POS1517-HPR PATIENT AND CLINICIAN PERSPECTIVES ON IMPLEMENTING THE RADAI-F5 TOOL TO HELP INFORM THE ASSESSMENT AND MANAGEMENT OF FOOT DISEASE IN RA: A QUALITATIVE STUDY

Background

While patient-reported outcome measures (PROMs) are widely recommended in clinical care, their application is limited [1]. The RADAI-F5 is a validated PROM to determine RA foot disease activity [2]. Patients’ and clinicians’ perceptions of the RADAI-F5’s clinical utility have yet to be captured.

Objectives

This study aims to explore patient and clinician opinions and perceptions of the clinical utility of the RADAI- F5’s in managing rheumatoid foot disease.

Methods

A 60-minute semi-structured interview using video conference calls with adult RA patients and rheumatologists, physiotherapists, and podiatrists was conducted as part of the interpretive phenomenological analysis research. The interviews included open-ended questions about the effect of foot disease, current clinical utilization of PROMS, and barriers and facilitators to the clinical application of the RADAI-F5. Inductive thematic data analysis with Nvivo12 identified emerging themes.

Results

Eight participants with rheumatoid arthritis: seven females; mean [standard deviation, SD] age 52.4 [9.5] years; mean [SD] disease duration 16.1 [16.4] years; eight clinicians; mean [SD] age 46.75 [5.3] years; mean [SD] years of clinical experience 19.5 [2.21] years. Four main themes were identified (Table 1); ‘Feet are a priority’ as the impact of RA on the feet was substantial and had a negative impact on quality of life. The second theme was ‘Need for a clinically feasible foot PROM’ as clinicians and patients recognised the lack of a clinically feasible tool that can determine RA foot disease. The third emerging theme was ‘RADAI-F5 facilitators’ as the tool can promote communication, guide management, help screen foot symptoms, monitor foot disease status and treatments longitudinally, and promote patient education. The final theme was ‘RADAI-F5 barriers’ as there were associated practical difficulties, including lack of appointment time, administrative burdens associated with PROM use, lack of trust in the RADAI-F5’s validity and IT barriers since there is no universal electronic system for reporting RADAI-F5 results.

Table 1.

Themes with respective quotes that emerged as part of the individual interviews to understand the clinical utility of the RADAI-F5

ThemeQuotationsTheme 1: Feet are important“Foot disease is common and it’s troublesome for patients” (C16) “I couldn’t see my friends because I was always so tired and in pain. It is very lonely.” (P07)Theme 2: Existing methods for measuring foot disease activity are inadequate“The feet are under-represented in the clinical tools for assessing disease activity, and clinicians don’t look at feet enough.” (C11)“We’ve tried numerous PROMS. Historically, I think probably it’s time-consuming for our clinical consultation”. (C12)Theme 3: RADAI-F5 facilitators“I think [The RADAI-F5] improves the clinician-patient relationship” (C15)“Using the RADAI-F5 could measure the success of the treatments that we are implicating.” (C12)Theme 4: RADAI-F5 barriers“I mean, this (RADAI-F5) will obviously go along with other tools. You know, the blood tests and things as well.” (P01)

Conclusion

The RADAI-F5 has significant potential as a therapeutic tool to aid in managing foot disease in RA. However, several implementation barriers need to be overcome before widespread use in rheumatology clinics can occur.

References

[1]Muradin I, van der Heide HJ. The foot function index is more sensitive to change than the Leeds Foot Impact Scale for evaluating rheumatoid arthritis patients after forefoot or hindfoot reconstruction. International orthopaedics. 2016; 40: pp.745-9.

[2]Hoque A, Gallagher K, McEntegart A, Porter D, Steultjens M, Woodburn J, Hendry GJ. Measuring Inflammatory Foot Disease in Rheumatoid Arthritis: Development and Validation of the Rheumatoid Arthritis Foot Disease Activity Index–5. Arthritis Care & Research. 2021;73: pp.1290-9.

Acknowledgements

Gordon Hendry, Diane Dickson and Martijn Steultjens

Disclosure of Interests

None declared

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

The application of subset correspondence analysis to address the problem of missing data in a study on asthma severity in childhood

Non-response in cross-sectional data is not uncommon and requires careful handling during the analysis stage so as not to bias results. In this paper, we illustrate how subset correspondence analysis can be applied in order to manage the non-response while at the same time retaining all observed data. This variant of correspondence analysis was applied to a set of epidemiological data in which relationships between numerous environmental, genetic, behavioural and socio-economic factors and their association with asthma severity in children were explored. The application of subset correspondence analysis revealed interesting associations between the measured variables that otherwise may not have been exposed. Many of the associations found confirm established theories found in literature regarding factors that exacerbate childhood asthma. Moderate to severe asthma was found to be associated with needing neonatal care, male children, 8- to 9-year olds, exposure to tobacco smoke in vehicles and living in areas that suffer from extreme air pollution. Associations were found between mild persistent asthma and low birthweight, and being exposed to smoke in the home and living in a home with up to four people. The classification of probable asthma was associated with a group of variables that indicate low socio-economic status.

A survey of foot problems in juvenile idiopathic arthritis

BACKGROUND

Evidence suggests that foot problems are common in juvenile idiopathic arthritis (JIA), with prevalence estimates over 90%. The aim of this survey was to describe foot-related impairment and disability associated with JIA and foot-care provision in patients managed under modern treatment paradigms, including disease-modifying anti-rheumatic drugs (DMARDs) and biologic therapies.

METHODS

The Juvenile Arthritis Foot Disability Index (JAFI), Child Health Assessment Questionnaire (CHAQ), and pain visual analogue scale (VAS) were recorded in 30 consecutive established JIA patients attending routine outpatient clinics. Foot deformity score, active/limited joint counts, walking speed, double-support time (s) (DS) and step length symmetry index % (SI) were also measured. Foot-care provision in the preceding 12 months was determined from medical records.

RESULTS

Sixty-three per cent of children reported some foot impairment, with a median (range) JAFI subscale score of 1 (0-3); 53% reported foot-related activity limitation, with a JAFI subscale score of 1 (0-4); and 60% reported participation restriction, with a JAFI subscale score of 1 (0-3). Other reported variables were CHAQ 0.38 (0-2), VAS pain 22 (0-79), foot deformity 6 (0-20), active joints 0 (0-7), limited joints 0 (0-31), walking speed 1.09 m/s (0.84-1.38 m/s), DS 0.22 s (0.08-0.26 s) and SI +/-4.0% (+/-0.2-+/-31.0%). A total of 23/30 medical records were reviewed and 15/23 children had received DMARDS, 8/23 biologic agents and 20/23 multiple intra-articular corticosteroid injections. Ten children received specialist podiatry care comprising footwear advice, orthotic therapy and silicone digital splints together with intrinsic muscle strengthening exercises.

CONCLUSION

Despite frequent use of DMARD/biologic therapy and specialist podiatry-led foot care, foot-related impairment and disability persists in some children with JIA.

Substrate water exchange in photosystem II depends on the peripheral proteins

The (18)O exchange rates for the substrate water bound in the S(3) state were determined in different photosystem II sample types using time-resolved mass spectrometry. The samples included thylakoid membranes, salt-washed Triton X-100-prepared membrane fragments, and purified core complexes from spinach and cyanobacteria. For each sample type, two kinetically distinct isotopic exchange rates could be resolved, indicating that the biphasic exchange behavior for the substrate water is inherent to the O(2)-evolving catalytic site in the S(3) state. However, the fast phase of exchange became somewhat slower (by a factor of approximately 2) in NaCl-washed membrane fragments and core complexes from spinach in which the 16- and 23-kDa extrinsic proteins have been removed, compared with the corresponding rate for the intact samples. For CaCl(2)-washed membrane fragments in which the 33-kDa manganese stabilizing protein (MSP) has also been removed, the fast phase of exchange slowed down even further (by a factor of approximately 3). Interestingly, the slow phase of exchange was little affected in the samples from spinach. For core complexes prepared from Synechocystis PCC 6803 and Synechococcus elongatus, the fast and slow exchange rates were variously affected. Nevertheless, within the experimental error, nearly the same exchange rates were measured for thylakoid samples made from wild type and an MSP-lacking mutant of Synechocystis PCC 6803. This result could indicate that the MSP has a slightly different function in eukaryotic organisms compared with prokaryotic organisms. In all samples, however, the differences in the exchange rates are relatively small. Such small differences are unlikely to arise from major changes in the metal-ligand structure at the catalytic site. Rather, the observed differences may reflect subtle long range effects in which the exchange reaction coordinates become slightly altered. We discuss the results in terms of solvent penetration into photosystem II and the regional dielectric around the catalytic site.

Proton irradiation of [18O]O2: production of [18F]F2 and [18F]F2 + [18F] OF2

The production of 18F electrophilic reagents via the 18O(p,n)18F reaction has been investigated in small-volume target bodies made of aluminum, copper, gold-plated copper and nickel, having straight or conical bore shapes. Three irradiation protocols-single-step, two-step and modified two-step-were used for the recovery of the 18F activity. The single-step irradiation protocol was tested in all the target bodies. Based on the single-step performance, aluminum targets were utilized extensively in the investigation of the two-step and modified two-step irradiation protocols. With an 11-MeV cyclotron and using the two-step irradiation protocol, > 1Ci [18F]F2 was recovered reproducibly from an aluminum target body. Probable radical mechanisms for the formation of OF2 and FONO2 (fluorine nitrate) in the single-step and modified two-step targets are proposed based on the amount of ozone generated and the nitrogen impurity present in the target gases, respectively.

Early continuous ST segment monitoring in unstable angina: prognostic value additional to the clinical characteristics and the admission electrocardiogram

BACKGROUND AND OBJECTIVE

In unstable angina, clinical characteristics, resting electrocardiography, and early continuous ST segment monitoring have been individually reported to identify subgroups at increased risk of adverse outcome. It is not known, however, whether continuous ST monitoring provides additional prognostic information in such a setting.

DESIGN

Observational study of 212 patients with unstable angina without evidence of acute myocardial infarction admitted to district general hospitals, who had participated in a randomised study comparing heparin and aspirin treatment versus aspirin alone.

METHODS

Clinical variables and a 12 lead electrocardiogram (ECG) were recorded at admission, and treatment was standardised to include aspirin, atenolol, diltiazem, and intravenous glyceryl trinitrate, in addition to intravenous heparin (randomised treatment). Continuous ST segment monitoring was performed for 48 h and all inhospital adverse events were recorded.

RESULTS

The admission ECG was normal in 61 patients (29%), showed ST depression in 59 (28%) (17 > or = 0.1 mV), and T wave changes in a further 69 (33%). The remaining 23 had Q waves (18), right bundle branch block (four), or ST elevation (one). During 8963 h of continuous ST segment monitoring (mean 42.3 h/patient), 132 episodes of transient myocardial ischaemia (104 silent) were recorded in 32 patients (15%). Forty patients (19%) had an adverse event (cardiac deaths (n = 3), non-fatal myocardial infarction (n = 6) and, emergency revascularisation (n = 31)). Both admission ECG ST depression (P = 0.02), and transient ischaemia (P < 0.001) predicted an increased risk of non-fatal myocardial infarction or death, while no patients with a normal ECG died or had a myocardial infarction. Adverse outcome was predicted by admission ECG ST depression (regardless of severity) (odds ratio (OR) 3.41) (P < 0.001), and maintenance beta blocker treatment (OR 2.95) (P < 0.01). A normal ECG predicted a favourable outcome (OR 0.38) (P = 0.04), while T wave or other ECG changes were not predictive of outcome. Transient ischaemia was the strongest predictor of adverse prognosis (OR 4.61) (P < 0.001), retaining independent predictive value in multivariate analysis (OR 2.94) (P = 0.03), as did maintenance beta blocker treatment (OR 2.85) (P = 0.01) and admission ECG ST depression, which showed a trend towards independent predictive value (OR 2.11) (P = 0.076).

CONCLUSIONS

Patients with unstable angina and a normal admission ECG have a good prognosis, while ST segment depression predicts an adverse outcome. Transient myocardial ischaemia detected by continuous ST segment monitoring in such patients receiving optimal medical treatment provides prognostic information additional to that gleaned from the clinical characteristics or the admission ECG.

Comparison of the effect of heparin and aspirin versus aspirin alone on transient myocardial ischemia and in-hospital prognosis in patients with unstable angina

OBJECTIVES

This study compared the effects of heparin and aspirin versus aspirin alone on transient myocardial ischemia and in-hospital prognosis in patients with unstable angina.

BACKGROUND

Transient myocardial ischemia occurring in patients with unstable angina is associated with an adverse prognosis. Heparin and aspirin are two drugs used frequently in the treatment of this condition, but the effect of combination therapy versus aspirin alone on transient myocardial ischemia is unknown.

METHODS

Two hundred eighty-five consecutive patients with unstable angina were randomized to receive either intravenous heparin plus oral aspirin (150 mg once daily) (Group H + A) or aspirin alone (Group A). Patients also received a beta-adrenergic blocking agent, diltiazem and intravenous nitrates. ST segment monitoring was performed for the 1st 48 h of treatment. Patients were followed up for the duration of their in-hospital stay.

RESULTS

One hundred fifty-four patients (30 women, mean [+/- SEM] age 58.3 +/- 0.8 years) received heparin and aspirin (Group H + A), and 131 patients (26 women, mean age 60.6 +/- 0.8 years) received aspirin only (Group A). ST segment monitoring (11,622 h) yielded 244 episodes of transient myocardial ischemia of a total duration of 7,819 min. There were no significant differences between the two treatment arms in the number of patients with transient myocardial ischemia (27 [18%] in Group H + A vs. 31 [24%] in Group A), number of episodes (96 in Group H + A vs. 148 in Group A) or total duration of transient myocardial ischemia (2,911 min in Group H + A vs. 4,908 min in Group A). The incidence of in-hospital myocardial infarction or death was significantly higher in patients with transient myocardial ischemia (53% vs. 22%, p < 0.0001). Five of the six deaths occurred in patients with transient myocardial ischemia. Event-free survival from myocardial infarction or death was similar in both treatment groups. Preadmission therapy with aspirin was associated with a lower in-hospital infarction rate (19% vs. 34%, p = 0.01).

CONCLUSIONS

The presence of transient myocardial ischemia in patients with unstable angina is associated with a significantly higher incidence of myocardial infarction or death in hospital. Combined therapy with heparin and aspirin compared with aspirin alone makes no difference in the development of these events, nor does it reduce the development of transient myocardial ischemia.

Radical formation and accumulation in vivo, in desiccation tolerant and intolerant mosses

Water loss in a desiccation-sensitive moss resulted in destruction of chlorophyll, loss of carotenoids and increased lipid peroxidation, indicating the presence of damaging forms of activated oxygen. These effects were exaggerated when the plants were desiccated at high light intensities. During water-deprivation there was a build up of a free radical, detected in vivo, with a close correlation between molecular damage and radical accumulation. In contrast, in a desiccation-tolerant moss there was almost no indication of molecular (oxidative) damage. However a stable radical similar in type and concentration to that found in the desiccation-sensitive species accumulated, particularly under high irradiances. The stable radical appears to be one of the end-products of a process initiated by environmental stress, desiccation and high irradiance: its association with molecular damage depending on the degree to which the species is tolerant of desiccation. Identification of the radical in intact tissue from EPR and ENDOR studies, suggests that this is not a short-lived peroxy-radical but instead is relatively stable and carbon-centred.

In-target production of [13N]ammonia via proton irradiation of dilute aqueous ethanol and acetic acid mixtures

A reliable, reproducible method has been developed for the in situ production of decicurie quantities of [13N]ammonia by proton irradiation of pressurized, dilute aqueous solutions of acetic acid and ethanol. Some of the parameters investigated for their effect on the 13N product distribution included dose, dose rate, solute concentration, target body material, beam strike volume and proton energy. For the conditions investigated, [13N]NH3 was produced directly in the target in yields greater than 75%.