subject areas] and 5. Tools of the trade [group v individual, verbal & written, audio-visual, web-based].DiscussionThis methodological approach of this study has revealed aspects of patient education, which this group of podiatrists find to be most influential in its overall delivery from their perspective. This adds new knowledge as no previous study has been carried out. The lead author is currently exploring the same area with patient participants. Ultimately the aim is to achieve the development of a patient-centred and negotiated approach to the provision of foot health education for people with RA

Evaluating joint protection education for people with rheumatoid arthritis

Joint Protection (JP) education is considered an essential component of therapeutic programmes for Rheumatoid Arthritis (RA) patients. The main emphasis is teaching alternate patterns of movement at affected joints to reduce joint stress, particularly in the hands and wrists (Hand JP). Little has been published investigating patients' knowledge of, attitudes towards and adherence to Hand JP following education. Assessments were developed to evaluate these constructs. Reliability and validity were established. A pretest-posttest trial was conducted with RA patients attending a 4 x 2 hour arthritis education programme, including 2.5 hours of JP over 2 sessions (n = 21). Teaching techniques typical of those current in the UK were used. Adherence was evaluated using the Joint Protection Behaviour Assessment. Subjects were videorecorded performing a standardised kitchen activity (making a hot drink and snack) in their own homes. Hand movements during 20 tasks within this (e.g. turning a tap) were analysed and scored as Correct (5%), Partial (2.5%) or Incorrect (0%) Hand JP behaviours. Maximum score =100%. A significant score increase was determined as 20%. Subjects were kept blind to trial aims. There was no significant behaviour change in the pre-education control phase (median score at assessment 1 = 18.40%, IQR 10.25-35.55%). No significant increase occurred at 6 and 12 week follow ups. Mean score change was +4.01% (SO 10.59%; p = 0.14). No significant knowledge increase occurred. Post-education interviews identified a number of barriers to behavioural change. A cognitive-behavioural JP education programme was developed, using motor learning, recall and adherence enhancement strategies, of 4 x 2 hours, with an optional home visit. A crossover trial was conducted (n = 35). There was no significant difference between treatment phase first (Tl, median 15.00%, IQR 5.15 - 25.60%) and control phase first(C1, median 8.75%, IQR 4.38 - 26.25%; p = 0.47) groups' scores pre-education. Both groups' scores rose significantly at 6 weeks post-education, which was sustained at 18 weeks (Tl: median 52.50%, IQR 31.75 - 65.00%; p = 0.00) (Cl: median 41.25%, IQR 30.00 - 60.23%j p =0.00). A significant increase in knowledge occurred. Factors most associated with behaviour change were: hours of education (8 or more); regular home practice; weaker grip, poorer hand range of movement and less hand pain. These results suggest: current JP education methods are ineffective; and this cognitive-behavioural programme significantly increases Hand JP at 4.5 month follow-up. Having demonstrated adherence can be achieved, it is essential to demonstrate whether any therapeutic benefit results before advocating the widespread use of this approach in practice

A geochemical study of the winonaites: Evidence for limited partial melting and constraints on the precursor composition

The winonaites are primitive achondrites which are associated with the IAB iron meteorites. Textural evidence implies heating to at least the Fe, Ni–FeS cotectic, but previous geochemical studies are ambiguous about the extent of silicate melting in these samples. Oxygen isotope evidence indicates that the precursor material may be related to the carbonaceous chondrites. Here we analysed a suite of winonaites for modal mineralogy and bulk major- and trace-element chemistry in order to assess the extent of thermal processing as well as constrain the precursor composition of the winonaite-IAB parent asteroid. Modal mineralogy and geochemical data are presented for eight winonaites. Textural analysis reveals that, for our sub-set of samples, all except the most primitive winonaite (Northwest Africa 1463) reached the Fe, Ni–FeS cotectic. However, only one (Tierra Blanca) shows geochemical evidence for silicate melting processes. Tierra Blanca is interpreted as a residue of small-degree silicate melting. Our sample of Winona shows geochemical evidence for extensive terrestrial weathering. All other winonaites studied here (Fortuna, Queen Alexander Range 94535, Hammadah al Hamra 193, Pontlyfni and NWA 1463) have chondritic major-element ratios and flat CI-normalised bulk rare-earth element patterns, suggesting that most of the winonaites did not reach the silicate melting temperature. The majority of winonaites were therefore heated to a narrow temperature range of between ∼1220 (the Fe, Ni–FeS cotectic temperature) and ∼1370 K (the basaltic partial melting temperature). Silicate inclusions in the IAB irons demonstrate partial melting did occur in some parts of the parent body (Ruzicka and Hutson, 2010), thereby implying heterogeneous heat distribution within this asteroid. Together, this indicates that melting was the result of internal heating by short-lived radionuclides. The brecciated nature of the winonaites suggests that the parent body was later disrupted by a catastrophic impact, which allowed the preservation of the largely unmelted winonaites. Despite major-element similarities to both ordinary and enstatite chondrites, trace-element analysis suggests the winonaite parent body had a carbonaceous chondrite-like precursor composition. The parent body of the winonaites was volatile-depleted relative to CI, but enriched compared to the other carbonaceous classes. The closest match are the CM chondrites; however, the specific precursor is not sampled in current meteorite collections

Evaluating joint protection education for people with rheumatoid arthritis

Joint Protection (JP) education is considered an essential component of therapeutic programmes for Rheumatoid Arthritis (RA) patients. The main emphasis is teaching alternate patterns of movement at affected joints to reduce joint stress, particularly in the hands and wrists (Hand JP). Little has been published investigating patients' knowledge of, attitudes towards and adherence to Hand JP following education. Assessments were developed to evaluate these constructs. Reliability and validity were established. A pretest-posttest trial was conducted with RA patients attending a 4 x 2 hour arthritis education programme, including 2.5 hours of JP over 2 sessions (n = 21). Teaching techniques typical of those current in the UK were used. Adherence was evaluated using the Joint Protection Behaviour Assessment. Subjects were videorecorded performing a standardised kitchen activity (making a hot drink and snack) in their own homes. Hand movements during 20 tasks within this (e.g. turning a tap) were analysed and scored as Correct (5%), Partial (2.5%) or Incorrect (0%) Hand JP behaviours. Maximum score =100%. A significant score increase was determined as 20%. Subjects were kept blind to trial aims. There was no significant behaviour change in the pre-education control phase (median score at assessment 1 = 18.40%, IQR 10.25-35.55%). No significant increase occurred at 6 and 12 week follow ups. Mean score change was +4.01% (SO 10.59%; p = 0.14). No significant knowledge increase occurred. Post-education interviews identified a number of barriers to behavioural change. A cognitive-behavioural JP education programme was developed, using motor learning, recall and adherence enhancement strategies, of 4 x 2 hours, with an optional home visit. A crossover trial was conducted (n = 35). There was no significant difference between treatment phase first (Tl, median 15.00%, IQR 5.15 - 25.60%) and control phase first(C1, median 8.75%, IQR 4.38 - 26.25%; p = 0.47) groups' scores pre-education. Both groups' scores rose significantly at 6 weeks post-education, which was sustained at 18 weeks (Tl: median 52.50%, IQR 31.75 - 65.00%; p = 0.00) (Cl: median 41.25%, IQR 30.00 - 60.23%j p =0.00). A significant increase in knowledge occurred. Factors most associated with behaviour change were: hours of education (8 or more); regular home practice; weaker grip, poorer hand range of movement and less hand pain. These results suggest: current JP education methods are ineffective; and this cognitive-behavioural programme significantly increases Hand JP at 4.5 month follow-up. Having demonstrated adherence can be achieved, it is essential to demonstrate whether any therapeutic benefit results before advocating the widespread use of this approach in practice

Cytochrome P450-mediated metabolism and cytotoxicity in rat cultured hepatocytes

The aim of this investigation was to define the in vitro conditions necessary to support cytochrome P450-mediated metabolism in rat cultured hepatocytes, such that this system could then be used as an in vitro model in the study of cytochrome P450-mediated cytotoxicity. Maintenance of P450-dependent enzyme activities in culture was not affected by supplementation of culture medium with haem, but was markedly influenced by the age and sex of the hepatocyte donor animal. Induction in primary culture by phenobarbitone and beta-naphthoflavone was investigated, and found to be quantitatively and qualitatively different to the induction observed in vivo, hepatocytes in culture being particularly refractive to induction by phenobarbitone. The maintenance in primary culture of a range of enzyme activities was determined following treatment of rats in vivo with isoniazid and dexamethasone, in addition to phenobarbitone and beta-naphthoflavone, and in general, there was good maintenance of the induced activities. The activities were chosen as possible selective substrates for the different induced isozymes, with a view to using the activity profiles to characterise different classes of inducer; however, although selective induction was observed with isoniazid, beta-naphthoflavone and dexamethasone, all the chosen activities were induced by phenobarbitone. The final part of this work involved determining cytotoxicity in vitro, following induction of P450 in vivo with phenobarbitone and beta-naphthoflavone. Seven known hepatotoxins were investigated, and the results obtained agreed well with available in vitro and in vivo literature data. In summary, a range of constitutive and induced enzyme activities were maintained at high levels in hepatocytes cultured for twenty-four hours from adult male rats, and an induction in vivo/hepatocyte culture protocol shown to be a viable in vitro model for the study of metabolism-mediated toxicity, as an alternative to induction and detection of toxicity in vitro. NB. This ethesis has been created by scanning the typescript original and may contain inaccuracies. In case of difficulty, please refer to the original text

Scale‐Banking for Patient Reported Outcome Measures (PROMs) Measuring Functioning in Rheumatoid Arthritis: A Daily Activities Metric

Objective Functioning is an important outcome for rheumatoid arthritis (RA) management. Heterogeneity of respective patient‐reported outcome measures (PROMs) challenges direct comparisons between their results. This study aimed to standardize reporting of such PROMs measuring functioning in RA to facilitate comparability. Methods Common Item Non‐Equivalent Groups Design (NEAT) with the Health Assessment Questionnaire (HAQ) as a common scale across data sets from various countries (incl. UK, Turkey and Germany) to establish a common metric. Other PROMs included are the Physical Function items of the Multidimensional Health Assessment Questionnaire (MDHAQ), Disabilities of Arm, Shoulder and Hand (DASH), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), World Health Organization Disability Assessment Schedule Version 2.0 (WHODAS 2.0), and four short forms (20, 10, 6, and 4 physical function items) from the Patient‐Reported Outcomes Measurement Information System (PROMIS). As the HAQ includes mobility, self‐care and domestic life items, this study focuses on these three domains. PROMs were described using Standard Error of Measurement (SEM) and Smallest Detectable Difference (SDD). Rasch Measurement model was used to create the common metric. Results Range of SEM is 0.2 (MDHAQ) to 7.4 (SF36‐PF). SDD revealed a range from 9.7 % (WOMAC‐RAT) to 33.5 % (WHODAS‐PF). PROMs co‐calibration revealed fit to the Rasch measurement model. A transformation table was developed to allow exchange between PROMs scores. Discussion Scores between the Daily Activity PROMs commonly used in RA can now be compared. Factors such as SEM and SDD help determine choice of PROM in clinical practice and research

A community-based cooking programme "Eat Better Feel Better" can improve child and family eating behaviours in low socioeconomic groups

Background: The immediate and sustained impacts of the Eat Better Feel Better cooking programme (EBFBCP) on food choices and eating behaviours in families and children were evaluated. Methods: The EBFBCP (6 weeks, 2 hours/week) was delivered by community-based organisations in Greater Glasgow and Clyde, Scotland. Before, after and at follow-up, parents/caregivers completed short pictorial questionnaires to report family/child eating behaviours and food literacy. Results: In total, 83 EBFBCPs were delivered and 516 participants enrolled, of which 432 were parents and caregivers. Questionnaire completion rates were 57% (n=250) for before and after and 13% (n=58) for follow-up. Most participants (80%) were female, 25–44 years old (51%) and considered socioeconomically deprived (80%). The immediate effects of the EBFBCP on eating behaviours and food literacy were families ate less takeaway/fast foods (10% reduction, p=0.019) and ready meals (15% reduction, p=0.003) and cooked more from scratch (20% increase, p<0.001). Children’s consumption of discretionary food/drinks was significantly reduced after the EBFBCP for sugary drinks (10% reduction, p=0.012), savoury snacks (18%, p=0.012), biscuits (17%, p=0.007), sweets/chocolates (23%, p=0.002), fried/roasted potatoes (17%, p<0.001) and savoury pastries (11%, p<0.001). The number of fruit (15%, p=0.008) and vegetable portions (10%, p<0.001) increased, while the number of biscuit portions decreased (13%, p=0.005). Parental food label reading increased (calories, 22%; fat, 23%; sugar, 22%; ingredients, 19%; and portion size, 19%). Most changes were sustained at a median of 10 months’ follow-up. Conclusion: The EBFBCP improved children’s and families’ food choices and behaviours. The EBFBCP can be recommended to support families to make better food choices

Mature neurons dynamically restrict apoptosis via redundant premitochondrial brakes

Apoptotic cell death is critical for the early development of the nervous system, but once the nervous system is established, the apoptotic pathway becomes highly restricted in mature neurons. However, the mechanisms underlying this increased resistance to apoptosis in these mature neurons are not completely understood. We have previously found that members of the miR-29 family of microRNAs (miRNAs) are induced with neuronal maturation and that overexpression of miR-29 was sufficient to restrict apoptosis in neurons. To determine whether endogenous miR-29 alone was responsible for the inhibition of cytochrome c release in mature neurons, we examined the status of the apoptotic pathway in sympathetic neurons deficient for all three miR-29 family members. Unexpectedly, we found that the apoptotic pathway remained largely restricted in miR-29-deficient mature neurons. We therefore probed for additional mechanisms by which mature neurons resist apoptosis. We identify miR-24 as another miRNA that is upregulated in the maturing cerebellum and sympathetic neurons that can act redundantly with miR-29 by targeting a similar repertoire of pro-death BH3-only genes. These results reveal that mature neurons engage redundant brakes to restrict the apoptotic pathway and ensure their long-term survival