A multi-professional survey of UK practice in the use of intra-articular corticosteroid injection for symptomatic first metatarsophalangeal joint osteoarthritis

BACKGROUND

The first metatarsophalangeal joint is the most common site of osteoarthritis (OA) in the foot and ankle. Intra-articular corticosteroid injections are widely used for this condition, but little is known about their use in practice. This study explored current practice within the UK National Health Service (NHS) relating to the administration of intra-articular corticosteroids for people with painful first metatarsophalangeal joint (MTPJ) OA.

METHODS

A cross-sectional survey using Qualtrics online survey platform (Qualtrics, Provo, UT, USA), distributed through professional bodies, special interest groups, and social media.

RESULTS

One hundred forty-four healthcare professionals responded, including podiatrists (53/144; 39%), orthopaedic surgeons (28/144; 19%), podiatric surgeons (26/144; 17%) and physiotherapists (24/144; 16%). Half of respondents administered up to 25 corticosteroid injections per year (67/136; 49%) but some administered more than fifty (21/136; 15%). Injections were administered across the healthcare system but were most common in hospital settings (64/136; 44%) followed by community (38/136; 26%), with less delivered in primary care (11/136; 8%). Half of respondents routinely used image-guidance, either ultrasound or x-ray/fluoroscopy (65/136; 48%) although over one third used none (52/136; 38%). Imaging guidance was more common amongst medical professionals (21/31; 68%) compared to non-medical health professionals (45/105; 43%). Overall, methylprednisolone acetate was the most common corticosteroid used. Medical professionals mostly injected methylprednisolone acetate (n = 15/27; 56%) or triamcinolone acetonide (n = 11/27; 41%), whereas premixed methylprednisolone acetate with lidocaine hydrochloride was the most common preparation used by non-medical health professionals (41/85; 48%). When injecting non premixed steroid, lidocaine hydrochloride (15/35; 43%) was the most common choice of local anaesthetic for non-medical health professionals but medical professionals showed more variation between lidocaine hydrochloride (8/23; 35%) levobupivacaine hydrochloride (9/23; 39%) and bupivacaine hydrochloride (5/23; 22%).

CONCLUSIONS

Multiple professional groups regularly administer intra-articular corticosteroids for symptomatic first MTPJ OA across a range of NHS healthcare settings. Overall, methylprednisolone acetate was the most commonly administered steroid and lidocaine hydrochloride the most common local anaesthetic. There was large variation in the use of imaging guidance, type and dose of steroid, local anaesthetic, and clinical pathways used in the intra-articular injection of corticosteroids for people with first MTPJ OA.

Research priority setting in UK podiatric surgery

Evidence-based practice provides the foundation for high quality patient care, and in the NHS, research is seen as vital to enable service transformation and improve outcomes. Research is one of the four pillars of enhanced and advanced clinical practice and is therefore a fundamental part of podiatric surgery services. In order to meet the UK health research strategies, the most recent being 'Saving and Improving Lives: The Future of UK Clinical Research Delivery' (2021), the Faculty of Podiatric Surgery in the UK agreed to support the development of research priorities in order to inform a future research strategy.The Podiatric Surgery Research Strategy Group was set up and embarked on a project with the aim of engaging its members in formulating and agreeing national research priorities. The initial stage included a national research scoping survey to identify key themes, topic, and research questions. The final stage consisted of developing and enabling a live consensus vote conducted at the 2022 national Faculty of Podiatric Surgery Conference. At the end of the vote, the top five research topics that met the agreement criteria were: 1. Surgical treatment - forefoot, 2. Patient reported outcome measures, 3. Post-operative management, 4. Surgical treatment - midfoot and 5. Service delivery. The top five research questions that met the criteria were1. How does quality of life improve following elective foot surgery? 2. How does podiatric surgery benefit the health of the population? 3. How does podiatric surgery benefit the health of the population in the at-risk foot? 4. What is the most effective Lapidus fixation option? and 5. What is the benefit of utilising PASCOM-10 to improve large scale outcome data? These will inform the initial UK podiatric surgery research priorities in the next three to five years.

Bone Marrow Lesions and Magnetic Resonance Imaging-Detected Structural Abnormalities in Patients With Midfoot Pain and Osteoarthritis: A Cross-Sectional Study

OBJECTIVE

To compare magnetic resonance imaging (MRI)-detected structural abnormalities in patients with symptomatic midfoot osteoarthritis (OA), patients with persistent midfoot pain, and asymptomatic controls, and to explore the association between MRI features, pain, and foot-related disability.

METHODS

One hundred seven adults consisting of 50 patients with symptomatic and radiographically confirmed midfoot OA, 22 adults with persistent midfoot pain but absence of radiographic OA, and 35 asymptomatic adults underwent 3T MRI of the midfoot and clinical assessment. MRIs were read for the presence and severity of abnormalities (bone marrow lesions [BMLs], subchondral cysts, osteophytes, joint space narrowing [JSN], effusion-synovitis, tenosynovitis, and enthesopathy) using the Foot Osteoarthritis MRI Score. Pain and foot-related disability were assessed with the Manchester Foot Pain and Disability Index.

RESULTS

The severity sum score of BMLs in the midfoot was greater in patients with midfoot pain and no signs of OA on radiography compared to controls (P = 0.007), with a pattern of involvement in the cuneiform-metatarsal joints similar to that in patients with midfoot OA. In univariable models, BMLs (ρ = 0.307), JSN (ρ = 0.423), and subchondral cysts (ρ = 0.302) were positively associated with pain (P < 0.01). In multivariable models, MRI abnormalities were not associated with pain and disability when adjusted for covariates.

CONCLUSION

In individuals with persistent midfoot pain but no signs of OA on radiography, MRI findings suggested an underrecognized prevalence of OA, particularly in the second and third cuneiform-metatarsal joints, where BML patterns were consistent with previously recognized sites of elevated mechanical loading. Joint abnormalities were not strongly associated with pain or foot-related disability.

Intrinsic foot muscle size and associations with strength, pain and foot-related disability in people with midfoot osteoarthritis

BACKGROUND

To compare intrinsic foot muscle size between people with and without symptomatic midfoot osteoarthritis, and examine the association between muscle size and strength, pain and foot-related disability.

METHODS

Twenty-three participants with symptomatic midfoot osteoarthritis and 23 age, sex and BMI matched controls were included. Intrinsic foot muscle cross-sectional area was measured using MRI. Hand-held dynamometry was used to assess foot and ankle muscle strength, and foot-related pain and disability was measured using Manchester Foot Pain & Disability Index.

FINDINGS

Small and non-statistically significant differences were found in intrinsic foot muscle cross-sectional area between the two groups (effect sizes 0.15-0.26, p > 0.05). Muscle strength was reduced in the midfoot osteoarthritis group, with differences of 12-33% (effect sizes 0.47-1.2). In the control group, moderate positive associations) existed between foot muscle cross-sectional area and lesser digits flexor strength (r = 0.5 to 0.7, p < 0.05). Conversely, in the midfoot osteoarthritis group, negligible positive associations were found (r < 0.3, p > 0.05). Associations between foot muscle cross-sectional with and pain and disability scores in the midfoot osteoarthritis group were negligible (r < -0.3, p > 0.05).

INTERPRETATION

Despite reductions in maximal isometric muscle strength, midfoot osteoarthritis does not appear to be associated with reduced intrinsic foot muscle cross-sectional area measured by MRI. Muscle compositional or neural factors may explain the reductions in muscle strength and variation in symptoms in people with midfoot osteoarthritis and should be investigated.

International Foot and Ankle Osteoarthritis Consortium review and research agenda for diagnosis, epidemiology, burden, outcome assessment and treatment

OBJECTIVE

To summarise the available evidence relating to the diagnosis, epidemiology, burden, outcome assessment and treatment of foot and ankle osteoarthritis (OA) and to develop an agenda to guide future research.

METHOD

Members of the International Foot and Ankle Osteoarthritis Consortium compiled a narrative summary of the literature which formed the basis of an interactive discussion at the Osteoarthritis Research Society International World Congress in 2021, during which a list of 24 research agenda items were generated. Following the meeting, delegates were asked to rank the research agenda items on a 0 to 100 visual analogue rating scale (0 = not at all important to 100 = extremely important). Items scoring a mean of 70 or above were selected for inclusion.

RESULTS

Of the 45 delegates who attended the meeting, 31 contributed to the agenda item scoring. Nineteen research agenda items met the required threshold: three related to diagnosis, four to epidemiology, four to burden, three to outcome assessment and five to treatment.

CONCLUSIONS

Key knowledge gaps related to foot and ankle OA were identified, and a comprehensive agenda to guide future research planning was developed. Implementation of this agenda will assist in improving the understanding and clinical management of this common and disabling, yet relatively overlooked condition.

Foot and Leg Muscle Weakness in People With Midfoot Osteoarthritis

OBJECTIVE

To compare foot and leg muscle strength in people with symptomatic midfoot osteoarthritis (OA) with asymptomatic controls, and to determine the association between muscle strength, foot pain, and disability.

METHODS

Participants with symptomatic midfoot OA and asymptomatic controls were recruited for this cross-sectional study from general practices and community health clinics. The maximum isometric muscle strength of the ankle plantarflexors, dorsiflexors, invertors and evertors, and the hallux and lesser toe plantarflexors was measured using hand-held dynamometry. Self-reported foot pain and foot-related disability were assessed with the Manchester Foot Pain and Disability Index. Differences in muscle strength were compared between groups. Multivariable regression was used to determine the association between muscle strength, foot pain, and disability after adjusting for covariates.

RESULTS

People with midfoot OA (n = 52) exhibited strength deficits in all muscle groups, ranging from 19% (dorsiflexors) to 30% (invertors) relative to the control group (n = 36), with effect sizes of 0.6-1.1 (P < 0.001). In those with midfoot OA, ankle invertor muscle strength was negatively and independently associated with foot pain (β = -0.026 [95% confidence interval (95% CI) -0.051, -0.001]; P = 0.045). Invertor muscle strength was negatively associated with foot-related disability, although not after adjustment for depressive symptoms (β = -0.023 [95% CI -0.063, 0.017]; P = 0.250).

CONCLUSION

People with symptomatic midfoot OA demonstrate weakness in the foot and leg muscles compared to asymptomatic controls. Preliminary indications from this study suggest that strengthening of the foot and leg muscles may offer potential to reduce pain and improve function in people with midfoot OA.

Development and Reliability of a Preliminary Foot Osteoarthritis Magnetic Resonance Imaging Score

OBJECTIVE

Foot osteoarthritis (OA) is very common but underinvestigated musculoskeletal condition and there is little consensus as to common magnetic resonance imaging (MRI) features. The aim of this study was to develop a preliminary foot OA MRI score (FOAMRIS) and evaluate its reliability.

METHODS

This preliminary semiquantitative score included the hindfoot, midfoot, and metatarsophalangeal joints. Joints were scored for joint space narrowing (JSN; 0-3), osteophytes (0-3), joint effusion/synovitis, and bone cysts (present/absent). Erosions and bone marrow lesions (BML) were scored (0-3) and BML were evaluated adjacent to entheses and at sub-tendon sites (present/absent). Additionally, tenosynovitis (0-3) and midfoot ligament pathology (present/absent) were scored. Reliability was evaluated in 15 people with foot pain and MRI-detected OA using 3.0T MRI multi-sequence protocols, and assessed using ICC as an overall score and per anatomical site.

RESULTS

Intrareader agreement (ICC) was generally good to excellent across the foot in joint features (JSN 0.90, osteophytes 0.90, effusion/synovitis 0.46, cysts 0.87), bone features (BML 0.83, erosion 0.66, BML entheses 0.66, BML sub-tendon 0.60) and soft tissue features (tenosynovitis 0.83, ligaments 0.77). Interreader agreement was lower for joint features (JSN 0.43, osteophytes 0.27, effusion/synovitis 0.02, cysts 0.48), bone features (BML 0.68, erosion 0.00, BML entheses 0.34, BML sub-tendon 0.13), and soft tissue features (tenosynovitis 0.35, ligaments 0.33).

CONCLUSION

This preliminary FOAMRIS demonstrated good intrareader reliability and fair interreader reliability when assessing the total feature scores. Further development is required in cohorts with a range of pathologies and to assess the psychometric measurement properties.

Comparability of off the shelf foot orthoses in the redistribution of forces in midfoot osteoarthritis patients

BACKGROUND

Midfoot osteoarthritis (OA) is more prevalent and strongly associated with pain than previously thought. Excessive mechanical loading of the midfoot structures may contribute to midfoot OA and studies suggest that functional foot orthoses (FFO) may relieve pain through improving function. This exploratory study aimed to evaluate the mechanical effect of two off-the-shelf FFOs, compared to a sham orthosis in people with midfoot OA.

METHODS

Thirty-three participants with radiographically confirmed symptomatic midfoot OA were randomly assigned to wear either a commercially available FFO or a sham orthosis. After wearing their assigned orthoses for 12 weeks, plantar pressure measurements were obtained under shoe-only and assigned orthoses conditions. Participants assigned to the sham, were additionally tested wearing a second type of FFO at the end of trial. Descriptive mean change (±95% confidence intervals) in plantar pressure for each orthoses condition, versus a shoe only baseline condition are presented.

FINDINGS

Compared to the shoe only conditions, both FFOs decreased hindfoot and forefoot maximum force and peak pressure, whilst increasing maximum force and contact area under the midfoot. The sham orthosis yielded plantar pressures similar to the shoe-only condition.

INTERPRETATION

Findings suggest that both types of off-the-shelf FFO may provide mechanical benefit, whilst the sham orthoses produced similar findings to the shoe only condition, indicating appropriate sham properties. This paper provides insight into the mechanisms of action underpinning the use of FFOs and sham orthoses, which can inform future definitive RCTs examining the effect of orthoses on midfoot OA.

The feasibility of a modified shoe for multi-segment foot motion analysis: a preliminary study

Background

The majority of multi-segment kinematic foot studies have been limited to barefoot conditions, because shod conditions have the potential for confounding surface-mounted markers. The aim of this study was to investigate whether a shoe modified with a webbed upper can accommodate multi-segment foot marker sets without compromising kinematic measurements under barefoot and shod conditions.

Methods

Thirty participants (15 controls and 15 participants with midfoot pain) underwent gait analysis in two conditions; barefoot and wearing a shoe (shod) in a random order. The shod condition employed a modified shoe (rubber plimsoll) with a webbed upper, allowing skin mounted reflective markers to be visualised through slits in the webbed material. Three dimensional foot kinematics were captured using the Oxford multi-segment foot model whilst participants walked at a self-selected speed.

Results

The foot pain group showed greater hindfoot eversion and less hindfoot dorsiflexion than controls in the barefoot condition and these differences were maintained when measured in the shod condition. Differences between the foot pain and control participants were also observed for walking speed in the barefoot and in the shod conditions. No significant differences between foot pain and control groups were demonstrated at the forefoot in either condition.

Conclusions

Subtle differences between pain and control groups, which were found during barefoot walking are retained when wearing the modified shoe. The novel properties of the modified shoe offers a potential solution for the use of passive infrared based motion analysis for shod applications, for instance to investigate the kinematic effect of foot orthoses.

Foot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study

This randomised feasibility study aimed to examine the clinical and biomechanical effects of functional foot orthoses (FFOs) in the treatment of midfoot osteoarthritis (OA) and the feasibility of conducting a full randomised controlled trial. Participants with painful, radiographically confirmed midfoot OA were recruited and randomised to receive either FFOs or a sham control orthosis. Feasibility measures included recruitment and attrition rates, practicality of blinding and adherence rates. Clinical outcome measures were: change from baseline to 12 weeks for severity of pain (numerical rating scale), foot function (Manchester Foot Pain and Disability Index) and patient global impression of change scale. To investigate the biomechanical effect of foot orthoses, in-shoe foot kinematics and plantar pressures were evaluated at 12 weeks. Of the 119 participants screened, 37 were randomised and 33 completed the study (FFO = 18, sham = 15). Compliance with foot orthoses and blinding of the intervention was achieved in three quarters of the group. Both groups reported improvements in pain, function and global impression of change; the FFO group reporting greater improvements compared to the sham group. The biomechanical outcomes indicated the FFO group inverted the hindfoot and increased midfoot maximum plantar force compared to the sham group. The present findings suggest FFOs worn over 12 weeks may provide detectable clinical and biomechanical benefits compared to sham orthoses. This feasibility study provides useful clinical, biomechanical and statistical information for the design and implementation of a definitive randomised controlled trial to evaluate the effectiveness of FFOs in treating painful midfoot OA.

Effectiveness of neuromuscular taping on pronated foot posture and walking plantar pressures in amateur runners

OBJECTIVES

To determine the effect kinesiotaping (KT) versus sham kinesiotaping (sham KT) in the repositioning of pronated feet after a short running.

DESIGN

Prospective, randomised, double-blinded, using a repeated-measures design with no cross-over.

METHODS

116 amateur runners were screened by assessing the post-run (45min duration) foot posture to identify pronated foot types (defined by Foot Posture Index [FPI] score of ≥6). Seventy-three runners met the inclusion criteria and were allocated into two treatment groups, KT (n=49) and sham KT (n=24). After applying either the KT or sham KT and completing 45min of running (mean speed of 12km/h), outcome measures were collected (FPI and walking Pedobarography).

RESULTS

FPI was reduced in both groups, more so in the KT group (mean FPI between group difference=0.9, CI 0.1-1.9), with a score closer to neutral. There were statistically significant differences between KT and sham KT (p<.05 and p<.01) in pressure time integral, suggesting that sham KT had a greater effect.

CONCLUSIONS

KT may be of some assistant to clinicians in correction of pronated foot posture in a short-term. There was no effect of KT, however on pressure variables at heel strike or toe-off following a short duration of running, the sham KT technique had a greater effect.

LEVEL OF EVIDENCE

Therapy, level 1b.

Weight-bearing passive dorsiflexion of the hallux in standing is not related to hallux dorsiflexion during walking

STUDY DESIGN

Case control study.

OBJECTIVE

To explore the validity of the assumptions underpinning the Hubscher maneuver of hallux dorsiflexion in relaxed standing, by comparing the relationship between static and dynamic first metatarsophalangeal (MTP) joint motions in groups differentiated by normal and abnormal clinical test findings.

BACKGROUND

Limitation of motion at the first MTP joint during gait may be due to either structural or functional factors. Functional hallux limitus (FHL) has been proposed as a term to describe the situation in which the first MTP joint shows no limitation when non-weight bearing, but shows limited dorsiflexion during gait. One clinical test of first MTP joint limitation during standing (the Hubscher maneuver or Jack's test) has become widely used in physical therapy, orthopedic, and podiatric assessments, supposedly to assess for the presence of hallux limitations during gait. The utility of the test is based on an assumption that restriction during the static maneuver is predictive of functional limitation at this joint during gait. Despite a lack of evidence for the validity of such an assumption, the outcome of the static test is often used to infer risk of overuse injury or as an outcome for functional therapy. This paper examines the validity of the assumptions supporting this widely used static test.

METHODS AND MEASURES

First-MTP-joint motion was assessed using an electromagnetic motion tracking system in cases (n = 15) demonstrating clinically limited passive hallux dorsiflexion in relaxed standing, and in 15 controls matched for age and gender and demonstrating a clinically normal Hubscher maneuver. Maximum hallux dorsiflexion was measured with the subject non-weight bearing (seated), during relaxed standing, and during normal walking.

RESULTS

Hallux dorsiflexion was similar in cases and controls when motions were measured non-weight bearing (cases mean +/- SD, 55.0 degrees +/- 11.0 degrees; controls mean + SD, 55.0 degrees +/- 10.7 degrees), confirming the absence of structural joint change. In relaxed standing, maximum dorsiflexion was 50% less in cases (mean +/- SD, 19.0 degrees +/- 8.9 degrees) than in the controls (mean +/- SD, 39.4 degrees +/- 6.1 degrees; P < .001), supporting the initial test outcome and confirming the visual test observation of static functional limitation in the case group. During gait, however, cases (mean +/- SD, 36.4 degrees +/- 9.1 degrees), and controls (mean +/- SD, 36.9 degrees +/- 7.9 degrees) demonstrated comparable maximum dorsiflexion (P = .902). There was no significant relationship between static and dynamic first MTP joint motions (r = 0.186, P = .325).

CONCLUSION

The clinical test of limited passive hallux dorsiflexion in stance is a valid test only of hallux dorsiflexion available during relaxed standing. There is no association between maximum dorsiflexion observed during a static weight-bearing examination and that occurring at the same joint during walking.

The relationship between hallux dorsiflexion and ankle joint complex frontal plane kinematics: a preliminary study

BACKGROUND

It has been suggested that the function of the first metatarsophalangeal joint may be related to the motion of the ankle joint complex.

OBJECTIVE

This study explored the relationship between ankle joint complex and first metatarsophalangeal joint motion during gait in a group of 14 who demonstrated clinically limited passive hallux dorsiflexion in quiet standing (cases), and 15 matched controls.

METHOD

An electromagnetic tracking system was used to measure the ankle joint complex frontal plane motion and first metatarsophalangeal joint sagittal plane motion during gait, in both cases and controls. The case group was then evaluated further to investigate the effect of an orthosis on first metatarsophalangeal joint motion.

FINDINGS

The correlation between maximum ankle joint complex eversion and maximum first metatarsophalangeal joint dorsiflexion during gait was r=0.471. Within the case group, maximum rearfoot eversion was reduced following the application of the orthoses, but there was no change in sagittal first metatarsophalangeal joint rotations.

INTERPRETATION

The relationship between maximum ankle joint complex eversion and first metatarsophalangeal joint dorsiflexion kinematics found in this study was moderate, and decreasing maximum ankle joint complex eversion with an orthosis did not result in any increase in first metatarsophalangeal joint dorsiflexion during gait in patients with functional first metatarsophalangeal joint limitation. These results do not support the assumption that ankle joint complex eversion influences first metatarsophalangeal joint motion substantially.

Risk factors for asthma morbidity and mortality in a large metropolitan city

Morbidity and mortality due to asthma continues to increase despite advances in understanding the pathophysiology and treatment of the disease. We evaluated the potential risk factors for asthma morbidity and mortality in a large metropolitan city (St. Louis, MO) using small area geographic analysis. We found that the risk of hospitalization for children with asthma was 8.4 times greater (95% confidence interval [CI] 7.0-9.9) in lower socioeconomic zip code areas and 5.3 times greater (95% CI 4.7-5.9) in those zip codes with a higher percentage of African Americans. Similarly, the risk of death due to asthma was 6.4 times greater in the lower socioeconomic zip code areas (95% CI3.4-12.1). Lower socioeconomic status and African American race are strong risk factors for hospitalization and mortality from asthma. Public policy and healthcare resources need to be organized and directed more efficiently to this population.

Conservative surgical treatment of valvular injury after blunt chest trauma

BACKGROUND

Blunt injury to the cardiac valves leads to progressive ventricular failure often requiring surgical management. Most frequently, prosthetic replacement is the chosen management.

METHODS

Three consecutive patients presenting to one surgeon with blunt traumatic valve lesions formed the study group.

RESULTS

At operation, the valvular pathology was assessed, and reparative techniques were used to correct the defects. All the patients had an excellent outcome at follow-up periods of 2 to 3 years.

CONCLUSIONS

Conservative operation to repair traumatic valve lesions is feasible and has potential advantages over replacement.

Sleep problems in emergency department patients with injuries

OBJECTIVES

To assess trauma patients' frequency of sleep problems, to evaluate their injuries in the context of their sleep habits, and to determine how often ED health care workers (HCWs) inquire about sleep complaints.

METHODS

This was a prospective observational study of patients evaluated in the ED for unintentional trauma. Patients answered a "sleep survey" that was reviewed for the amount and timing of sleep in the preinjury period and for indications of a sleep problem. Preinjury sleep characteristics were compared with the individual's usual habits, and the group's sleep features were compared with "normal" sleep and the prevalence of sleep problems in historical controls.

RESULTS

Seventy patients were surveyed. Mechanisms and types of injury included motor vehicle collisions (MVCs), falls, lacerations, bruises, sprains, and fractures. The mean total sleep time in the preinjury period (6.9 hours) was significantly shorter than that obtained during usual weekday and weekend sleep. Twenty-four patients (34.3%) were at high risk for a sleep problem. Few patients thought a sleep problem contributed to the injury. No other ED HCW asked about the patient's sleep habits.

CONCLUSIONS

Acute sleep deprivation in the preinjury period, and chronic sleep deprivation with a variety of other sleep problems are found in this patient population. Despite the association of sleep problems and certain types of injury (e.g., MVC), ED HCWs do not inquire about sleep in their initial ED evaluations. This important issue may be overlooked in trauma risk assessment and prevention.

Psychosocial risk factors in near-fatal asthma and in asthma deaths

BACKGROUND

A description of near-fatal asthma (NFA) and comparison with patients who died of asthma in an English health district between 1988 and 1995.

METHODS

The hospital case notes of patients aged under 65 years with NFA, identified from the intensive therapy unit register, were reviewed using forms based on those of the East Anglian confidential asthma death enquiry. Details were compared with patients dying from asthma in the same population during the same period.

RESULTS

Between 1988 and 1995, 19 patients suffered 23 episodes of NFA and 44 died from asthma. Those with NFA were significantly younger. There were more women in both groups. Two patients with NFA subsequently died of asthma. Significantly more patients with NFA had had a previous NFA episode than those who died. Five had a cardio-respiratory arrest. Thirteen required intermittent positive pressure ventilation (IPPV). PaCO2 ranged from 6.1 to 17.8 kPa; nine had PaCO2 > or = 10 kPa and three recovered without IPPV. Adverse psychological and social factors were similar in both groups. Denial was the commonest psychological factor and domestic, financial or employment stress, smoking or passive smoking the commonest adverse social factors; only two with NFA and seven who died had no recorded adverse psychological or social factors.

CONCLUSIONS

NFA and deaths from asthma occur in asthmatics who have many psychosocial risk factors in common. Special attention needs to be directed at patients with these adverse psychosocial factors, emphasising that they need continued follow-up with support to help them manage their asthma according to currently recommended practice.

Outcomes of time-limited psychotherapy in applied settings: replicating the Second Sheffield Psychotherapy Project

In a replication and extension of the Second Sheffield Psychotherapy Project (SPP2), a collaborative psychotherapy project (CPP) was carried out at 3 sites within the National Health Service of the United Kingdom. Clients (N = 36) stratified at 3 levels of severity of depression were randomly assigned to one of 2 treatment approaches (psychodynamic-interpersonal or cognitive-behavioral) of 2 time-limited durations (8 or 16 sessions). Gains in both treatment approaches were approximately equivalent and were similar for CPP and SPP2 clients when measured at the end of treatment. However, CPP patients did not maintain their gains to the extent that the SPP2 clients did at 3-month and 1-year follow-up assessments. In the CPP, clients given 16 sessions showed a statistically significant advantage over clients given 8 sessions on some measures at some assessments; in the SPP2, similar effects were noted only among some subgroups of clients.

Outcomes of time-limited psychotherapy in applied settings: replicating the Second Sheffield Psychotherapy Project

In a replication and extension of the Second Sheffield Psychotherapy Project (SPP2), a collaborative psychotherapy project (CPP) was carried out at 3 sites within the National Health Service of the United Kingdom. Clients (N = 36) stratified at 3 levels of severity of depression were randomly assigned to one of 2 treatment approaches (psychodynamic-interpersonal or cognitive-behavioral) of 2 time-limited durations (8 or 16 sessions). Gains in both treatment approaches were approximately equivalent and were similar for CPP and SPP2 clients when measured at the end of treatment. However, CPP patients did not maintain their gains to the extent that the SPP2 clients did at 3-month and 1-year follow-up assessments. In the CPP, clients given 16 sessions showed a statistically significant advantage over clients given 8 sessions on some measures at some assessments; in the SPP2, similar effects were noted only among some subgroups of clients.

Evidence for involvement of phosphatidylcholine-phospholipase C and protein kinase C in transforming growth factor-beta signaling

Transforming growth factor-beta (TGF-beta) is a multifunctional peptide that elicits a wide variety of responses in cells. TGF-beta binds to cell surface receptors that contain cytoplasmic serine/threonine kinase domains. Here we provide evidence that both phospholipase C and protein kinase C (PKC) are involved in the TGF-beta activation of transcription and luciferase expression from the p3TP-Lux plasmid. Down-regulation of PKC prevents TGF-beta 1 induction of luciferase expression. Staurosporin and Calphostin C, inhibitors of PKC, block the ability of TGF-beta 1 to initiate transcription of the luciferase gene. Further, D609, an inhibitor of phosphatidylcholine-phospholipase C (PC-PLC), and secondarily PKC also blocks TGF-beta 1-induced transcription of the transgene in A549 cells while the phosphatidylinositol-PLC pathway inhibitor U73122 is without effect. TGF-beta elevates steady-state mRNA levels for the endogenous PAI-1 and fibronectin genes. Treatment of cells with calphostin C or D609 prevents the TGF-beta-induced increase in these mRNAs. Together, these results suggest that PC-PLC and PKC are in a TGF-beta signaling pathway that results in elevated gene expression.

Nursing student information network: fostering collegial communications using a computer conference

This article describes the development and implementation of a student-based computer information network in a university setting. A computer conference was established as a pilot project on two campuses in a large multipurpose, multicampus university school of nursing, and it was used to communicate information and facilitate collegial interaction among students, faculty, academic counselors, and administrators. The project demonstrates that computer conferences can be used to disseminate information effectively to diverse and geographically distant student populations. Such networks have the potential to enhance opportunities for collaborative learning experiences and student-faculty communication.

The genetic advantage hypothesis in cystic fibrosis heterozygotes: a murine study

1. The delta F508 mutation of the cystic fibrosis (CF) gene is of high frequency in man (1 in 25) and in homozygotes causes cystic fibrosis. It is suggested that cystic fibrosis heterozygotes withstand secretory diarrhoea better than normal individuals and so are genetically advantaged. This hypothesis has been examined by measuring electrogenic chloride secretion in gut epithelia of normal and heterozygous CF mice. 2. Chloride secretory responses of normal and heterozygous colonic epithelia to forskolin, vasoactive intestinal polypeptide (VIP), isoprenaline, cholera toxin, heat-stable enterotoxin (STa), guanylin, carbachol and lysylbradykinin were examined. No significant differences in responses of tissues of the two genotypes were found. 3. Responses of normal and heterozygous ileal epithelia to forskolin and glucose were investigated. Heterozygous tissues responded as well as normal tissues. 4. Frusemide (furosemide) caused virtually identical inhibition of the chloride secretory responses to forskolin in colonic epithelia of both genotypes. 5. No evidence to support the genetic advantage hypothesis in ileal or colonic epithelia of the null CF mouse has been found, at least for acute responses. If the hypothesis is true then either (a) other non-cystic fibrosis transmembrane conductance regulator (non-CFTR) transport processes are involved, (b) prolonged exposure to secretagogues is required, or (c) delta F508 CFTR is responsible for the protective effect.

Revascularization of the right coronary artery

This study was undertaken to evaluate revascularization of the right coronary artery with regard to factors that enter into the decision to graft less significant lesions, such as graft flow, graft patency and progression of proximal disease. The results of grafting the right coronary artery were studied in 23 patients with lesions reducing luminal diameter by less than 50 percent (Group 1), 35 patients with luminal narrowing of 50 to 70 percent (Group 2) and 112 patients with greater than 70 percent luminal narrowing (Group 3). At operation there was no significant difference in saphenous vein graft flows among the three groups. Postoperatively the mean follow-up period was 20, 27 and 26 months, respectively. Graft patency was not significantly different among the three groups. Progression of the proximal lesion was studied and compared with that in 71 ungrafted right coronary arteries, 60 with less than 50 percent stenosis and 11 with more than 50 percent stenosis. Among vessels with less than 50 percent narrowing, the proximal lesion showed progression in 26 percent of the ungrafted vessels and in 83 percent of the grafted vessels (P less than 0.005); progression to total occlusion occurred in 3 percent of the former and in 28 percent of the latter (P less than 0.005). Progression to total occlusion was more frequently associated with a patent than with an occluded graft (P less than 0.05). The occurrence of significant progression in ungrafted vessels and the lack of effect on graft patency of the severity of the proximal disease suggest that revascularization of less significant lesions may be of value. However, the resultant increase in progression of proximal disease makes the patient dependent on the long-term patency of the vein graft.

Evaluation of a prepared childbirth program

A study was undertaken to ascertain what effects on the outcome of labor and delivery could be attributed to a prepared childbirth program. Three tables are included setting forth statistical relationships. The basic conclusion was that more than five hours of structured prenatal education has a positive impact on maternal-child health.