Can routine assessment of older people's mental health lead to improved outcomes: A regression discontinuity analysis

OBJECTIVE

To assess whether case finding for depression among people aged 65 and above improves mental health.

DESIGN

Opportunistic evaluation using a regression discontinuity analysis with data from a randomised controlled trial.

SETTING

The REFORM trial, a falls prevention study that recruited patients from NHS podiatry clinics.

PARTICIPANTS

1010 community-dwelling adults over the age of 65 with at least one risk factor for falling (recent previous fall or fear of falling).

INTERVENTION

Letter sent to patient's General Practitioner if they scored 10 points or above on the 15-item Geriatric Depression Scale (GDS-15) informing them of the patient's risk of depression.

MAIN OUTCOME MEASURE

GDS-15 score six months after initial completion of GDS-15.

RESULTS

895 (88.6%) of the 1010 participants randomised into REFORM had a valid baseline and six-month GDS-15 score and were included in this study. The mean GDS-15 baseline score was 3.5 (SD 3.0, median 3.0, range 0-15); 639 (71.4%) scored 0-4, 204 (22.8%) scored 5-9 indicating mild depression, and 52 (5.8%) scored 10 or higher indicating severe depression. At six months follow-up, those scoring 10 points or higher at baseline had, on average, a reduction of 1.08 points on the GDS-15 scale (95% confidence interval -1.83 to -0.33, p = 0.005) compared to those scoring less than 10, using the simplest linear regression model.

CONCLUSION

Case finding of depression in podiatry patients based on a GDS-15 score of 10 or more followed by a letter to their General Practitioner significantly reduced depression severity. Whether this applies to all older patients in primary care is unknown. Further research is required to confirm these findings. Regression discontinuity analyses could be prespecified and embedded within other existing research studies.

The Application of Forensic Podiatry to Clinical Practice

The practice of the clinical podiatrist traditionally focuses on the diagnosis and treatment of conditions of the foot, ankle, and related structures of the leg. Clinical podiatrists are expected to be mindful of "the principles and applications of scientific enquiry." This includes the evaluation of treatment efficacy and the research process. In contrast, the forensic podiatrist specializes in the analysis of foot-, ankle-, and gait-related evidence in the context of the criminal justice system. Although forensic podiatry is a separate, specialized field, many aspects of this discipline can be useful in the clinical treatment and management of foot and ankle problems. The authors, who are forensic podiatrists, contend that the clinical podiatrist can gain significant insights from the field of forensic podiatry. This article aims to provide clinical podiatrists with an overview of the principles and methods that have been tested and applied by forensic podiatrists in their practice, and suggests that the clinical practice of the nonforensic foot practitioner may benefit from such knowledge.

A study update newsletter or Post-it® note did not increase postal questionnaire response rates in a falls prevention trial: an embedded randomised factorial trial

Background: Participants not returning data collection questionnaires is a problem for many randomised controlled trials. The resultant loss of data leads to a reduction in statistical power and can result in bias. The aim of this study was to assess whether the use of a study update newsletter and/or a handwritten or printed Post-it® note sticker increased postal questionnaire response rates for participants of a randomised controlled trial. Method: This study was a factorial trial embedded within a host trial of a falls-prevention intervention among men and women aged ≥65 years under podiatric care. Participants were randomised into one of six groups: newsletter plus handwritten Post-it®; newsletter plus printed Post-it®; newsletter only; handwritten Post-it® only; printed Post-it® only; or no newsletter or Post-it®. The results were combined with those from previous embedded randomised controlled trials in meta-analyses. Results: The overall 12-month response rate was 803/826 (97.2%) (newsletter 95.1%, no newsletter 99.3%, printed Post-it® 97.5%, handwritten Post-it® 97.1%, no Post-it® 97.1%). The study update newsletter had a detrimental effect on response rates (adjusted odds ratio 0.14, 95% CI 0.04 to 0.48, p<0.01) and time to return the questionnaire (adjusted hazard ratio 0.86, 95% CI 0.75 to 0.99, p=0.04). No other statistically significant differences were observed between the intervention groups on response rates, time to response, and the need for a reminder. Conclusions: Post-it® notes have been shown to be ineffective in three embedded trials, whereas the evidence for newsletter reminders is still uncertain.

A nested randomised controlled trial of a newsletter and Post-it® note did not increase postal questionnaire response rates in a falls prevention trial

Background: Attrition (i.e. when participants do not return the questionnaires) is a problem for many randomised controlled trials. The resultant loss of data leads to a reduction in statistical power and can lead to bias. The aim of this study was to assess whether a pre-notification newsletter and/or a handwritten or printed Post-it® note sticker, as a reminder, increased postal questionnaire response rates for participants of randomised controlled trials. Method: This study was a factorial trial embedded within a trial of a falls-prevention intervention among men and women aged ≥65 years under podiatric care. Participants were randomised into one of six groups: newsletter plus handwritten Post-it®; newsletter plus printed Post-it®; newsletter only; handwritten Post-it® only; printed Post-it® only; or no newsletter or Post-it®. The results were combined with those from previous embedded randomised controlled trials in a meta-analysis. Results: The 12-month response rate was 803/826 (97.2%) (newsletter 95.1%, no newsletter 99.3%, printed Post-it® 97.5%, handwritten Post-it® 97.1%, no Post-it® 97.1%). Pre-notification with a newsletter had a detrimental effect on response rates (adjusted odds ratio (OR), 0.14; 95% CI, 0.04 to 0.48; p<0.01) and time to return the questionnaire (adjusted hazard ratio, 0.86; 95% CI, 0.75 to 0.99; p=0.04). No other statistically significant differences were observed between the intervention groups on response rates, time to response, and the need for a reminder. Conclusions: Post-it® notes have been shown to be ineffective in three embedded trials, whereas the evidence for newsletter reminders is still uncertain.

'A good fit?' Bringing the sociology of footwear to the clinical encounter in podiatry services: a narrative review

Background

This narrative review explores the ways in which drawing on theories and methods used in sociological work on footwear and identity can contribute to healthcare research with podiatrists and their patients, highlighting recent research in this field, implications for practice and potential areas for future development.

Traditionally, research within Podiatry Services has tended to adopt a quantitative, positivist focus, developing separately from a growing body of sociological work exploring the importance of shoes in constructing identity and self-image. Bringing qualitative research drawing on sociological theory and methods to the clinical encounter has real potential to increase our understanding of patient values, motivations and – crucially – any barriers to adopting ‘healthier’ footwear that they may encounter. Such work can help practitioners to understand why patients may resist making changes to their footwear practices, and help us to devise new ways for practitioners to explore and ultimately break down individual barriers to change (including their own preconceptions as practitioners). This, in turn, may lead to long-term, sustainable changes to footwear practices and improvements in foot health for those with complex health conditions and the wider population.

Conclusion

A recognition of the complex links between shoes and identity is opening up space for discussion of patient resistance to footwear changes, and paving the way for future research in this field beyond the temporary ‘moment’ of the clinical encounter.

A review of the historical use and criticisms of gait analysis evidence

The use of gait analysis is a well-established facet of practice for many professions and a fundamental aspect of clinical practice. In recent times, gait analysis evidence has emerged as a new area of forensic practice. As its use has continued to spread and develop, the area of work has come under close scrutiny and subsequent criticism. The purpose of this paper is to examine the historical use of gait analysis evidence and consider the criticisms of this work. Through the use of the historical records of cases within the public domain it has been determined that gait analysis as evidence was first presented in court over 175 years ago, although it has only been utilized by experts in more recent times. The quality of analysis underpinning such evidence has been variable, and has been undertaken by both non-expert and expert witnesses. The work undertaken by expert witnesses appears to have been both non-scientific and scientific in nature, though there is limited reporting of cases involving scientific approaches. Given the variation in the quality of the methodologies utilized, there is the potential for confusion within the courts, where it may be difficult for the judge or jury to determine the appropriate weight that can be attributed to the evidence. It is concluded that future publications should explore the scientific basis of forensic gait analysis to evaluate standards, reliability and validity, as well as reporting the methodologies utilized in relevant cases in the field. It is also recommended that courts consider in greater depth an expert's theoretical approach and experience prior to admitting their evidence. The publication of 'Forensic gait analysis: a primer for courts', although limited in some aspects of its consideration of practice, is a welcome addition to the information available for guidance.

Clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for falls prevention in older people: a multicentre cohort randomised controlled trial (the REducing Falls with ORthoses and a Multifaceted podiatry intervention trial)

BACKGROUND

Falls are a serious cause of morbidity and cost to individuals and society. Evidence suggests that foot problems and inappropriate footwear may increase the risk of falling. Podiatric interventions could help reduce falls; however, there is limited evidence regarding their clinical effectiveness and cost-effectiveness.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for preventing falls in community-dwelling older people at risk of falling, relative to usual care.

DESIGN

A pragmatic, multicentred, cohort randomised controlled trial with an economic evaluation and qualitative study.

SETTING

Nine NHS trusts in the UK and one site in Ireland.

PARTICIPANTS

In total, 1010 participants aged ≥ 65 years were randomised (intervention, n = 493; usual care, n = 517) via a secure, remote service. Blinding was not possible.

INTERVENTIONS

All participants received a falls prevention leaflet and routine care from their podiatrist and general practitioner. The intervention also consisted of footwear advice, footwear provision if required, foot orthoses and foot- and ankle-strengthening exercises.

MAIN OUTCOME MEASURES

The primary outcome was the incidence rate of falls per participant in the 12 months following randomisation. The secondary outcomes included the proportion of fallers and multiple fallers, time to first fall, fear of falling, fracture rate, health-related quality of life (HRQoL) and cost-effectiveness.

RESULTS

The primary analysis consisted of 484 (98.2%) intervention and 507 (98.1%) usual-care participants. There was a non-statistically significant reduction in the incidence rate of falls in the intervention group [adjusted incidence rate ratio 0.88, 95% confidence interval (CI) 0.73 to 1.05; p = 0.16]. The proportion of participants experiencing a fall was lower (50% vs. 55%, adjusted odds ratio 0.78, 95% CI 0.60 to 1.00; p = 0.05). No differences were observed in key secondary outcomes. No serious, unexpected and related adverse events were reported. The intervention costs £252.17 more per participant (95% CI -£69.48 to £589.38) than usual care, was marginally more beneficial in terms of HRQoL measured via the EuroQoL-5 Dimensions [mean quality-adjusted life-year (QALY) difference 0.0129, 95% CI -0.0050 to 0.0314 QALYs] and had a 65% probability of being cost-effective at the National Institute for Health and Care Excellence threshold of £30,000 per QALY gained. The intervention was generally acceptable to podiatrists and trial participants.

LIMITATIONS

Owing to the difficulty in calculating a sample size for a count outcome, the sample size was based on detecting a difference in the proportion of participants experiencing at least one fall, and not the primary outcome. We are therefore unable to confirm if the trial was sufficiently powered for the primary outcome. The findings are not generalisable to patients who are not receiving podiatry care.

CONCLUSIONS

The intervention was safe and potentially effective. Although the primary outcome measure did not reach significance, a lower fall rate was observed in the intervention group. The reduction in the proportion of older adults who experienced a fall was of borderline statistical significance. The economic evaluation suggests that the intervention could be cost-effective.

FUTURE WORK

Further research could examine whether or not the intervention could be delivered in group sessions, by physiotherapists, or in high-risk patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68240461.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 24. See the NIHR Journals Library website for further project information.

An optimised patient information sheet did not significantly increase recruitment or retention in a falls prevention study: an embedded randomised recruitment trial

Background

Randomised controlled trials are generally regarded as the ‘gold standard’ experimental design to determine the effectiveness of an intervention. Unfortunately, many trials either fail to recruit sufficient numbers of participants, or recruitment takes longer than anticipated. The current embedded trial evaluates the effectiveness of optimised patient information sheets on recruitment of participants in a falls prevention trial.

Methods

A three-arm, embedded randomised methodology trial was conducted within the National Institute for Health Research-funded REducing Falls with ORthoses and a Multifaceted podiatry intervention (REFORM) cohort randomised controlled trial. Routine National Health Service podiatry patients over the age of 65 were randomised to receive either the control patient information sheet (PIS) for the host trial or one of two optimised versions, a bespoke user-tested PIS or a template-developed PIS. The primary outcome was the proportion of patients in each group who went on to be randomised to the host trial.

Results

Six thousand and nine hundred patients were randomised 1:1:1 into the embedded trial. A total of 193 (2.8%) went on to be randomised into the main REFORM trial (control n = 62, template-developed n = 68; bespoke user-tested n = 63). Information sheet allocation did not improve recruitment to the trial (odds ratios for the three pairwise comparisons: template vs control 1.10 (95% CI 0.77–1.56, p = 0.60); user-tested vs control 1.01 (95% CI 0.71–1.45, p = 0.94); and user-tested vs template 0.92 (95% CI 0.65–1.31, p = 0.65)).

Conclusions

This embedded methodology trial has demonstrated limited evidence as to the benefit of using optimised information materials on recruitment and retention rates in the REFORM study.

Trial registration

International Standard Randomised Controlled Trials Number registry, ISRCTN68240461. Registered on 01 July 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1797-7) contains supplementary material, which is available to authorized users.

Cohort Randomised Controlled Trial of a Multifaceted Podiatry Intervention for the Prevention of Falls in Older People (The REFORM Trial)

BACKGROUND

Falls are a major cause of morbidity among older people. A multifaceted podiatry intervention may reduce the risk of falling. This study evaluated such an intervention.

DESIGN

Pragmatic cohort randomised controlled trial in England and Ireland. 1010 participants were randomised (493 to the Intervention group and 517 to Usual Care) to either: a podiatry intervention, including foot and ankle exercises, foot orthoses and, if required, new footwear, and a falls prevention leaflet or usual podiatry treatment plus a falls prevention leaflet. The primary outcome was the incidence rate of self-reported falls per participant in the 12 months following randomisation. Secondary outcomes included: proportion of fallers and those reporting multiple falls, time to first fall, fear of falling, Frenchay Activities Index, Geriatric Depression Scale, foot pain, health related quality of life, and cost-effectiveness.

RESULTS

In the primary analysis were 484 (98.2%) intervention and 507 (98.1%) control participants. There was a small, non statistically significant reduction in the incidence rate of falls in the intervention group (adjusted incidence rate ratio 0.88, 95% CI 0.73 to 1.05, p = 0.16). The proportion of participants experiencing a fall was lower (49.7 vs 54.9%, adjusted odds ratio 0.78, 95% CI 0.60 to 1.00, p = 0.05) as was the proportion experiencing two or more falls (27.6% vs 34.6%, adjusted odds ratio 0.69, 95% CI 0.52 to 0.90, p = 0.01). There was an increase (p = 0.02) in foot pain for the intervention group. There were no statistically significant differences in other outcomes. The intervention was more costly but marginally more beneficial in terms of health-related quality of life (mean quality adjusted life year (QALY) difference 0.0129, 95% CI -0.0050 to 0.0314) and had a 65% probability of being cost-effective at a threshold of £30,000 per QALY gained.

CONCLUSION

There was a small reduction in falls. The intervention may be cost-effective.

TRIAL REGISTRATION

ISRCTN ISRCTN68240461.

If the shoe fits: development of an on-line tool to aid practitioner/patient discussions about 'healthy footwear'

BACKGROUND

A previous study highlighted the importance of footwear to individuals' sense of their identity, demonstrating that shoes must 'fit' someone socially, as well as functionally. However, unhealthy shoes can have a detrimental effect on both foot health and mobility. This project utilises qualitative social science methods to enable podiatrists to understand the broader contribution of footwear to patients' sense of themselves and from this an online toolkit was developed to aid footwear education.

METHOD

Semi-structured interviews were conducted with six podiatrists/shoe-fitters and 13 people with foot pathologies, some of whom also completed shoe diaries. These were supplemented with some follow-up interviews and photographs of participants' own shoes were taken to allow in-depth discussions.

RESULTS

Four areas related to 'fit' were identified; practicalities, personal, purpose and pressures, all of which need to be considered when discussing changes in footwear. These were incorporated into an online toolkit which was further validated by service users and practitioners in a focus group.

CONCLUSION

This toolkit can support podiatrists in partnership with patients to identify and address possible barriers to changing footwear towards a more suitable shoe. Enabling patients to make healthier shoe choices will help contribute to improvements in their foot health and mobility.

Terminology and forensic gait analysis

The use of appropriate terminology is a fundamental aspect of forensic gait analysis. The language used in forensic gait analysis is an amalgam of that used in clinical practice, podiatric biomechanics and the wider field of biomechanics. The result can often be a lack of consistency in the language used, the definitions used and the clarity of the message given. Examples include the use of 'gait' and 'walking' as synonymous terms, confusion between 'step' and 'stride', the mixing of anatomical, positional and pathological descriptors, and inability to describe appropriately movements of major body segments such as the torso. The purpose of this paper is to share the well-established definitions of the fundamental parameters of gait, common to all professions, and advocate their use in forensic gait analysis to establish commonality. The paper provides guidance on the selection and use of appropriate terminology in the description of gait in the forensic context. This paper considers the established definitions of the terms commonly used, identifies those terms which have the potential to confuse readers, and suggests a framework of terminology which should be utilised in forensic gait analysis.

The REFORM study protocol: a cohort randomised controlled trial of a multifaceted podiatry intervention for the prevention of falls in older people

INTRODUCTION

Falls and fall-related injuries are a serious cause of morbidity and cost to society. Foot problems and inappropriate footwear may increase the risk of falls; therefore podiatric interventions may play a role in reducing falls. Two Cochrane systematic reviews identified only one study of a podiatry intervention aimed to reduce falls, which was undertaken in Australia. The REFORM trial aims to evaluate the clinical and cost-effectiveness of a multifaceted podiatry intervention in reducing falls in people aged 65 years and over in a UK and Irish setting.

METHODS AND ANALYSIS

This multicentre, cohort randomised controlled trial will recruit 2600 participants from routine podiatry clinics in the UK and Ireland to the REFORM cohort. In order to detect a 10% point reduction in falls from 50% to 40%, with 80% power 890 participants will be randomised to receive routine podiatry care and a falls prevention leaflet or routine podiatry care, a falls prevention leaflet and a multifaceted podiatry intervention. The primary outcome is rate of falls (falls/person/time) over 12 months assessed by patient self-report falls diary. Secondary self-report outcome measures include: the proportion of single and multiple fallers and time to first fall over a 12-month period; Short Falls Efficacy Scale-International; fear of falling in the past 4 weeks; Frenchay Activities Index; fracture rate; Geriatric Depression Scale; EuroQoL-five dimensional scale 3-L; health service utilisation at 6 and 12 months. A qualitative study will examine the acceptability of the package of care to participants and podiatrists.

ETHICS AND DISSEMINATION

The trial has received a favourable opinion from the East of England-Cambridge East Research Ethics Committee and Galway Research Ethics Committee. The trial results will be published in peer-reviewed journals and at conference presentations.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN68240461 assigned 01/07/2011.

The effectiveness of salicylic acid plasters compared with 'usual' scalpel debridement of corns: a randomised controlled trial

BACKGROUND

Corns are a common foot problem and surveys have indicated that between 14-48% of people suffer from them. Many of these will seek podiatry treatment, however there is little evidence to indicate which current treatments provide long term resolution. This study compared 'usual' treatment (enucleation with a scalpel) with the application of 40% salicylic acid plasters to corns to investigate which is the most effective in terms of clinical, economic and patient-centred outcomes.

METHODS

A parallel-group randomised controlled trial was carried out in two centres where adults who presented with one or more corns and who met the inclusion criteria were allocated to either 'usual' scalpel debridement or corn plaster treatment. All participants had measurements of corn size, pain using a 100 mm visual analogue scale (VAS) and health-related quality of life (EQ-5D) measures by an independent podiatrist, blind to treatment allocation at baseline, 3, 6, 9 and 12 months.

RESULTS

202 participants were randomised to receive scalpel debridement or corn plaster treatment (101 in each group). At 3 months 34% (32/95) of corns had completely resolved in the corn plaster group compared with 21% (20/94) in the scalpel group (p = 0.044), and 83% (79/95) had reduced in size in the corn plaster group compared with 56% (53/94) in the scalpel group (p < 0.001). At 12 months, time to corn recurrence was longer in the corn plaster group (p < 0.001). Pain from the corns was significantly lower in the corn plaster group at 3 months (p < 0.001) and EQ-5D scores changed (improved), from baseline, by 0.09 (SD ±0.31) and 0.01 (SD ±0.25) points in the corn plaster and scalpel groups respectively (p = 0.056). By month 12, EQ-5D scores had changed by 0.12 and -0.05 in the corn plaster and scalpel groups respectively (p = 0.005). The EQ-5D, VAS scores and the four domains of the Foot Disability Scale were similar in both groups at 3 and 12 months. The economic analysis indicated that corn plasters were a cost effective intervention.

CONCLUSIONS

The use of corn plasters was associated with a higher proportion of resolved corns, a prolonged time to corn recurrence, less pain and reduced corn size over the first 6 months in comparison with 'usual' scalpel treatment and this intervention was cost effective. Used under supervision of a podiatrist on appropriate patients, corn plasters offer an effective alternative to scalpel debridement.

Comparison of shoe-length fit between people with and without diabetic peripheral neuropathy: a case-control study

Background

Amongst the many identified mechanisms leading to diabetic foot ulceration, ill-fitting footwear is one. There is anecdotal evidence that people with diabetic peripheral neuropathy wear shoes that are too small in order to increase the sensation of fit. The aim of this study was to determine whether people with diabetic sensory neuropathy wear appropriate length footwear.

Methods

A case–control design was used to compare internal shoe length and foot length differences between a group of people with diabetes and peripheral sensory neuropathy and a group of people without diabetes and no peripheral sensory neuropathy. Shoe and foot length measurements were taken using a calibrated Internal Shoe Size Gauge® and a Brannock Device®, respectively.

Results

Data was collected from 85 participants with diabetes and 118 participants without diabetes. The mean difference between shoe and foot length was not significantly different between the two groups. However, a significant number of participants within both groups had a shoe to foot length difference that lay outside a previously suggested 10 to 15 mm range. From the diabetic and non-diabetic groups 82% (70/85) and 66% (78/118), respectively had a foot to shoe length difference outside this same range.

Conclusions

This study shows that although there is no significant difference in shoe-length fit between participants with and without neuropathy, a significant proportion of these populations wear shoes that are either too long or too short for their foot length according to the 10 to 15 mm value used for comparison. The study has highlighted the need for standardised approaches when considering the allowance required between foot and internal shoe length and for the measurement and comparison of foot and shoe dimensions.

Classical conditioning of pain-elicited aggression

Unconditioned aggression between paired animals in response to electric shock has been previously demonstrated. In this study, with the use of classical Pavlovian conditioning procedures, aggression was produced between paired rats as a response to a tone stimulus.

Achieving professional status: Australian podiatrists' perceptions

Background

This paper explores the notion of professional status from the perspective of a sample of Australian podiatrists; how it is experienced, what factors are felt to affect it, and how these are considered to influence professional standing within an evolving healthcare system. Underpinning sociological theory is deployed in order to inform and contextualise the study.

Methods

Data were drawn from a series of in-depth semi-structured interviews (n = 21) and focus groups (n = 9) with podiatrists from across four of Australia's eastern states (Queensland, New South Wales, Victoria and Australian Capital Territory), resulting in a total of 76 participants. Semi-structured interview schedules sought to explore podiatrist perspectives on a range of features related to professional status within podiatry in Australia.

Results

Central to the retention and enhancement of status was felt to be the development of specialist roles and the maintenance of control over key task domains. Key distinctions in private and public sector environments, and in rural and urban settings, were noted and found to reflect differing contexts for status development. Marketing was considered important to image enhancement, as was the cache attached to the status of the universities providing graduate education.

Conclusion

Perceived determinants of professional status broadly matched those identified in the wider sociological literature, most notably credentialism, client status, content and context of work (such as specialisation) and an ideological basis for persuading audiences to acknowledge professional status. In an environment of demographic and workforce change, and the resultant policy demands for healthcare service re-design, enhanced opportunities for specialisation appear evident. Under the current model of professionalism, both role flexibility and uniqueness may prove important.

Forensic podiatry: a review

Abstract Although forensic podiatry has been around for a number of years, it has only recently become formally established through research being carried out in the field and resultant professional and regulatory board acceptance. A critical review of forensic podiatry is presented, covering its' history, areas of practice and evidence base. The need for further research is recognized, which will, in turn bring about further practice development in this specialized area.

The development and practice of forensic podiatry

Forensic podiatry is a small, but potentially useful specialty using clinical podiatric knowledge for the purpose of person identification. The practice of forensic podiatry began in the early 1970s in Canada and the UK, although supportive research commenced later in the 1990s. Techniques of forensic podiatry include identification from podiatry records, the human footprint, footwear, and the analysis of gait forms captured on Closed Circuit Television Cameras. The most valuable techniques relate to the comparison of the foot impressions inside shoes. Tools to describe, measure and compare foot impressions with footwear wear marks have been developed through research with potential for further development. The role of forensic podiatrists is of particular value when dealing with variable factors relating to the functioning and the shod foot. Case studies demonstrate the approach of podiatrists, in footwear identification, when comparing exemplar with questioned foot impressions. Forensic podiatry practice should be approached cautiously and it is essential for podiatrists undertaking this type of work to understand the context within which the process of person identification takes place.

A theory of shoe wear pattern influence incorporating a new paradigm for the podiatric medical profession

Qualitative analysis of shoe wear patterns collected from a questionnaire evaluating podiatric physicians' experiences in this area suggests that wear patterns could indicate causative function within a known pathologic context. Several different functions are suggested by patterns associated with each of the pathologic entities involved, and analysis of the relationship between patterns and reasons given by respondents for pattern-form variations show the strongest associations to be with functionally termed conditions. A basic model is proposed to present factors important in wear pattern production, suggesting that a new concept of primary walking intention is more influential than foot pathologies in wear pattern formation and that external factors are also influential, with the combined factors being described as the "holistic foot function." This model may provide a variety of benefits to podiatric medicine; as shoe wear patterns are records of the usual long-term activity of the functioning foot, this paradigm could form a basis for podiatric medical practice.

Search for pi(0)-->nu(mu)nu(mu) decays in the LSND detector

We observe a net beam excess of 8.7+/-6.3(stat)+/-2.4(syst) events, above 160 MeV, resulting from the charged-current reaction of nu(micro) and/or nu;(mu) on C and H in the LSND detector. No beam-related muon background is expected in this energy regime. Within an analysis framework of pi(0)-->nu(mu)nu;(mu), we set a direct upper limit for this branching ratio of Gamma(pi(0)-->nu(mu)nu;(mu))/Gamma(pi(0)-->all)<1.6 x 10(-6) at 90% confidence level.

Effect of scalpel debridement on the pain associated with plantar hyperkeratosis

Seventy-nine subjects from 14 centers in eight English National Health Service Trusts recorded their levels of preoperative and postoperative pain and perceived change in pain on 100-mm visual analog scales before and after scalpel debridement of painful plantar hyperkeratosis. A significant reduction in pain was reported following treatment, and there were highly significant differences between the preoperative and postoperative scores. There were no age- or sex-related differences in any of the preoperative, postoperative, or perceived-change scores. The objective data support the anecdotal evidence that scalpel debridement of painful plantar hyperkeratosis is immediately effective in the palliative management of such patients.

Localization of the locus causing Spider Lamb Syndrome to the distal end of ovine Chromosome 6

Spider Lamb Syndrome (SLS) is a semi-lethal congenital disorder, causing severe skeletal abnormalities in sheep. The syndrome has now been disseminated into several sheep breeds in the United States, Canada, and Australia. The mode of inheritance for SLS is autosomal recessive, making the identification and culling of carrier animals difficult due to their normal phenotype. Two large pedigrees segregating for the SLS mutation were established, and a genome scan with genetic markers from previously published genome maps of cattle and sheep was used to map the locus causing SLS. Genetic linkage between SLS and several microsatellite markers, OarJMP8, McM214, OarJMP12, and BL1038, was detected, thereby mapping the SLS locus to the telomeric end of ovine Chromosome (Chr) 6. Alignment of ovine Chr 6 with its evolutionary ortholog, human Chr 4, revealed a positional candidate gene, fibroblast growth factor receptor 3 (FGFR3).