OP0207-HPR EFFECT OF FOOT ORTHOSES IN REDUCING PAIN IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS: A 12-MONTH RANDOMISED CLINICAL TRIAL

Background

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children and adolescents [1]. The manifestation of JIA may include joint swelling, tenderness, and painful limitation with joint movement. Only few studies have explored the effect of foot orthoses (FOs) alone in children with JIA [2,3]. These studies showed FOs can reduce pain in children with JIA, however, further research with larger sample sizes and longer follow-ups are needed [4]. Prescribing FOs on the same day of the initial assessment may promote early clinical and targeted intervention, which is the gold standard approach in paediatric rheumatology.

Objectives

This single blinded multicentre randomised clinical trial (RCT) aims to investigate the effect of customised prefabricated FOs in reducing pain amongst children and adolescents with JIA.

Methods

Overall, 66 children and adolescents with JIA presenting with foot symptoms were recruited from the Sydney Children’s Hospitals Network (Westmead and Randwick) and John Hunter Children’s Hospital (Newcastle). The primary outcome measure was pain with a minimal clinical significance of 8mm on the visual analogue scale (VAS). Participants were randomly allocated to receive either customised prefabricated or sham FOs. The trial intervention was a low-density Slimflex Simple device that was customised at chair-side. The control (sham) device was made of 2mm flat leather board with no corrective modifications. Standardised tests such as the Foot Posture Index, navicular drift and drop were used to identify biomechanical abnormalities. The FOs were worn for a total of 12 months, with data collected at baseline, 4 weeks, 3, 6 months and 12 months.

Results

Reduction in self-reported pain was statistically and clinically significant at 4-weeks (p=0.018, -14.92 [-27.30, -2.55]) and 3 months (p=<0.001, -28.93 [-40.90, -16.96]) post intervention in favour of the trial group. The 6- and 12-month follow-ups were not statistically or clinically significant. Parent reported pain was statistically and clinically significant at the 3-month (p=<0.001, -21.92 [-33.16, -10.67]) in the reduction of pain in favour of the trial group. However, parent reported pain was not statistically significant at the 4-week, 6- and 12- month follow-ups. These results are similar to child reported pain with a p-value of less than 0.001 and average coefficients twice that of the clinical significance cut-off for VAS pain in paediatric rheumatology. The trial intervention was safe and tolerated well by participants with high compliance and adherence rates.

Conclusion

Results of this clinical trial indicate customised preformed FOs can be effective in reducing pain and in children with JIA experiencing foot and ankle symptoms. Significant clinical effects appear to be within the first 3-months of intervention prescription and reduce beyond 6 months. Overall, this podiatric intervention was safe, inexpensive, well tolerated and it can be easily implemented as part of the multidisciplinary paediatric rheumatology care.

References

[1]Ravelli A, Martini A. Juvenile idiopathic arthritis. Lancet. 2007;369:767–78.

[2]Powell M, Seid M, Szer IS. Efficacy of custom foot orthotics in improving pain and functional status in children with juvenile idiopathic arthritis: a randomized trial. J Rheumatol 2005;32:943–50.

[3]Coda A, Fowlie PW, Davidson JE et al. Foot orthoses in children with juvenile idiopathic arthritis: a randomised controlled trial. Arch Dis Child 2014;99:649–51.

[4]Fellas A, Coda A, Hawke F. Physical and mechanical therapies for lower-limb problems in juvenile idiopathic arthritis: a systematic review with meta-analysis. Journal of the American Podiatric Medical Association. 2017 Sep;107(5):399-412.

Acknowledgements

We would like to acknowledge all parents and children for their precious time.

Disclosure of Interests

None declared

CD36 polymorphisms and the age of disease onset in patients with pathogenic variants within the mutation cluster region of APC

Background

Familial adenomatous polyposis (FAP) is an autosomal dominant condition that predisposes patients to colorectal cancer. FAP is the result of a loss of APC function due to germline pathogenic variants disrupting gene expression. Genotype-phenotype correlations are described for FAP. For example attenuated forms of the disease are associated with pathogenic variants at the 5’ and 3’ ends of APC whilst severe forms of the disease appear to be linked to variants occurring in the mutation cluster region (MCR) of the gene. Variants occurring in the MCR are phenotypically associated with hundreds to thousands of adenomas carpeting the colon and rectum and patients harbouring changes in this region have a high propensity to develop colorectal cancer. Not all patients who carry pathogenic variants in this region have severe disease which may be a result of environmental factors. Alternatively, phenotypic variation observed in these patients could be due to modifier genes that either promote or inhibit disease expression. Mouse models of FAP have provided several plausible candidate modifier genes, but very few of these have survived scrutiny. One such genetic modifier that appears to be associated with disease expression is CD36. We previously reported a weak association between a polymorphism in CD36 and a later age of disease onset on a relatively small FAP patient cohort.

Methods

In the current study, we enlarged the FAP cohort. 395 patients all carrying pathogenic variants in APC were tested against three CD36 Single Nucleotide Polymorphisms (SNP)s (rs1049673, rs1761667 rs1984112), to determine if any of them were associated with differences in the age of disease expression.

Results

Overall, there appeared to be a statistically significant difference in the age of disease onset between carriers of the variant rs1984112 and wildtype. Furthermore, test equality of survivor functions for each SNP and mutation group suggested an interaction in the Log Rank, Wilcoxon, and Tarone-Ware methods for rs1049673, rs1761667, and rs1984112, thereby supporting the notion that CD36 modifies disease expression.

Conclusions

This study supports and strengthens our previous findings concerning CD36 and an association with disease onset in FAP, AFAP and FAP-MCR affected individuals. Knowledge about the role CD36 in adenoma development may provide greater insight into the development of colorectal cancer.

Automated facial recognition for wildlife that lack unique markings: A deep learning approach for brown bears

Emerging technologies support a new era of applied wildlife research, generating data on scales from individuals to populations. Computer vision methods can process large datasets generated through image-based techniques by automating the detection and identification of species and individuals. With the exception of primates, however, there are no objective visual methods of individual identification for species that lack unique and consistent body markings. We apply deep learning approaches of facial recognition using object detection, landmark detection, a similarity comparison network, and an support vector machine-based classifier to identify individuals in a representative species, the brown bear Ursus arctos. Our open-source application, BearID, detects a bear's face in an image, rotates and extracts the face, creates an "embedding" for the face, and uses the embedding to classify the individual. We trained and tested the application using labeled images of 132 known individuals collected from British Columbia, Canada, and Alaska, USA. Based on 4,674 images, with an 80/20% split for training and testing, respectively, we achieved a facial detection (ability to find a face) average precision of 0.98 and an individual classification (ability to identify the individual) accuracy of 83.9%. BearID and its annotated source code provide a replicable methodology for applying deep learning methods of facial recognition applicable to many other species that lack distinguishing markings. Further analyses of performance should focus on the influence of certain parameters on recognition accuracy, such as age and body size. Combining BearID with camera trapping could facilitate fine-scale behavioral research such as individual spatiotemporal activity patterns, and a cost-effective method of population monitoring through mark-recapture studies, with implications for species and landscape conservation and management. Applications to practical conservation include identifying problem individuals in human-wildlife conflicts, and evaluating the intrapopulation variation in efficacy of conservation strategies, such as wildlife crossings.

A hypothetico-deductive approach to assessing the social function of chemical signalling in a non-territorial solitary carnivore

The function of chemical signalling in non-territorial solitary carnivores is still relatively unclear. Studies on territorial solitary and social carnivores have highlighted odour capability and utility, however the social function of chemical signalling in wild carnivore populations operating dominance hierarchy social systems has received little attention. We monitored scent marking and investigatory behaviour of wild brown bears Ursus arctos, to test multiple hypotheses relating to the social function of chemical signalling. Camera traps were stationed facing bear 'marking trees' to document behaviour by different age sex classes in different seasons. We found evidence to support the hypothesis that adult males utilise chemical signalling to communicate dominance to other males throughout the non-denning period. Adult females did not appear to utilise marking trees to advertise oestrous state during the breeding season. The function of marking by subadult bears is somewhat unclear, but may be related to the behaviour of adult males. Subadults investigated trees more often than they scent marked during the breeding season, which could be a result of an increased risk from adult males. Females with young showed an increase in marking and investigation of trees outside of the breeding season. We propose the hypothesis that females engage their dependent young with marking trees from a young age, at a relatively 'safe' time of year. Memory, experience, and learning at a young age, may all contribute towards odour capabilities in adult bears.

South Birmingham Coronary Prevention Project: a district approach to the prevention of heart disease

The South Birmingham Coronary Prevention Project is described, in which health checks by practice nurses in GPs' surgeries are combined with direct patient access to a secondary referral system. Where appropriate, health check attenders are offered the choice of either (a) counselling by the practice nurse, (b) direct referral to their GP, or (c) direct referral to secondary intervention, including specialist dietary advice for patients with high (greater than 6.5 mmol/l) serum cholesterol, stress management training for mild hypertension (diastolic blood pressure greater than 90 less than 105 mmHg), and smoking cessation groups. Significant reductions in blood pressure (p less than 0.005) and serum cholesterol levels (p less than 0.001) have been achieved. Further, substantial numbers of smokers have ceased since attending smoking cessation groups. This multidisciplinary approach to the identification and modification of risk factors for coronary heart disease may provide a powerful adjunct to wider ranging population interventions.

A multi-disciplinary approach to the prevention of coronary heart disease

The South Birmingham Coronary Prevention Project is described, in which health checks by practice nurses in GPs' surgeries are combined with direct patient access to a secondary referral system. Where appropriate, health check attenders are offered the choice of either counselling by the practice nurse, direct referral to their GP, or direct referral to secondary intervention, including dietary advice for patients with high serum cholesterol, stress management training for mild hypertension, and smoking cessation groups run by specialist workers. Further developments of the project may be toward increasing areas of nurses intervention, for example running lipid clinics, and combining with Look After Your Heart! in the workplace. Progress in each of these areas is described and discussed.

The effects of formulation and addition of adrenaline to cocaine for haemostasis in intranasal surgery

Twenty patients presenting for submucous resection of the nasal septum under general anaesthesia were randomly allocated to four groups to receive either 1.0 ml 25% cocaine HCl in paraffin paste, 1.0 ml 25% cocaine HCl combined with 0.1% adrenaline in paraffin paste, 4.0 ml aqueous 4% cocaine HCl combined with 0.05% adrenaline or 4.0 ml aqueous 4% cocaine HCl on ribbon gauze applied to the nasal mucosa. Mean intraoperative blood loss was significantly decreased when the 25% cocaine 0.1% adrenaline combination in paraffin paste was used (11 (SD 8) ml, 60 (SD 30) ml, P less than 0.05, for adrenaline and plain paste respectively). Combination of adrenaline with cocaine in the aqueous formulation was not associated with a significant decrease in blood loss compared with aqueous cocaine alone (75 (SD 51), 96 (SD 66) ml respectively). Cocaine adrenaline paste and plain cocaine paste were associated with higher mean maximum cocaine blood concentrations (1.6 (SD 1.4), 2.0 (SD 1.5) micrograms/ml respectively) when compared with aqueous cocaine adrenaline and aqueous cocaine alone (0.03 (SD 0.003), 0.5 (SD 0.3) microgram/ml respectively). Heart rate and blood pressure changes were similar in all four groups and cardiovascular toxicity was not observed. One ml of topical intranasal 25% cocaine HCl with 0.1% adrenaline in paraffin paste provided the best haemostasis for nasal septal surgery.

The validity of oxygen content calculations

Blood oxygen content calculated from haemoglobin concentration, measured haemoglobin oxygen saturation and measured oxygen tension was compared with three other methods of estimating oxygen content. These other methods were those of Van Slyke and Zander, which are direct methods, and a method using Kelman's equation to estimate the saturation from measured oxygen tension and hence content. The coefficients of correlation (corr coeff) (r) were 0.9050 (n = 22), 0.9919 (n = 24) and 0.9862 (n = 25) for the respective methods when compared with oxygen content calculated using measured saturation. The Van Slyke method proved to be imprecise in our hands. The direct measurement using the oxygen cuvette of Zander gave oxygen content values similar to those estimated from measured saturation. The oxygen content calculated from pO2 alone when compared to that derived from measured saturation had a corr coeff (r) of 0.9862 (n = 25), but the high residual standard deviation (So) of 6.939 ml/l indicates that the practice of calculating oxygen content from oxygen tension alone is imprecise. We conclude that oxygen content may be satisfactorily estimated by the Zander method when it becomes generally available, but until then the measurement of oxygen saturation is a necessary prerequisite to the estimation of blood oxygen content.