BACKGROUND:Research suggests that healthcare professionals find it more difficult to correctly diagnose dermatological conditions in the nonwhite patient demographic. People of colour experience higher rates of delayed and misdiagnosis, contributing to an increased mortality risk and increased health inequalities that remain widespread throughout the health care setting. This study aimed to investigate podiatry student's ability, confidence, approaches and perceptions in diagnosing dermatology pathologies in different skin tones. METHODS:A mixed methods explanatory sequential design was undertaken with pre-registration podiatry students from universities across South-central England. Participants completed a validated pictorial multiple-choice questionnaire comprising six images of either eczema or psoriasis in three different skin tone categories: light, medium or dark. Results were used to inform focus groups and a process of thematic analysis explored participants perceptions surrounding their diagnostic approaches and underpinning confidence. RESULTS:The medium skin tone (Fitzpatrick groups III/IV) was associated with the most correct responses for psoriasis (69%) followed by light skin tone (Fitzpatrick groups I/II) with 48%. Psoriasis in darker skin tones (Fitzpatrick groups V/VI) received the least correct responses (3%). In eczema, results were more evenly spread with darker skin tones (Fitzpatrick groups V/VI), receiving a slightly higher percentage of correct diagnoses (39%). Qualitative analysis revealed two emergent themes: (i) reports on confidence and apprehension and (ii) limitations in education provision: each with a series of sub-themes. Participants reported barriers to their diagnostic ability included an underrepresentation of dark skin tones in medical images and inadequate exposure to pathology on patients with dark skin tones. CONCLUSIONS:There was a notable lack of confidence in participants' ability to correctly diagnose dermatological pathology, particularly in dark skin tones. This study addresses the research gap in podiatric health inequalities and pinpoints the associated educational shortcomings from the podiatry education perspective.

ABSTRACT Background Endorsement for scheduled medicines has been available to Australian podiatrists for over a decade. However, uptake and prescribing rates remain low. A key barrier is the limited number of endorsed prescribers, which restricts access to mentorship opportunities for podiatrists seeking endorsement. While existing literature explores practicing podiatrists' perspectives on endorsement, the views of students regarding prescribing remain underrepresented. This study aimed to explore final‐year podiatry students' experiences with non‐medical prescribing during clinical placements. Methods This qualitative study purposively recruited final‐year podiatry students from the University of Western Australia. Semi‐structured interviews were undertaken to explore participants' experiences of non‐medical prescribing during clinical placements, which were audio‐recorded, transcribed verbatim and analysed using constant comparative analysis until data saturation was reached. Data recorded prior to interview included demographic information, academic characteristics were determined using self‐reported questionnaires to describe motivation, self‐efficacy and mental wellbeing and clinical logbook records were retrospectively reviewed for data on prescribing encounters recorded by students during clinical placements. Results Fifteen participants aged between 23 and 46 years were recruited. Retrospective clinical logs showed that 631 of 7613 cases (8.3%) involved prescription of a scheduled medicine, with most prescribing opportunities occurring in public health settings. Six global themes relating to prescribing experiences emerged: limited exposure, confidence, learning experiences, proposed improvements, pursuit of endorsement and future career impacts. Relationships between themes were developed based on key concepts, particularly scarcity of endorsed prescribers, and limited amount and variety of prescribing encounters. Conclusion This study demonstrated that although podiatry students experienced limited exposure to endorsed prescribing and low self‐confidence in prescribing ability, they continued to see value in non‐medical prescribing with a willingness to pursue endorsement in the future. Future implications to address limited student exposure to prescribing due to shortage of endorsed podiatrists may facilitate the uptake of endorsement for scheduled medicines.

AbstractBackgroundHealth inequalities are a well‐known and widespread phenomenon throughout health care settings. In particular, people of color experience higher rates of delayed and/or misdiagnosis contributing to poorer outcomes and an increased mortality risk. Research suggests that health care professionals find it more difficult to correctly diagnose dermatological conditions in the non‐White patient demographic. Although podiatrists routinely examine and assess skin lesions, there is a paucity of research exploring their accuracy or confidence in recognizing skin pathologies. This study aims to investigate podiatry student's ability, confidence, approaches, and perceptions in diagnosing dermatology pathologies in different skin tones.A mixed methods exploratory sequential design is proposed. In stage one, podiatry students from different higher education institutions will be invited to complete a pictorial survey. We have designed a survey comprising six validated images of inflammatory skin pathology (either eczema or psoriasis) in three different skin tone categories, standardized using the Fitzpatrick scale. Data from the survey in stage one will then be utilized to inform the next stage of the research. In stage two, respondents who completed the initial survey will be invited to participate in focus groups to explore their perceptions surrounding diagnostic approaches, confidence, and perceptions of skin conditions in different skin tone. A process of thematic analysis will be employed to identify emergent themes from these data.MethodsA mixed methods exploratory sequential design is proposed. In stage one, podiatry students from different higher education institutions will be invited to complete a pictorial survey. We have designed a survey comprising six validated images of inflammatory skin pathology (either eczema or psoriasis) in three different skin tone categories, standardized using the Fitzpatrick scale. Data from the survey in stage one will then be utilized to inform the next stage of the research. In stage two, respondents who completed the initial survey will be invited to participate in focus groups to explore their perceptions surrounding diagnostic approaches, confidence, and perceptions of skin conditions in different skin tone. A process of thematic analysis will be employed to identify emergent themes from these data.

Final year podiatry students volunteer annually as part of the wider interprofessional medical team at both the Brighton and London Marathon race events, supervised by qualified podiatrists, allied health professionals and physicians. Volunteering has been reported to be a positive experience for all participants and a way of developing a range of professional, transferable, and where appropriate, clinical skills. We sought to explore the lived experience of 25 students who volunteered at one of these events and aimed to: i) examine the experiential learning reported by students while volunteering in a dynamic and demanding clinical field environment; ii) determine whether there were elements of learning that could be translated to the traditional teaching environment in a pre-registration podiatry course. A qualitative design framework informed by the principles of interpretative phenomenological analysis, was adopted to explore this topic. We used IPA principles to enable analysis of four focus groups over a two-year period to generate findings. Focus group conversations were led by an external researcher, recorded, independently transcribed verbatim and anonymised prior to analysis by two different researchers. To enhance credibility, data analysis was followed by independent verification of themes, in addition to respondent validation. In total, five themes were identified: i) a new inter-professional working environment, ii) identification of unexpected psychosocial challenges, iii) the rigors of a non-clinical environment, iv) clinical skill development, and v) learning in an interprofessional team. Throughout the focus group conversations, a range of positive and negative experiences were reported by the students. This volunteering opportunity fills a gap in learning as perceived by students, particularly around developing clinical skills and interprofessional working. However, the sometimes-frantic nature of a Marathon race event can both facilitate and impede learning. To maximize learning opportunities, particularly in the interprofessional environment, preparing students for new or different clinical settings remains a considerable challenge.

We sought to explore the factors that attract ‘generation Z’ (those born 1995-2010) to a potential career in podiatry. This project comprised a qualitative design framework utilising underpinning phenomenological principles used four focus groups over a two-year period to generate data from participants at University and in Further Education. Focus group conversations were led by external facilitator, recorded, independently transcribed verbatim and anonymised prior to thematic analysis followed by external, independent verification of themes.

Issue The over-the-counter drug dextromethorphan (DXM) shows anti-diabetic and islet cell-protective effects in vitro and in vivo, without inducing hypoglycemia. However, DXM is able to pass the blood-brain barrier (BBB) and potential CNS-related side effects limit its use as anti-diabetic drug. We chemically generated novel derivatives of DXM to prevent compound distribution to the CNS, while maintaining the anti-diabetic and islet cell-protective potential.

This editorial refers to 'A clinical audit into the adherence of foot health management standards of rheumatoid arthritis compared with the foot health management standards of diabetes mellitus in North-East London', by Christopher Joyce & Rizwan Rajak. doi.org/10.1093/rap/rkab006

Background Gout has been associated with weaker foot/leg muscles and altered gait patterns. There is also evidence of on-going foot pain and an increased risk of tendinopathy, with the Achilles and patellar tendons most frequently affected in gout. Additionally, the inflammation associated with gout may change tissue elasticity. Ultrasound imaging utilising shear wave elastography (SWE) offers a non-invasive method of quantifying changes in tendon stiffness. SWE findings have not previously been reported in individuals with gout. We sought to determine differences in Achilles tendon stiffness in people with gout compared to controls (non-gout). Methods: A cross sectional study comparing 24 people with gout and 26 age/sex-matched controls. Clinical and demographic data were collated, and US imaging used to determine tendon thickness, presence of gouty tophi and/or aggregates and levels of angiogenesis. Ten shear wave elastography (SWE) measures were taken along the centre of a longitudinal section of the mid-portion of each Achilles tendon. Prior to data collection, intra-observer error was good (0.75). Data were summarised using descriptive statistics and a repeated measures ANCOVA was used to compare SWE measures between the two groups for the left and right foot separately after accounting for Body Mass Index (BMI). Results: A small proportion of those with gout presented with intra-tendon aggregates and/or intra-tendon tophi in one or both tendons. There was no statistically significant difference in tendon thickness between groups. Neo-vascularity was present in a third of gout participants. SWE findings demonstrated significantly reduced tendon stiffness in those with gout compared to controls: right Achilles mdiff =1.04m/s (95% CI (0.38 to 1.7) p=0.003 and left Achilles mdiff = 0.7m/s (95% CI 0.09 to 1.32) p=0.025. No relationship between the presence of tophi and SWE values were detected. Conclusion: Subjects with chronic gout show significantly reduced Achilles tendon stiffness compared to non-gout controls. From a clinical standpoint, our findings were similar to SWE measurements in subjects with Achilles tendinopathy and who did not have gout.

Background Increasing numbers of nurses, pharmacists and allied health professionals across the world have prescribing rights for medicines: over 90,000 of the eligible United Kingdom workforce are qualified as non-doctor prescribers. In order to inform future developments, it is important to understand the benefits and impact of prescribing by allied health professionals including physiotherapists and podiatrists. Aim: to compare outcomes of physiotherapist and podiatrist Independent Prescriber (PP- IP) patients with those of physiotherapist and podiatrist non-prescribers (PP-NPs). Outcome measures included patient satisfaction, ease of access to services, quality of life and cost implications. Design: a mixed method comparative case study Methods: Using mixed methods of data collection, outcomes were compared between 7 sites where care was provided from a PP-IP (3 podiatrist and 4 physiotherapist IPs) and 7 sites from a PP-NP (3 podiatrist and 4 physiotherapist NPs). Patients were followed up for 2 months (2015-2016). Results: 489 patients were recruited: n=243 IP sites, and n=246 NP sites. Independent prescribing was found to be highly acceptable, and equivalent in terms of quality of life (p>0.05) and patient satisfaction (p≤0.05) compared to care provided by NPs. PP-IP care delivery was found to be more resource intensive than PP-NP, with longer consultation duration for IPs (around 6.5 mins), and a higher proportion of physiotherapy patients discussed with medical colleagues (around 9.5 minutes). Conclusion This study provides new knowledge that PP-IPs provide high levels of care. PP-IP care delivery was found to be more resource intensive. Further research is required to explore cost effectiveness. A more focussed exploration within each profession using targeted outcome measures would enable a more robust comparison, inform future developments around the world and help ensure non-doctor prescribing is recognised as an effective way to alleviate shortfalls in the global workforce.

Background Increasing numbers of nurses, pharmacists and allied health professionals across the world have prescribing rights: over 90,000 of the eligible United Kingdom workforce are qualified as non-doctor prescribers. In order to inform future developments, it is important to understand the benefits and impact of prescribing by allied health professionals including physiotherapists and podiatrists. Aim: to compare outcomes of Physiotherapist and Podiatrist Independent Prescriber (PP-IP) patients with those of Physiotherapist and Podiatrist non-prescribers (PP-NPs). Outcome measures included patient satisfaction, ease of access to services, quality of life and cost implications. Design: a quasi-experimental, post-test control group design Methods: Using mixed methods outcomes were compared between 7 sites where care was provided from a PP-IP (3 podiatrist and 4 physiotherapist IPs) and 7 sites from a PP-NP (3 podiatrist and 4 physiotherapist NPs). Patients were followed up for 2 months (2015-2016). Results: 489 patients were recruited: n=243 IP sites, and n=246 NP sites. Independent prescribing was found to be highly acceptable, and equivalent in terms of quality of life (p>0.05) and patient satisfaction (p≤0.05) compared to care provided by NPs. PP-IP care delivery was found to be more resource intensive than NP-PP, with longer consultation duration for IPs (around 6.5 mins), and a higher proportion of physiotherapy patients discussed with medical colleagues (around 9.5 minutes). Conclusion This study provides new knowledge that PP-IPs provide high levels of care. PP-IP care delivery was found to be more resource intensive. Further research is required to explore cost effectiveness. A more focussed exploration within each profession using targeted outcome measures would enable a more robust comparison, inform future developments around the world and help ensure non-doctor prescribing is recognised as an effective way to alleviate shortfalls in the global workforce.

We have recently shown that the N-Methyl-D-Aspartate receptor (NMDAR) antagonist and over-the-counter drug dextromethorphan (DXM) and its active metabolite dextrorphan (DXO) have antidiabetic and islet cell protective properties. However, both molecules are associated with central nervous system related side effects. To reduce these effects, we are currently developing and testing derivates of DXO that have a reduced blood-brain barrier (BBB) permeability while having a preserved antidiabetic potential.

Background In addition to acute attacks of severe joint pain and swelling, chronic gout has been associated with weaker foot/leg muscles, altered gait patterns and on-going foot pain. Inflammation associated with gout may change tissue elasticity and ultrasound imaging (US) utilising elastography is a non-invasive method of quantifying these changes in tendon stiffness and elastography findings have not previously been reported in individuals with gout. Objectives To determine differences in Achilles tendon stiffness in people with chronic gout compared to controls (non gout) Methods A cross sectional study comparing people with gout according to 2015 ACR/EULAR criteria and age/sex matched controls. Clinical and demographic data were collated and US imaging used to determine tendon thickness, presence of gouty tophi and/or aggregates and levels of angiogenesis. Previously validated protocols for conventional US imaging [1] and shear wave elastography [2] were used. Prior to data collection, intra-observer error was good (ICC (2) 0.69 (95%CI 0.62-0.89)). Ten elastography measures were taken along a longitudinal section of the mid-point of the Achilles tendon bilaterally. Data were summarised using descriptive statistics and a repeated measures ANCOVA was used to compare elastography outcomes between the two groups for the left and right foot separately after accounting for Body Mass Index (BMI). Results A total of 14 people with gout and 13 age/sex matched control subjects participated. Table 1 displays clinical and demographic data. A small proportion of those with gout presented with intra-tendon aggregates and/or intra-tendon tophi in one or both tendons n=7 (27%) for both). There was no significant difference in tendon thickness between groups, neo-vascularity was present in n=3 (21%) gout participants. Elastography findings (table 2) demonstrated significantly reduced tendon stiffness in those with gout compared to controls. Conclusion Subjects with chronic gout show reduced Achilles tendon stiffness compared to controls. From a clinical standpoint, our findings were similar to elastography measurements in otherwise healthy subjects with Achilles tendinopathy and who did not have gout [3]. References [1] Carroll M, Dalbeth N, Allen B, et al. Ultrasound Characteristics of the Achilles Tendon in Tophaceous Gout: A Comparison with Age- and Sex-matched Controls. J Rheumatol. 2017 44(10):1487-1492. [2] Payne C, Watt P, Cercignani M, Webborn N. Reproducibility of shear wave elastography measures of the Achilles tendon. Skeletal Radiol. 2017 17 2846-8. [3] Payne C 2018 Clinical Applications of shear wave elastography to Achilles tendon imaging and monitoring of a rehabilitation protocol for Achilles tendonopathy PhD Thesis, University of Brighton Disclosure of Interests None declared

BACKGROUND:In 2015 the Health and Care Professions Council (HCPC) reported that annotation of the register for podiatric surgery would improve the way in which risks are currently managed. The academic institutions provide the teaching environment for the 'learnt' Diploma in principles of podiatric surgery however the podiatric surgery departments facilitate the production of the next generation of podiatric surgeons. This research aimed to identify the major elements that contribute to the educational environment, and find and utilise a valid assessment tool which could identify discrete areas to be targeted for improvement as well as being used for monitoring of the environment.METHODS:A quantitative study using the Surgical Theatre Educational Environment Measure (STEEM) via an online tool was utilised for podiatrists working within podiatric surgery, podiatric surgical trainees and podiatric surgeons working towards the Certificate of Completion of Podiatric Surgery Training (CCPST) with a view to assessing the educational environment within the podiatric surgical theatre in the UK.RESULTS:16/33 responses with a response rate of 48.4% the overall STEEM mean score was 122/160. Four subscales included teaching and training, learning opportunities, atmosphere, and workload/supervision/support were measured. The overall mean score of 76.73% suggests the learning environment may be considered satisfactory; however, areas for potential improvement are identifiable. Results reveal strengths such as a non-discriminatory surgical theatre atmosphere on racial grounds.CONCLUSIONS:Perception was of a very satisfactory 'Atmosphere' within the theatre environment and a very satisfactory 'opportunity to assist' within the podiatric surgery theatre environment. The STEEM has potential to be applied further as a quality assessment tool whose results could be used to demonstrate part of the HCPC standards.

•Medicines management by allied health professions could contribute to service improvement.•United Kingdom policy is extending prescribing rights to a range of allied health professions.•Robust evaluation of medicines management by podiatrists and physiotherapists is lacking.•Internationally, physiotherapists are highly involved in administering medicines and providing medicines advice.•Improvements to training and education around medications are recommended.

Betazelldysfunktionen und die durch Betazelltod hervorgerufene progressive Reduktion funktionaler Betazellmasse haben eine zentrale Bedeutung für die Entstehung und das Fortschreiten der Diabeteserkrankung. Unsere Arbeitsgruppe hat kürzlich zeigen können, dass der N-Methyl-D-Aspartat-Rezeptor (NMDAR) Antagonist Dextromethorphan (DXM) selektiv die glukosestimulierte Insulinsekretion steigert, die Glukosetoleranz verbessert und unter diabetogenen Bedingungen in vitro sowie in einem Mausmodell für den Typ 2 Diabetes mellitus T2DM (db/db) in vivo Inselzellschutz vermittelt. Auf der Grundlage dieser Ergebnisse untersuchen wir aktuell die Rolle des NMDAR in der Pathophysiologie des T1DM. Unsere Hypothese ist, dass die frühzeitige Verabreichung des NMDAR Antagonisten DXM die autoimmunbedingte Zerstörung der Betazellen in einem Tiermodell für den T1DM (NOD Maus) reduzieren kann.

Background: Foot complaints have been shown to be common in systemic lupus erythematosus (SLE) and heterogeneous in nature. We aimed to categorize self-reported foot complaints in people with SLE and foot symptoms.Methods: A self-administered validated questionnaire was posted to 406 people with SLE attending adult rheumatology clinics across three health boards in Auckland, New Zealand. In addition to foot pain, vascular complaints, dermatological lesions and neurological symptoms were included in the analysis. Pairwise correlations among the variables were undertaken followed by factor analysis to identify and categorise associations between reported foot complaints.Results: From the questionnaires returned, 93 full datasets were analysed. Participants' were predominantly female (n = 87, 93.7%), with mean (SD) age of 50.4 (14.3) years and a mean (SD) disease duration of 13.1 (11) years. Three categories of foot complaint were determined: 'foot pain', 'skin disorders' and 'vascular insufficiency'. These three groups provided the best fit (0.91) to describe the wide range of foot complaints reported by those with SLE. Factor analysis for foot pain demonstrated a high positive loading for the inter-correlation of foot pain in past month (0.83), foot pain today (0.71), intermittent claudication (0.71), numbness (0.62), loss of balance (0.81), swelling (0.59), foot joint pain (0.77), arch pain (0.68) and tendon pain (0.77). Skin disorders demonstrated a very high positive loading for 3 factors skin rash (0.82), blistering skin rash (0.95) and foot ulceration (0.88). In vascular insufficiency a high positive loading for cold feet (0.83), chilblains (0.76) and Raynaud's phenomenon (0.70).Conclusions: This work suggests people with SLE report three independent categories of foot complaints; foot pain, skin disorders or vascular insufficiency.

This Department of Health funded study is the first to evaluate the effectiveness and efficiency physiotherapist and podiatrist independent prescribing (IP) in England. We found: found that: Patients and healthcare professionals were generally positive about physiotherapist and podiatrist independent prescribing. A majority of patients agreed that physiotherapists and podiatrists should be able to prescribe medicine, although a minority of patients would prefer a doctor to prescribe their medicine. Physiotherapist and podiatrist independent prescribers were more active than non-prescribers in most aspects of medicines management, including providing medicine and giving advice or information to patients about medicine. Among physiotherapists, the predominant activity was pain/movement control. Among podiatrists, the predominant medications used were antibiotics, antifungal/microbial topical creams, emollients and pain medication. Perceived benefits included: reduced patient journey, fewer GP appointments, streamlining service, enabling services to continue when a doctor was not available, increased choice and enhanced quality of advice and information given. Benefits for physiotherapist and podiatrist independent prescribers included: improved knowledge around medicine management and safety, enhanced professional reputation, facilitation of advanced practice roles, and improved clarity over legality of medicines management activity practice. Barriers to independent prescribing included: finding a suitable Designated Medical Practitioner, access to a prescribing budget and patient medical records, clinical governance support for monitoring and auditing prescribing practice.  Patients of physiotherapist and podiatrist independent prescribers received more information about how often to take medicines and more often intended to follow the advice of the physiotherapist and podiatrist independent prescribers than patients of non-prescribers. Additional benefits differed between the professions. Patients of physiotherapist independent prescribers received more information about their medicines, were more satisfied, able to understand and inclined to take their medicine than patients of physiotherapist non-prescribers. Patients of podiatrist independent prescribers were more satisfied with aspects of access to services than those of non-prescribing podiatrists. Health related quality of life, as measured by the EQ-5D-L, improved equally for patients in both independent prescriber and non-prescriber groups between baseline and two-month follow-up. Care delivery by physiotherapist and podiatrist independent prescribers was more resource intensive and costly than physiotherapist and podiatrist non-prescribers due to longer consultation duration and more frequent medicines management activities, however there are many limitations to the economic analysis so findings should be treated with caution.

BACKGROUND:The foot and ankle represent a common site for tophi in people with gout, yet it is unclear whether the presence of tophi is related to impaired muscle function. This study aimed to determine the association between foot and ankle tophi and muscle force in people with gout. METHODS:Participants with gout were stratified into two groups based on the presence of clinically-evident tophi affecting the foot or ankle on physical examination. Isometric muscle force for plantarflexion, dorsiflexion, inversion and eversion was measured using static dynamometry. Mixed-models regression was used to determine the difference in muscle force between the two groups while adjusting for age, disease duration and foot pain. This model was also used to determine the difference in muscle force between presence and absence of tophi at specific locations within the foot and ankle. In addition, Pearson's correlations were used to determine the association between total foot tophus count and muscle force. RESULTS:Fifty-seven participants were included (22 with foot or ankle tophi and 35 without foot or ankle tophi). Foot and ankle tophi were most often seen at the Achilles tendon. After adjusting for age, disease duration and foot pain, participants with tophi had significantly reduced muscle force during plantarflexion (P < 0.001), dorsiflexion (P = 0.003), inversion (P = 0.003) and eversion (P = 0.001) when compared to participants without tophi. Those with Achilles tophi had significantly reduced force during plantarflexion (P < 0.001), inversion (P = 0.008) and eversion (P = 0.001). No significant differences in muscle force were observed between the presence and absence of tophi at other foot or ankle locations. There were also no significant correlations between total foot tophus count and muscle force (all P > 0.05). CONCLUSION:In people with gout, clinically-evident foot or ankle tophi are associated with muscle force deficits during foot plantarflexion, dorsiflexion, inversion and eversion, which persist despite adjusting for age, disease duration and foot pain. Tophi at the Achilles tendon, which associate with force deficits, may contribute to reduced muscular activation and consequent disuse muscle atrophy.

BackgroundAssessing diabetic foot ulcers (DFUs) for infection is difficult because clinical symptoms and signs may be masked by neuropathy and vasculopathy and there are no objective tests available at point of care to guide clinicians.Empirical prescription of antibiotics compromises antibiotic stewardship, while missing early infection may lead to severe infection and amputation.In 2011-12, the cost of managing DFUs and associated amputations borne by NHS England was £650 million, nearly 1% of its budget.Our INDUCE study had two aims: (1) to develop an online educational tool for DFU infection and (2) to conduct a pilot study investigating C-reactive protein (CRP) and procalcitonin from venous blood and calprotectin from wound exudate as inflammatory biomarkers of mild DFU infection.Methods Yola software was used to develop an online educational tool covering DFU history and examination, arterial assessment, microbiology, radiology and management of osteomyelitis.The tool contains links to NICE guidance and other relevant learning resources.A quiz using patient scenarios is included.Feedback from podiatrists was elicited by questionnaires and a focus group.Patients with non-infected or mildly infected DFUs were recruited from community podiatry clinics in 2 UK regions.Exclusion criteria included immunosuppression or receipt of antibiotics within the previous 2 weeks.Antibiotics were prescribed based on clinical judgement at the baseline assessment.Our gold standard defining DFU infection was the clinician's judgement one week later, while still blinded to test results, factoring in the response to antibiotic therapy, if prescribed.All 3 inflammatory biomarkers were measured at weeks 0 and 1, including assessment of CRP using a point-of-care device. ResultsFeedback regarding the educational tool from end-users ranging from trainee to senior podiatrists was very positive.The main improvement requested was a printable certificate after successful completion of the quiz and provision of CPD points.Between September 2014 and September 2015, the INDUCE study recruited 67 patients with DFUs, from a total of 363 potential participants.Primary endpoints were available for 37 participants with non-infected ulcers and 28 with mild infection, following early study withdrawal by one patient in each group.Median CRP was slightly higher in the infected ulcer group, 7.50 mg/ml compared to 6.00 mg/ml for noninfected ulcers, but the area under the receiver operating characteristic curve (AUROC) was only 0.52, demonstrating poor predictive efficacy.Most of the procalcitonin results were below the lower limit of the assay and levels were lower in the infected DFU group.Median calprotectin levels were nearly doubled in infected ulcers, 1437 ng/ml compared with 879 ng/ml in non-infected DFUs, but with an insufficient AUROC of 0.56.Conclusions Feedback from a range of podiatrists confirmed that assessment of DFU infection remains challenging and showed that the INDUCE tool is a useful learning resource.The tool will be made freely available via the internet.Based on their sensitivity and specificity, neither venous CRP or procalcitonin should be pursued as biomarkers of DFU infection, alone or in combination.Calprotectin in wound exudate may have value, but only in combination with other biomarkers.

BACKGROUND:This pilot study investigated whether semi-rigid and soft orthoses had an effect on pain, disability and functional limitation in participants with chronic rheumatoid hindfoot involvement. METHODS:Participants with chronic hindfoot pain were randomly assigned to 2 groups, commencing either with semi-rigid Subortholene orthoses or soft EVA orthoses. The Foot Function Index and the Ritchie Articular Index were administered pre- and post-intervention, which lasted for 3 months. Following a 2 week washout period, each group was switched over to the other type of orthoses. RESULTS:Nine female participants (mean age 52.2years (SD 9.1); mean weight 71kg (SD 12.64); mean height 160cm (SD 5.18)) with a mean RA duration of 11.7years (SD 7.83), and a mean ankle/subtalar joint pain duration of 5.7years (SD 2.62), completed the programme. Mean improvement in FFI score for both orthoses resulted in the same statistical significance (p=0.001). Statistically significant reduction in pain, disability and functional limitation was observed for both interventions, together with improvement in the Ritchie Articular Index score. CONCLUSION:Both Subortholene and EVA orthoses significantly reduced pain, disability and functional limitations in participants with chronic ankle/subtalar joint pain in rheumatoid arthritis.