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Abstract Increasing rate of genetic gain for key agronomic traits through genomic selection requires the development of new molecular methods to run genome‐wide single‐nucleotide polymorphisms (SNPs). The main limitation of current methods is the cost is too high to screen breeding populations. Molecular inversion probes (MIPs) are a targeted genotyping‐by‐sequencing (GBS) method that could be used for soybean [Glycine max (L.) Merr.] that is both cost‐effective, high‐throughput, and provides high data quality to screen breeder's germplasm for genomic selection. A 1K MIP SNP set was developed for soybean with uniformly distributed markers across the genome. The SNPs were selected to maximize the number of informative markers in germplasm being tested in soybean breeding programs located in the northern‐central and middle‐southern regions of the United States. The 1K SNP MIP set was tested on diverse germplasm and a recombinant inbred line (RIL) population. Targeted sequencing with MIPs obtained an 85% enrichment for the targeted SNPs. The MIP genotyping accuracy was 93% overall, whereas homozygous call accuracy was 98% with

AbstractRecombination allows for the exchange of genetic material between two parents, which plant breeders exploit to make improved cultivars. This recombination is not distributed evenly across the chromosome. Recombination mostly occurs in euchromatic regions of the genome and even then, recombination is focused into clusters of crossovers termed recombination hotspots. Understanding the distribution of these hotspots along with the sequence motifs associated with them may lead to methods that enable breeders to better exploit recombination in breeding. To map recombination hotspots and identify sequence motifs associated with hotspots in soybean [Glycine max

Verification of clonal identity of hop (Humulus lupulus L.) cultivars within breeding programs and germplasm collections is vital to conserving genetic resources. Accurate and economic DNA-based tools are needed in dioecious hop to confirm identity and parentage, neither of which can be reliably determined from morphological observations. In this study, we developed two fingerprinting sets for hop: a 9-SSR fingerprinting set containing high-core repeats that can be run in a single PCR reaction and a kompetitive allele specific PCR (KASP) assay of 25 single nucleotide polymorphisms (SNPs). The SSR set contains a sex-linked primer pair, HI-AGA7, that was used to genotype 629 hop accessions from the US Department of Agriculture (USDA) National Clonal Germplasm Repository (NCGR), the USDA Forage Seed and Cereal Research (FSCR), and the University of Nebraska-Lincoln (UNL) collections. The SSR set identified unique genotypes except for 89 sets of synonymous samples. These synonyms included: cultivars with different designations, the same cultivars from different sources, heat-treated clones, and clonal variants. Population structure analysis clustered accessions into wild North American (WNA) and cultivated groups. Diversity was slightly higher in the cultivated samples due to larger sample size. Parentage and sib-ship analyses were used to identify true-to-type cultivars. The HI-AGA7 marker generated two male- and nine female-specific alleles among the cultivated and WNA samples. The SSR and KASP fingerprinting sets were compared in 190 samples consisting of cultivated and WNA accession for their ability to confirm identity and assess diversity and population structure. The SSR fingerprinting set distinguished cultivars, selections and WNA accessions while the KASP assays were unable to distinguish the WNA samples and had lower diversity estimates than the SSR set. Both fingerprinting sets are valuable tools for identity confirmation and parentage analysis in hop for different purposes. The 9-SSR assay is cost efficient when genotyping a small number of wild and cultivated hop samples (

Aphid herbivory elicits plant defense-related networks that are influenced by host genetics. Plants of the upland switchgrass (Panicumvirgatum) cultivar Summer can be a suitable host for greenbug aphids (Schizaphis graminum; GB), and yellow sugarcane aphids (Sipha flava, YSA), whereas the lowland cultivar Kanlow exhibited multi-species resistance that curtails aphid reproduction. However, stabilized hybrids of Summer (♀) x Kanlow (♂) (SxK) with improved agronomics can be damaged by both aphids. Here, hormone and metabolite analyses, coupled with RNA-Seq analysis of plant transcriptomes, were utilized to delineate defense networks induced by aphid feeding in SxK switchgrass and pinpoint plant transcription factors (TFs), such as WRKYs that potentially regulate these responses. Abscisic acid (ABA) levels were significantly higher in GB infested plants at 5 and 10 days after infestation (DAI). ABA levels were highest at 15DAI in YSA infested plants. Jasmonic acid levels were significantly elevated under GB infestation, while salicylic acid levels were signifi40cantly elevated only at 15 DAI in YSA infested plants. Similarly, levels of several metabolites were altered in common or specifically to each aphid. YSA infestation induced a significant enrichment of flavonoids consistent with an upregulation of many genes associated with flavonoid biosynthesis at 15DAI. Gene co-expression modules that responded singly to either aphid or in common to both aphids were differentiated and linked to specific TFs. Together, these data provide important clues into the interplay of metabolism and transcriptional remodeling accompanying defense responses to aphid herbivory in hybrid switchgrass.

The study of fitness costs of insecticide resistance mutations in Aedes aegypti has generally been focused on life history parameters such as fecundity, mortality, and energy reserves. In this study we sought to investigate whether trade-offs might also exist between insecticide resistance and other abiotic stress resistance parameters. We evaluated the effects of the selection for permethrin resistance specifically on larval salinity and thermal tolerance. A population of A. aegypti originally from Southern Mexico was split into two strains, one selected for permethrin resistance and the other not. Larvae were reared at different salinities, and the fourth instar larvae were subjected to acute thermal stress; then, survival to both stresses was compared between strains. Contrary to our predictions, we found that insecticide resistance correlated with significantly enhanced larval thermotolerance. We found no clear difference in salinity tolerance between strains. This result suggests that insecticide resistance does not necessarily carry trade-offs in all traits affecting fitness and that successful insecticide resistance management strategies must account for genetic associations between insecticide resistance and abiotic stress resistance, as well as traditional life history parameters.

Alkaline soils comprise 30% of the earth and have low plant-available iron (Fe) concentration, and can cause iron deficiency chlorosis (IDC). IDC causes soybean yield losses of $260 million annually. However, it is not known whether molecular responses to IDC are equivalent to responses to low iron supply. IDC tolerant and sensitive soybean lines provide a contrast to identify specific factors associated with IDC. We used RNA-seq to compare gene expression under combinations of normal pH (5.7) or alkaline pH (7.7, imposed by 2.5 mM bicarbonate, or pH 8.2 imposed by 5 mM bicarbonate) and normal (25 μM) or low (1 μM) iron conditions from roots of these lines. Thus, we were able to treat pH and Fe supply as separate variables. We also noted differential gene expression between IDC sensitive and tolerant genotypes in each condition. Classical iron uptake genes, including ferric-chelate reductase (FCR) and ferrous transporters, were upregulated by both Fe deficiency and alkaline stress, however, their gene products did not function well at alkaline pH. In addition, genes in the phenylpropanoid synthesis pathway were upregulated in both alkaline and low Fe conditions. These genes lead to the production of fluorescent root exudate (FluRE) compounds, such as coumarins. Fluorescence of nutrient solution increased with alkaline treatment, and was higher in the IDC tolerant line. Some of these genes also localized to previously identified QTL regions associated with IDC. We hypothesize that FluRE become essential at alkaline pH where the classical iron uptake system does not function well. This work could result in new strategies to screen for IDC tolerance, and provide breeding targets to improve crop alkaline stress tolerance.

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., (© 2022 The Authors. Arthritis Care & Research published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

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., Competing Interests: Declaration of Competing Interest The authors have no financial or other competing interests to declare., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: End-stage ankle osteoarthritis typically causes severe pain and impaired function. Surgical treatment involves total ankle replacement (TAR) or ankle fusion. Definitive evidence about which procedure is optimal is lacking. No previous studies have thoroughly explored patients' experiences across the entire TAR/ankle fusion pathway. This study aimed to address this gap by exploring perceptions of surgery, education, rehabilitation and outcomes among patients who had undergone TAR or ankle fusion., Methods: Seven participants were purposively selected from an orthopaedic centre in northern England (3 females, 4 males). Participants had undergone primary TAR without revision (n = 2), TAR requiring revision (n = 3) or ankle fusion (n = 2). Each participant completed a single semi-structured interview. Interviews were digitally recorded, transcribed verbatim and analysed thematically., Results: Three themes, each with two subthemes, were identified: decision-making (seeking help; surgical options), perceptions of support (information/education; clinical support) and impact on the individual (personal circumstances and beliefs; post-operative outcomes). Pain affecting participants' valued activities was key to their decision to seek help. Participants' decision between TAR and ankle fusion was influenced by multiple factors. Concerns regarding the lack of joint flexibility following fusion were highlighted, with some participants perceiving TAR as a "proper ankle" that would enable them to avoid limping. Participants obtained information from various sources, with most feeling that the education from their care team was inadequate. Participants' individual circumstances and beliefs influenced their decision-making and perceptions of their post-operative outcomes. Finally, whilst most participants were pleased with their outcomes, some experienced substantial ongoing problems such as difficulty walking and chronic pain., Conclusions: This study demonstrates the importance of providing adequate education about TAR and ankle fusion to enable patients to make informed decisions. Most participants felt that the education and clinical support they received did not fully meet their needs. Participants' personal circumstances and beliefs had a strong influence on their decision-making and perceptions of their post-operative outcomes, highlighting the need to personally tailor education and clinical support. Future work with a larger sample of patients and other key stakeholders is required to develop consensus-based guidelines on pre- and post-operative support for patients undergoing TAR/ankle fusion., (© 2022. The Author(s).)

Objectives: Evidence on the current status of gender equity in academic rheumatology in Europe and potential for its improvement is limited. The EULAR convened a task force to obtain empirical evidence on the potential unmet need for support of female rheumatologists, health professionals and non-clinical scientists in academic rheumatology., Methods: This cross-sectional study comprised three web-based surveys conducted in 2020 among: (1) EULAR scientific member society leaders, (2) EULAR and Emerging EULAR Network (EMEUNET) members and (3) EULAR Council members. Statistics were descriptive with significance testing for male/female responses assessed by χ 2 test and t-test., Results: Data from EULAR scientific member societies in 13 countries indicated that there were disproportionately fewer women in academic rheumatology than in clinical rheumatology, and they tended to be under-represented in senior academic roles. From 324 responses of EULAR and EMEUNET members (24 countries), we detected no gender differences in leadership aspirations, self-efficacy in career advancement and work-life integration as well as the share of time spent on research, but there were gender differences in working hours and the levels of perceived gender discrimination and sexual harassment. There were gender differences in the ranking of 7 of 26 factors impacting career advancement and of 8 of 24 potential interventions to aid career advancement., Conclusions: There are gender differences in career advancement in academic rheumatology. The study informs a EULAR task force developing a framework of potential interventions to accelerate gender-equitable career advancement in academic rheumatology., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: We have developed and feasibility tested an activity pacing framework for clinicians to standardise their recommendations of activity pacing to patients with chronic pain/fatigue. This study aimed to explore the acceptability and fidelity to this framework in preparation for a future trial of activity pacing., Design: Acceptability and fidelity were explored using semi-structured interviews. Data were analysed using framework analysis., Participants: Patients who attended a rehabilitation programme for chronic pain/fatigue underpinned by the framework, and clinicians (physiotherapists and psychological wellbeing practitioners) who led the programmes., Results: Seventeen interviews were conducted, involving 12 patients with chronic pain/fatigue and five clinicians. The framework analysis revealed four deductive themes: (1) Acceptability of the activity pacing framework, (2) Acceptability of the feasibility study methods, (3) Processes of change and (4) Barriers and facilitators to activity pacing; and one inductive theme: (5) Perspectives of patients and clinicians., Conclusions: The activity pacing framework appeared acceptable to patients and clinicians, and adherence to the framework was demonstrated. Processes of behaviour change included patients' regulation of activities through activity pacing. Barriers to pacing included work/social commitments and facilitators included identifying the benefits of pacing on symptoms. Different perspectives emerged between clinicians and patients regarding interpretations of symptom-contingent and quota-contingent strategies. The framework recognises fluctuations in symptoms of chronic pain/fatigue and encourages a quota-contingent approach with flexibility. Future work will develop a patient friendly guide ahead of a clinical trial to explore the effects of pacing., (© 2021 The Authors. Musculoskeletal Care published by John Wiley & Sons Ltd.)

Background: Medical imaging can be used to assist with the diagnosis of plantar heel pain. The aim of this study was to synthesise medical imaging features associated with plantar heel pain., Methods: This systematic review and meta-analysis conducted searches in MEDLINE, CINAHL, SPORTDiscus, Embase and the Cochrane Library from inception to 12th February 2021. Peer-reviewed articles of cross-sectional observational studies written in English that compared medical imaging findings in adult participants with plantar heel pain to control participants without plantar heel pain were included. Study quality and risk of bias was assessed using the National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies. Sensitivity analyses were conducted where appropriate to account for studies that used unblinded assessors., Results: Forty-two studies (2928 participants) were identified and included in analyses. Only 21% of studies were rated 'good' on quality assessment. Imaging features associated with plantar heel pain included a thickened plantar fascia (on ultrasound and MRI), abnormalities of the plantar fascia (on ultrasound and MRI), abnormalities of adjacent tissue such as a thickened loaded plantar heel fat pad (on ultrasound), and a plantar calcaneal spur (on x-ray). In addition, there is some evidence from more than one study that there is increased hyperaemia within the fascia (on power Doppler ultrasound) and abnormalities of bone in the calcaneus (increased uptake on technetium-99 m bone scan and bone marrow oedema on MRI)., Conclusions: People with plantar heel pain are more likely to have a thickened plantar fascia, abnormal plantar fascia tissue, a thicker loaded plantar heel fat pad, and a plantar calcaneal spur. In addition, there is some evidence of hyperaemia within the plantar fascia and abnormalities of the calcaneus. Whilst these medical imaging features may aid with diagnosis, additional high-quality studies investigating medical imaging findings for some of these imaging features would be worthwhile to improve the precision of these findings and determine their clinical relevance., (© 2021. The Author(s).)

Objective: Computerised clinical decision support systems (CDSS) are an increasingly important part of nurse and allied health professional (AHP) roles in delivering healthcare. The impact of these technologies on these health professionals' performance and patient outcomes has not been systematically reviewed. We aimed to conduct a systematic review to investigate this., Materials and Methods: The following bibliographic databases and grey literature sources were searched by an experienced Information Professional for published and unpublished research from inception to February 2021 without language restrictions: MEDLINE (Ovid), Embase Classic+Embase (Ovid), PsycINFO (Ovid), HMIC (Ovid), AMED (Allied and Complementary Medicine) (Ovid), CINAHL (EBSCO), Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), Social Sciences Citation Index Expanded (Clarivate), ProQuest Dissertations & Theses Abstracts & Index, ProQuest ASSIA (Applied Social Science Index and Abstract), Clinical Trials.gov, WHO International Clinical Trials Registry (ICTRP), Health Services Research Projects in Progress (HSRProj), OpenClinical(www.OpenClinical.org), OpenGrey (www.opengrey.eu), Health.IT.gov, Agency for Healthcare Research and Quality (www.ahrq.gov). Any comparative research studies comparing CDSS with usual care were eligible for inclusion., Results: A total of 36 106 non-duplicate records were identified. Of 35 included studies: 28 were randomised trials, three controlled-before-and-after studies, three interrupted-time-series and one non-randomised trial. There were ~1318 health professionals and ~67 595 patient participants in the studies. Most studies focused on nurse decision-makers (71%) or paramedics (5.7%). CDSS as a standalone Personal Computer/LAPTOP-technology was a feature of 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile/handheld-technology., Discussion: CDSS impacted 38% of the outcome measures used positively. Care processes were better in 47% of the measures adopted; examples included, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling and documenting care. Patient care outcomes in 40.7% of indicators were better; examples included, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity and triaging appropriateness., Conclusion: CDSS may have a positive impact on selected aspects of nurses' and AHPs' performance and care outcomes. However, comparative research is generally low quality, with a wide range of heterogeneous outcomes. After more than 13 years of synthesised research into CDSS in healthcare professions other than medicine, the need for better quality evaluative research remains as pressing., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To test the feasibility of using a new activity pacing framework to standardise healthcare professionals' instructions of pacing, and explore whether measures of activity pacing/symptoms detected changes following treatment., Design: Single-arm, repeated measures study., Setting: One National Health Service (NHS) Pain Service in Northern England, UK., Participants: Adult patients with chronic pain/fatigue, including chronic low back pain, chronic widespread pain, fibromyalgia and chronic fatigue syndrome/myalgic encephalomyelitis., Interventions: Six-week rehabilitation programme, standardised using the activity pacing framework., Outcome Measures: Feasibility was explored via patients' recruitment/attrition rates, adherence and satisfaction, and healthcare professionals' fidelity. Questionnaire data were collected from patients at the start and end of the programme (T1 and T2, respectively) and 3 months' follow-up (T3). Questionnaires included measures of activity pacing, current/usual pain, physical/mental fatigue, depression, anxiety, self-efficacy, avoidance, physical/mental function and quality of life. Mean changes in activity pacing and symptoms between T1-T2, T2-T3 and T1-T3 were estimated., Results: Of the 139 eligible patients, 107 patients consented (recruitment rate=77%); 65 patients completed T2 (T1-T2 attrition rate=39%), and 52 patients completed T3 (T1-T3 attrition rate=51%). At T2, patients' satisfaction ratings averaged 9/10, and 89% attended ≥5 rehabilitation programme sessions. Activity pacing and all symptoms improved between T1 and T2, with smaller improvements maintained at T3., Conclusion: The activity pacing framework was feasible to implement and patients' ability to pace and manage their symptoms improved. Future work will employ a suitable comparison group and test the framework across wider settings to explore the effects of activity pacing in a randomised controlled trial., Trial Registration Number: NCT03497585., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: AMK is Deputy Director of the NIHR Leeds Biomedical Research Centre and an NIHR Senior Investigator. The other authors declare no competing interests. S-AY is funded by the Royal College of Physicians, Rosetrees Trust, NIHR UCLH Biomedical Research Centre, and UCLH Charities. MC is funded by the NIHR UCLH Biomedical Research Centre. Funding support has been received from the NIHR UCLH Biomedical Research Centre to run the UCLH Patient Partners in Rheumatology Research Initiative. LCC is an NIHR Clinician Scientist and Senior Clinical Research Fellow funded by an NIHR Clinician Scientist award. The OPEN ARMS group is supported by the NIHR Oxford Biomedical Research Centre. The NIHR Leeds, UCLH, and Oxford Biomedical Research Centres are funded by the NIHR. The views expressed are of those of the authors and not necessarily those of the funders, the National Health Service, the NIHR, or the Department of Health and Social Care. None of the funding bodies have been involved in the direct funding or preparation of this manuscript. All authors accept responsibility to submit for publication. The authors also acknowledge team members who have been instrumental in enabling the success of these patient and public involvement initiatives: Leeds—Gwyneth Cracknell, Amy Rebane, Sue Smith, Donna Johnstone; UCLH—Eleanor Hawkins, Raj Amarnani, James Kimpton, Christopher Wincup, Meena Naja; Oxford—Cushla Cooper, Matthew Costa, Josie Eade, Natalie Ford, Matthew Gardiner, Jenny Gould, Dave Greenall, Jonathan Rees, Kassim Javaid, Sarah Snelling, Esther Williamson

Over the past decade, the role of nurses, midwives and allied health professionals (NMAHPs) have been transformed within the UK research community. Assisted by new funding opportunities and a recognition of their role in interdisciplinary working, NMAHPs are driving innovative patient care. Challenges still remain to maximise the potential of NHAMPs in clinical research; signposting opportunities to become involved in research, promoting clear career pathways and developing innovative roles with the NHS to attract and retain this community are critical., (© Royal College of Physicians 2021. All rights reserved.)

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., (© 2020 The Authors. Arthritis Care & Research published by Wiley Periodicals, Inc. on behalf of American College of Rheumatology.)

Background: Heart failure with reduced ejection fraction (HFrEF) is characterized by blunting of the positive relationship between heart rate and left ventricular (LV) contractility known as the force-frequency relationship (FFR). We have previously described that tailoring the rate-response programming of cardiac implantable electronic devices in patients with HFrEF on the basis of individual noninvasive FFR data acutely improves exercise capacity. We aimed to examine whether using FFR data to tailor heart rate response in patients with HFrEF with cardiac implantable electronic devices favorably influences exercise capacity and LV function 6 months later., Methods: We conducted a single-center, double-blind, randomized, parallel-group trial in patients with stable symptomatic HFrEF taking optimal guideline-directed medical therapy and with a cardiac implantable electronic device (cardiac resynchronization therapy or implantable cardioverter-defibrillator). Participants were randomized on a 1:1 basis between tailored rate-response programming on the basis of individual FFR data and conventional age-guided rate-response programming. The primary outcome measure was change in walk time on a treadmill walk test. Secondary outcomes included changes in LV systolic function, peak oxygen consumption, and quality of life., Results: We randomized 83 patients with a mean±SD age 74.6±8.7 years and LV ejection fraction 35.2±10.5. Mean change in exercise time at 6 months was 75.4 (95% CI, 23.4 to 127.5) seconds for FFR-guided rate-adaptive pacing and 3.1 (95% CI, -44.1 to 50.3) seconds for conventional settings (analysis of covariance; P =0.044 between groups) despite lower peak mean±SD heart rates (98.6±19.4 versus 112.0±20.3 beats per minute). FFR-guided heart rate settings had no adverse effect on LV structure or function, whereas conventional settings were associated with a reduction in LV ejection fraction., Conclusions: In this phase II study, FFR-guided rate-response programming determined using a reproducible, noninvasive method appears to improve exercise time and limit changes to LV function in people with HFrEF and cardiac implantable electronic devices. Work is ongoing to confirm our findings in a multicenter setting and on longer-term clinical outcomes. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02964650.

Objectives: Due to the current absence of a standardized guide for activity pacing, the concept of pacing is interpreted in various ways by healthcare professionals, patients and researchers. Consequently, the effects of pacing across different conditions are unclear. The present study aimed to undertake the second stage in the development of an activity pacing framework for chronic pain/fatigue., Methods: The newly developed activity pacing framework was refined using a consensus method. A nominal group technique (NGT) was selected to engage stakeholders to reach agreement on the top 10 priorities for inclusion in the framework and accompanying appendices. Participants included patients with diagnoses of chronic pain/fatigue and healthcare professionals working in fields of chronic pain/fatigue., Results: Ten participants were recruited via purposive sampling: four patients, two physiotherapists, two occupational therapists and two psychological wellbeing practitioners. The top priorities for the pacing framework included a clear definition of pacing, and stating the aims and context of pacing. The appendices were refined as a teaching guide, including priorities of detailing the stages of pacing, the overactivity-underactivity cycle/pain cycle and goal setting., Conclusions: Incorporating a diverse panel of stakeholders was an effective and inclusive method to refine the activity pacing framework. The framework has been purposefully designed for wider use across patients with chronic pain/fatigue and by various healthcare professionals. The framework provides a comprehensive definition, background and manual for healthcare professionals to instruct activity pacing. Further study will test the clinical usability of the framework, to enable the standardization of activity pacing in future investigations., (© 2019 John Wiley & Sons, Ltd.)

Introduction: Activity pacing is considered a key component of rehabilitation programmes for chronic pain/fatigue. However, there are no widely used guidelines to standardize how pacing is delivered. This study aimed to undertake the first stage in developing a comprehensive evidence-based activity pacing framework., Methods: An online survey across pain/fatigue services in English National Health Service trusts explored healthcare professionals' opinions on the types/uses of pacing, aims, facets and perceived effects. Data were analysed using descriptive statistics for closed-ended questions and thematic analysis for open-ended questions. Purposeful recruitment with a snowball effect engaged 92 healthcare professionals (physiotherapists, occupational therapists, nurses, doctors and psychologists) to the study., Results: Pacing was highly utilized, with perceived long-term benefits for patients (n = 83, 90.2% healthcare professionals instructed pacing). The most endorsed aim of pacing was "achievement of meaningful activities" (24.5% of ranked votes). The least endorsed aim was "to conserve energy" (0.1% of ranked votes). The most frequently supported facet of pacing was "breaking down tasks" (n = 91, 98.9%). The least supported facet was "stopping activities when symptoms increase" (n = 6, 6.5%). Thematic analysis showed recurring themes that pacing involved flexibility and sense of choice., Conclusions: Pacing is a multidimensional coping strategy and complex behaviour. The message is clear that pacing should enable increases in meaningful activities, as opposed to attempting to avoid symptoms. The survey findings have informed the development of an activity pacing framework to guide healthcare professionals on the multiple components of pacing. This will help to standardize and optimize treatments for chronic pain/fatigue and enable future investigations., (© 2019 The Authors. Musculoskeletal Care published by John Wiley & Sons Ltd.)

Background: While the prevalence and impact of musculoskeletal problems are high, most attention has been directed towards the back, knee and hip disorders. Foot pain is known to be common in older adults and accounts for a significant burden on health services. The aim of this study was to assess the impact of foot and ankle joint pain, considering age, presence of co-morbidities and other site joint pain, in a large community sample., Methods: In the North Yorkshire Health study, 16,222 people over 55 years participated in a detailed survey of the prevalence and impact of lower limb joint problems. Self-assessment of overall body pain and functional activities of daily living were assessed. Participants indicated the presence of joint pain, stiffness or swelling during the last 3 months which had lasted for more than 6 weeks on a manikin: data were captured on the foot and the ankle., Results: The prevalence of self-reported foot and ankle joint pain was substantial: 184.33 per 1000, second only to knee problems. While foot pain was common, it was mostly associated with joint pain at other sites; only 1 in 11 of those with foot and ankle pain reported it only in the foot. Logistic regression modeling revealed while established factors such as co-morbidities, knee and hip problems contributed to functional impairment, foot and ankle problems contributed to an additional increased risk of having difficulty standing and walking by two fold (OR = 2.314, 95%CI 2.061-2.598), going up and down stairs by 71% (OR = 1.711, 95%CI 1.478-1.980) and getting up from a seated position by 44% (OR = 1.438, 95%CI 1.197-1.729)., Conclusion: These results suggest that not only are foot problems in the over 55 age group extremely prevalent, they have a considerable impact on functional abilities., Competing Interests: Competing interestsThe authors declare they have no competing interests., (© The Author(s). 2019.)

Background: Guidelines recommend foot orthoses for people with both early (< 2 years) and established rheumatoid arthritis (RA). While prefabricated foot orthoses are cheaper and can exhibit comparable effects to customised devices, the available evidence for their effectiveness is inconsistent. Little is known about what types of foot orthoses clinicians prescribe. This study describes the foot orthoses prescription habits of podiatrists for people with rheumatoid arthritis., Methods: One hundred and eighty-three podiatrists from the United Kingdom (UK) ( n  = 88), Australia ( n  = 68) and New Zealand ( n  = 27) completed a self-administered, online survey regarding the types of foot orthoses prescribed in clinical practice for people with RA. This study forms part of a wider international survey exploring foot orthosis prescription habits., Results: UK respondents were more likely to prescribe prefabricated orthoses for early RA ( n  = 47, 53%) and customised orthoses for established RA (n = 47, 53%). Respondents in Australia were more likely to prescribe customised orthoses for both early ( n  = 32, 47%) and established ( n  = 46, 68%) RA, whilst respondents in New Zealand were more likely to prescribe prefabricated orthoses for both early ( n  = 16, 59%) and established ( n  = 10, 37%) disease.Irrespective of disease stage, the use of foam impression boxes was more prevalent in the UK and New Zealand when capturing a model of the feet prior to manufacturing customised orthoses. In contrast, electronic scanning and plaster of Paris were more common in Australia. Computer aided manufacture was utilised more frequently among respondents in Australia than in the UK and New Zealand. Respondents in all three countries specified more flexible shell materials for established RA, compared to early disease. Cushioning top covers (e.g. PORON® or polyurethane) were most frequently specified in all countries for both disease stages., Conclusions: Considerable variation was seen in the self-reported foot orthoses prescription habits of respondents for people with RA. Variation between countries and disease stage was seen in type of orthoses, specific brands, manufacturing methods, and materials prescribed. The results allow podiatrists and broader health service providers to compare their practice against reported national and international patterns., Competing Interests: Ethical approval was received from the School of Medicine Research Ethics Committee, University of Leeds (Ref: MREC15–052). Subsequent approval was also gained from La Trobe University (Ref: MREC15–052) and Auckland University (Ref: 16/133) of Technology.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Foot orthoses are frequently used but little is known about which types are used in contemporary practice. This study aimed to explore the types of foot orthoses currently used by podiatrists and the prescription variations in a range of conditions., Methods: A web-based, cross-sectional survey was distributed through professional bodies in the United Kingdom (UK), Australia, and New Zealand. Questions focussed on foot orthosis prescription habits in relation to 26 conditions affecting the back and lower limb., Results: Two hundred and sixty-four podiatrists practising in 19 different countries completed the survey; the majority practised in the UK (47%, n  = 124), Australia (30%, n  = 79) and New Zealand (12%, n  = 32). Respondents qualified between 1968 and 2016, and 147 (56%) were female. Respondents worked in different healthcare sectors and this varied between countries: 42 (34%) respondents in the UK worked solely in the public sector, compared to 3 (4%) in Australia and 2 (6%) in New Zealand. Forty-four (35%) respondents in the UK worked solely in private practice, compared to 64 (81%) in Australia and 14 (44%) in New Zealand.UK respondents prescribed more prefabricated orthoses per week (mean 5.5 pairs) than simple insole-type devices (±2.7) and customised devices (±2.9). Similarly, respondents in New Zealand prescribed more prefabricated orthoses per week (±7.7) than simple (±1.4) and customised (±2.8) devices. In contrast, those in Australia prescribed more customised orthoses per week (±4.4) than simple (±0.8) and prefabricated (±1.9) orthoses. Differences in the types of orthoses prescribed were observed between country of practice, working sector, and the condition targeted. Generally, prefabricated orthoses were commonly prescribed for the 26 highlighted conditions in the UK and New Zealand. Australian podiatrists prescribed far fewer devices overall, but when they did prescribe, they were more likely to prescribe custom devices. Respondents in all three countries were more likely to prescribe customised orthoses for people with diabetes complicated by peripheral neuropathy than for diabetes without this complication., Conclusions: Foot orthosis prescription habits vary between countries. Prefabricated orthoses were frequently prescribed in the UK and New Zealand, and customised orthoses in Australia. Prescriptions for people with diabetes differed depending on the presence of neuropathy, despite a lack of robust evidence supporting these decisions. This study provides new insight into contemporary practice., Competing Interests: Ethical approval was received from the School of Medicine Research Ethics Committee, University of Leeds (Ref: MREC15–052). Subsequent approval was also gained from La Trobe University (Ref: MREC15–052) and Auckland University (Ref: 16/133) of Technology.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Introduction: To measure the range of T 1 values of synovitis using three Tesla (3 T) magnetic resonance imaging (MRI) in patients with osteoarthritis to assess the potential of T 1 mapping for identifying synovitis from other features in the knee on unenhanced magnetic resonance scans., Methods: After receiving institutional ethical approval, 83 patients who met the American College of Rheumatology criteria for diagnosis of osteoarthritis of the knee were scanned using a 3 T Magnetic Resonance Imaging scanner. T 1 maps were calculated from spoiled gradient echo images acquired with five different flip angles of 5°-25°. Mean values for the T 1 measurements were calculated and compared to existing data from the published literature for anatomical and pathological structures of the knee., Results: T 1 values recorded in patients suffering from osteoarthritis demonstrated that T 1 values for synovitis (confirmed on gadolinium enhanced images) fall in a narrow range (849-1277 ms, mean 1005 ms SD 91) delineating this from other structures of the knee such as muscle (T 1 value range 1305-2638 ms, mean 1785 ms SD 304) and synovial fluid (T 1 value range 3867-4129 ms, mean 3915 SD 899) at 3 T., Conclusion: T 1 values measured in synovitis in patients with osteoarthritis of the knee demonstrated a range of values distinct to those measured in muscle and synovial fluid at 3 T. This offers potential for the use of T 1 maps to delineate or quantify synovitis in patients who are unwilling or unable to receive injectable contrast agents., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

This brief communication responds to the paper by Jeong and Cho (Qual Life Res 26(4):903-911, 2017) that has described activity pacing in limited terms of adjusting activities through going at a slower rate and taking breaks. Activity pacing was reported as not involving goal setting, in comparison to other strategies for long-term conditions such as Acceptance and Commitment Therapy. This brief communication aims to challenge this limited perception of activity pacing in light of numerous studies that recognise pacing to be a more complex strategy. Pacing is considered to be a multifaceted coping strategy, including broad themes of not only adjusting activities, but also planning activities, having consistent activity levels, acceptance of current abilities and gradually increasing activities, and one that includes goal setting as a key facet. It is essential that pacing is both defined and measured as a multifaceted strategy in order to assess the outcomes of pacing, and for meaningful comparisons with other strategies regarding efficacy for the management of long-term conditions.

Objectives: A framework for the advanced practice nurse (APN) role was developed in our Canadian Tertiary Care Centre, delineating five domains of advanced nursing practice: clinical practice, consultation, research, education and leadership. The goal of this study was to evaluate perceptions of the effectiveness of the implementation of an innovative APN role on an in-patient Neurosurgery unit., Methods: A pre-and-post implementation design, incorporating both qualitative and quantitative data, was utilized. An innovative APN role was implemented within the Neurosurgery program focusing on the clinical domain and required the successful candidates to be NP prepared. This APN role was designed to improve patient flow, documentation, communication and patient and staff satisfaction. Three primary outcomes were measured: pre-implementation questionnaire (nurses), post-implementation questionnaire (nurses and residents) and number of pages to the on-call resident., Results: Survey scores by nurses and residents indicated improvement across all aspects studied. Average scores increased from 1.1 to 2.6, reflecting an overall statistically significant increase. The number of pages to the on-call resident also showed a decrease., Conclusion: Perceptions of patient care delivery and professional collaboration improved following implementation of the APN role. Responses indicated that APNs significantly impacted patient care and improved nurses and residents' job satisfaction.

Peer review is routine among physicians, nurses, and pharmacy staff yet is uncommon in the field of nuclear medicine technology. Although not a requirement of regulatory agencies, nuclear medicine technical peer review can greatly enhance the quality of patient care in both hospital and outpatient settings. To date, detailed methods for accomplishing this task have not been published. Methods: 19,688 nuclear medicine studies performed at a single institution over a 5-y period were critically reviewed. Major findings (errors with potential to change physician interpretation of the study or resulting in prescription error) and minor findings (errors without an adverse effect on study outcome or interpretation) were identified and tabulated monthly according to finding type, study type, and individual staff member. Results: The technical peer review method used at our institution provided a comprehensive means to measure the rate and types of errors. Over time, this system tracked the performance of nuclear medicine staff and students, providing feedback that led to a measurable reduction in errors. Conclusion: We present a technical peer review system based on our own experience that can be adapted by other nuclear medicine facilities to fit their needs., (© 2017 by the Society of Nuclear Medicine and Molecular Imaging.)

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.

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.

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.

Background: Foot surgery is common in RA but the current lack of understanding of how patients interpret outcomes inhibits evaluation of procedures in clinical and research settings. This study aimed to explore which factors are important to people with RA when they evaluate the outcome of foot and ankle surgery., Methods and Results: Semi structured interviews with 11 RA participants who had mixed experiences of foot surgery were conducted and analysed using thematic analysis. Responses showed that while participants interpreted surgical outcome in respect to a multitude of factors, five major themes emerged: functional ability, participation, appearance of feet and footwear, surgeons' opinion, and pain. Participants interpreted levels of physical function in light of other aspects of their disease, reflecting on relative change from their preoperative state more than absolute levels of ability. Appearance was important to almost all participants: physical appearance, foot shape, and footwear were closely interlinked, yet participants saw these as distinct concepts and frequently entered into a defensive repertoire, feeling the need to justify that their perception of outcome was not about cosmesis. Surgeons' post-operative evaluation of the procedure was highly influential and made a lasting impression, irrespective of how the outcome compared to the participants' initial goals. Whilst pain was important to almost all participants, it had the greatest impact upon them when it interfered with their ability to undertake valued activities., Conclusions: People with RA interpret the outcome of foot surgery using multiple interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than anticipated. These factors can help clinicians in discussing surgical options in patients.

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.

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.

Objective: The eumusc.net project is an initiative founded by the European Community and the European League Against Rheumatism. One aim of the project was to facilitate equal standards for musculoskeletal health across Europe. The aim of this work-package was to develop patient-centred and consensus based standards of care (SOC) for osteoarthritis (OA), which should be available in a professional and a patient version., Methods: A systematic review concerning guidelines dealing with OA was conducted. Furthermore, experts in musculoskeletal diseases were contacted to ensure that 'grey' literature was not excluded. Documents that fulfilled predefined inclusion/exclusion criteria were included and all interventions for OA were extracted and categorised. Based on this list of interventions, a three round Delphi exercise with an international and multidisciplinary expert panel, including patient research partners, was performed to achieve expert consensus., Results: Six documents were included and used for further analysis. Out of them, 46 interventions have been extracted and 10 consensus based SOC were formulated. In addition, a patient version, written in a lay-understandable wording and in the format of checklist questions was developed. An example is SOC 5: "People with OA should achieve optimal pain control using pharmacological and non-pharmacological means." The matching patient-centred checklist question reads: "Do I know how to control pain associated with OA?", Conclusions: The SOC for OA will be available in the 23 languages of the European Union to enhance unified information to patients and professionals and to further harmonise the treatment/care of OA within Europe., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Rheumatoid Arthritis (RA) is one of the most common autoimmune diseases, affecting approximately 1% of the UK adult population. Patients suffer considerable pain, stiffness and swelling and can sustain various degrees of joint destruction, deformity, and significant functional decline. In addition, the economic burden due to hospitalisation and loss of employment is considerable, with over 50% of patients being work-disabled within 10 years of diagnosis. Despite several biologic disease modifying anti-rheumatic drugs (bDMARD) now available, there is a lack of data to guide biologic sequencing. In the UK, second-line biologic treatment is restricted to a single option, rituximab. The aim of the SWITCH trial is to establish whether an alternative-mechanism-TNF-inhibitor (TNFi) or abatacept are as effective as rituximab in patients with RA who have failed an initial TNFi drug., Methods/design: SWITCH is a pragmatic, phase IV, multi-centre, parallel-group design, open-label, randomised, controlled trial (RCT) comparing alternative-mechanism-TNFi and abatacept with rituximab in patients with RA who have failed an initial TNFi drug. Participants are randomised in a 1:1:1 ratio to receive alternative mechanism TNFi, (monoclonal antibodies: infliximab, adalimumab, certolizumab or golimumab or the receptor fusion protein, etanercept), abatacept or rituximab during the interventional phase (from randomisation up to week 48). Participants are subsequently followed up to a maximum of 96 weeks, which constitutes the observational phase. The primary objective is to establish whether an alternative-mechanism-TNFi or abatacept are non-inferior to rituximab in terms of disease response at 24 weeks post randomisation. The secondary objectives include the comparison of alternative-mechanism-TNFi and abatacept to rituximab in terms of disease response, quality of life, toxicity, safety and structural and bone density outcomes over a 12-month period (48 weeks) and to evaluate the cost-effectiveness of switching patients to alternative active therapies compared to current practice., Discussion: SWITCH is a well-designed trial in this therapeutic area that aims to develop a rational treatment algorithm to potentially inform personalised treatment regimens (as opposed to switching all patients to only one available (and possibly unsuccessful) therapy), which may lead to long-term improved patient outcomes and gains in population health., Trial Registration: UKCRN Portfolio ID: 12343; ISRCTN89222125 ; NCT01295151.

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., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: In disease modifying antirheumatic drug (DMARD)-naive early rheumatoid arthritis (RA), to compare the efficacy of methotrexate (MTX) and infliximab (IFX) with MTX and intravenous corticosteroid for remission induction., Methods: In a 78-week multicentre randomised controlled trial, double-blinded to week 26, 112 treatment-naive RA patients (1987 American College of Rheumatology classification criteria) with disease activity score 44 (DAS44)>2.4 were randomised to MTX + IFX or MTX + single dose intravenous methylprednisolone 250 mg. A treat-to-target approach was used with treatment escalation if DAS44>2.4. In the IFX group, IFX was discontinued for sustained remission (DAS44<1.6 for 6 months). The primary outcome was change in modified total Sharp-van der Heijde score (mTSS) at week 50., Results: The mean changes in mTSS score at week 50 in the IFX and intravenous steroid groups were 1.20 units and 2.81 units, respectively (adjusted difference (95% CI) -1.45 (-3.35 to 0.45); p=0.132). Radiographic non-progression (mTSS<2.0) occurred in 81% vs 71% (OR 1.77 (0.56 to 5.61); p=0.328). DAS44 remission was achieved at week 50 in 49% and 36% (OR 2.13 (0.91 to 5.00); p=0.082), and at week 78 in 48% and 50% (OR 1.12 (0.47 to 2.68); p=0.792). Exploratory analyses suggested higher DAS28 remission at week 6 and less ultrasound synovitis at week 50 in the IFX group. Of the IFX group, 25% (14/55) achieved sustained remission and stopped IFX. No substantive differences in adverse events were seen., Conclusions: In DMARD-naive early RA patients, initial therapy with MTX+high-dose intravenous steroid resulted in good disease control with little structural damage. MTX+IFX was not statistically superior to MTX+intravenous steroid when combined with a treat-to-target approach.