Development and use of the PodEssential and Paeds-PodEssential triage tools to define "essential" podiatry services. A Delphi survey, scoping review, and face validity testing study.

BACKGROUND: The coronavirus pandemic resulted in unique challenges for podiatrists in Australia. Podiatrists were tasked with having to make triage decisions about face-to-face care without clear guidelines. This research aimed to develop podiatry triage tools to understand individual risk for adults and children, and explore the face validity of both tools. METHODS: An online three-round modified Delphi technique was used to elicit podiatrists' opinions on conditions, assessments and social factors that elevate risk. Additional elements of known foot and/or leg risk were informed by a synchronous scoping review. Australian podiatrists who held a clinical role treating patients or directly managing podiatrists treating patients within the past six months were recruited. Where 70% of participants reported the same or similar theme in Round 1, statements were accepted with consensus. Where 50-69% of participants reported a similar theme, these were returned to participants to rate agreement using a four-point Likert agreement scale. Statements identified in the scoping review were added at Round 2, if not already identified by participants. The final round presented participants with triage tools, and a series of mock patient scenarios.. Participants were asked to indicate if they would or would not provide face to face podiatry service based on these scenarios. RESULTS: There were 40 participants who responded to Round 1 (Adult presentations), of these, 23 participants also provided paediatric presentation responses. Participants developed and agreed upon 20 statements about risk in podiatry service delivery for both adults and children across Rounds 1 and 2. The PodEssential and Paed-PodEssential were developed based on these statements indicating stand-alone condition risk (tier 1), elements that should elevate risk (in the absence of a stand-alone condition) (tier 2), and assessments results identifiying a limb at risk (tier 3) in adults and children respectively. Participants utilising these tools in Round 3 more frequently indicated face-to-face service when mock patient scenarios included a greater number elements, suggesting the tool can be useful in making triage decisions. CONCLUSION: The PodEssential and Paeds-PodEssential tools direct conditions requiring urgent attention as well as providing considered elements to a person's health status to assist in making triage decisions.

Validity and reliability of the Australian Therapy Outcome Measures - Physiotherapy, for podiatry (AusTOMs-PT for use in podiatry).

BACKGROUND: Valid and reliable outcome measure enable measurement of health care service impact. There are limited valid and reliable outcome measures for use in podiatry practice to measure the impact of treatment. This research aimed to test the face validity of the AusTOMs for Physiotherapy (AusTOMs-PT), it's adaptability to podiatry clinical practice and the reliability of its use with podiatrists. METHODS: Stage 1 used a nominal group technique with podiatrists who worked in public and/or private settings. All podiatrists underwent self-directed training in the AusTOMs framework and measures prior to interviews or focus group discussion. Discussion was centred about transferability of the core scales of the AusTOMs-PT and an adjunct measure, AusTOMs for Occupational Therapy (AusTOMs-OT) to podiatry practice. Stage 2 used 10 case studies representative of people who had foot or ankle concerns. Podiatrists were recruited and trained in the use of the relevant AusTOMs-PT scales. Podiatrists individually scored the cases at two timepoints (1 month apart) using the six scales from the AusTOMs-PT deemed by stage 1 as relevant to podiatry. Intra and inter-rater reliability of scales were determined using intraclass correlation coefficients (ICCs). RESULTS: Thirteen podiatrists participated in individual or focus group interviews in Stage 1. Consensus was gained on six of the nine core scales adopted from the AusTOMs-PT. These were 1. Balance and Postural Control, 3. Musculoskeletal Movement Related Functions, 4. Neurological Movement Related Functions, 5. Pain, 7. Sensory Functions, 8. Skin Functions. Each core scale rated the functional domains of Impairment, Activity Limitation, Participation Restriction and Wellbeing/Distress relating to that presentation of goals of the person in the case study. There were 22 podiatrists complete training and scored two rounds of case studies using the six scales in Stage 2. There were 91%(n = 20) participants with an intra-rater ICC > 0.5 (moderate or greater). Each domain had an inter-rater reliability of > 0.9 (excellent) during the first round. CONCLUSIONS: The AusTOMs-PT for use in podiatry may be implemented to record change in impairment, function, participation and wellbeing of people receiving podiatry treatment. Podiatry specific training and mentoring, together with repeated use could be expected to improve intra-reliability.

Partnering with African American Churches to Create a Community Coalition for Mental Health.

Community partnered participatory research (CPPR) emphasizes community engagement, respect, and empowerment as guiding principles to promote mental health equity. This article describes the "Vision" stage of a CPPR-informed model to implement evidence-based practices for depression in two African American churches in Harlem, New York. Essential parts of the Vision include engagement of stakeholders and collaborative planning. The engagement process increased awareness about the project via a community-focused mental health symposium. The collaborative planning stage resulted in creating a multi-disciplinary Community Coalition for Mental Health, establishing the Coalition's values, agreeing to change the initial chosen study intervention from Interpersonal Counseling to Mental Health First Aid, and developing a website to disseminate the group's work. Key lessons learned from our partnered process are: 1) support from the lead pastor is crucial; 2) balancing community and academic interests can be challenging; 3) icebreaker activities foster relationships and reinforce CPPR principles; 4) multiple communication channels can enhance community participation; and, 5) should organize data in ways that make them easier to interpret.

Implementing a podiatry prescribing mentoring program in a public health service: a cost-description study.

BACKGROUND: In the management of diabetes and high-risk patients, timely treatment with scheduled medicines is critical to prevent severe infections and reduce the risk of lower extremity amputation. However, in Australia, few podiatrists have attained endorsement to prescribe. The aims of this study were to identify the costs associated with developing and implementing a podiatry prescribing mentoring program; and to compare the cost of this program against potential healthcare savings produced. METHODS: This was a cost-description analysis, involving the calculation of costs associated with the development and implementation of a mentoring program to train podiatrists to become endorsed prescribers. Costs were calculated using the Ingredients Method and examined from the perspective of a public health service provider, and the individual learner podiatrist. Breakeven analysis compared the cost of training a podiatry prescriber for endorsement against the potential benefit (savings) made by averting complications of an infected foot ulcer. A sensitivity analysis was conducted to allow for uncertainty in the results of an economic evaluation. RESULTS: Total start-up cost for the podiatry prescriber mentoring program was $13, 251. The total cost to train one learner podiatrist was $30, 087, distributed between the hospital $17, 046 and the individual learner $13, 041. In the setting studied, a podiatry prescriber must avert 0.40 major amputations arising from an infected foot ulcer through prescribing to recover the cost of training. If in-kind training costs are included, total cost increases to $50, 654, and the breakeven point shifts to 0.68 major amputations averted. CONCLUSION: The economic benefits (savings) created by an endorsed prescribing podiatrist over their career in a public health service are likely to outweigh the costs to train a podiatrist to attain endorsement. Further research is required to help understand the effectiveness of podiatry prescribing in reducing diabetic foot related complications and the potential economic impact of podiatry prescribers on this health condition.

Comparative effectiveness research for the clinician researcher: a framework for making a methodological design choice.

Comparative effectiveness research compares two active forms of treatment or usual care in comparison with usual care with an additional intervention element. These types of study are commonly conducted following a placebo or no active treatment trial. Research designs with a placebo or non-active treatment arm can be challenging for the clinician researcher when conducted within the healthcare environment with patients attending for treatment.A framework for conducting comparative effectiveness research is needed, particularly for interventions for which there are no strong regulatory requirements that must be met prior to their introduction into usual care. We argue for a broader use of comparative effectiveness research to achieve translatable real-world clinical research. These types of research design also affect the rapid uptake of evidence-based clinical practice within the healthcare setting.This framework includes questions to guide the clinician researcher into the most appropriate trial design to measure treatment effect. These questions include consideration given to current treatment provision during usual care, known treatment effectiveness, side effects of treatments, economic impact, and the setting in which the research is being undertaken.

Health related quality of life of children with calcaneal apophysitis: child & parent perceptions.

BACKGROUND: Children with a clinical diagnosis of calcaneal apophysitis reportedly experience impaired physical ability. Patient reported outcome assessments measure the level of conditional specific interference in everyday life. The aim of this study was to assess and compare the child and parent perceptions of health related quality of life (QOL) associated with calcaneal apophysitis. METHODS: This is a longitudinal repeated measure study nested within a randomized comparative effectiveness trial. Children who had symptoms of calcaneal apophysitis were recruited from local advertising and from the caseload of podiatrists within the health setting (Australia). The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) was completed at baseline, 1, 2, 6 and 12 month time points by both child and parent. RESULTS: A total of 133 children were recruited and 124 participated in the study with 101 completing the OxAFQ-C at all five time points. The inter-rater reliability between the child and parent for the physical domain ranged between poor (0.06) to good (0.77) agreement, and the footwear domain ranged between poor (0.09) to good (0.66) across the time points. Both the school and emotional domains had moderate (0.46) to good (0.77) agreement. CONCLUSION: Children with calcaneal apophysitis have differing perceptions of health related QOL impact compared to their parents. Parents initially reported greater impact than their child however there was convergence of agreement over the follow-up period. These findings suggest understanding the impact from both child and parent perspective is imperative during treatment. TRIAL NUMBER: ACTRN12609000696291.

Effectiveness of footwear and foot orthoses for calcaneal apophysitis: a 12-month factorial randomised trial.

OBJECTIVE: Calcaneal apophysitis, is a relatively common cause of heel pain in children. Very few randomised studies have evaluated treatment options. This trial compared the effectiveness of currently employed treatment options for the relief of pain and disability associated with calcaneal apophysitis. DESIGN: Factorial 2×2 randomised comparative effectiveness trial with 1, 2, 6 and 12-month follow-up. SETTING: Participants were recruited from the caseload of podiatrists at Monash health and Peninsula Health. PARTICIPANTS: Children aged 8-14 years with clinically diagnosed calcaneal apophysitis. INTERVENTIONS: Treatment factor 1: two different types of in-shoe orthoses: a heel raise or prefabricated orthoses. Treatment factor 2: footwear replacement or no footwear replacement. OUTCOMES: Our primary outcome was functional disability, the secondary outcomes were pain and ankle dorsiflexion range. RESULTS: A total of 133 children and their parents responded to the recruitment advertisement, 124 participated in the trial.At the 1 and 2-month follow-up points, there was a main effect of the shoe insert (heel raise) in only the physical domain for the Oxford ankle foot questionnaire (p=0.04). At the 6 and 12-month follow-up points, there was no main effect or interaction effect for any outcome measure. CONCLUSION: This trial indicates at the 2-month time point there is a relative advantage in the use of heel raises over prefabricated orthoses for the treatment for calcaneal apophysitis. At 12 months there was no relative advantage to any one of the investigated treatment choices over another. Therefore, if a physical impact is experienced for greater than 2 months, the selection of treatment choice may defer to clinical judgement, cost-minimisation and or patient preference. TRIAL REGISTRATION NUMBER: ACTRN12609000696291.

Factors Associated with Pain Severity in Children with Calcaneal Apophysitis (Sever Disease).

OBJECTIVE: To identify any association between the pain experienced as a result of calcaneal apophysitis, anthropometric data, and lower limb measurements. STUDY DESIGN: This study was a cross-sectional study, nested within a wider randomized, comparative efficacy trial. One hundred twenty-four children between the ages of 8 and 14 years with a clinical diagnosis of calcaneal apophysitis were recruited for this study. Of the participating children, 72 were male. The measures recorded were height, weight, waist circumference, body mass index, foot posture, and ankle joint range of motion; comparison with normative values was also completed. Univariate and multivariable regression analyses were undertaken to identify factors associated with the severity of pain experienced (visual analog scale). RESULTS: The children within this study had a higher mean body mass index (P < .001), increased weight (P < .001), and were taller (P < .001) compared with normative values. The children also demonstrated differences in foot posture and ankle joint range of motion. Multivariable regression analyses identified that older participants (P = .046) and those who had experienced pain for longer (P = .043) reported higher pain severity. CONCLUSIONS: Children presenting with calcaneal apophysitis were anthropometrically different from their peers and had experienced a lengthy period of pain. Therefore, early management focussing on the anthropometric differences may minimize the intensity and duration of pain experienced. TRIAL REGISTRATION: Registered with Australian New Zealand Clinical Trials Registry: ACTRN12609000696291.

Statin use and peripheral sensory perception: a pilot study.

OBJECTIVES: Peripheral sensory neuropathy is a neurological deficit resulting in decreased detection of sensation through the peripheral nervous system. Peripheral sensory neuropathy is commonly diagnosed with the use of a monofilament and either a tuning fork or neurothesiometer. Statins are a widely used medication and there has been some debate of association with their use and peripheral sensory neuropathy. This pilot study aimed to test the sensory perception of participants with long-term statin use and compare these results to their peers who were not taking statins. METHODS: Thirty participants were recruited and equally divided into a statin and non-statin group. Healthy participants were screened by their medical and medication history, Australian Type 2 Diabetes Risk assessment, and random blood glucose level. An assessor who was blinded to the participant group conducted sensory assessments using a 10 g monofilament and neurothesiometer. RESULTS: There was no difference in monofilament testing results between the groups. The statin group was less sensate at the styloid process (p = 0.031) and medial malleolus (p = 0.003) than the control group. Results at the hallux were not statistically significant (p = 0.183). CONCLUSION: This result is suggestive of a potential association between long-term statin use and a decrease in peripheral sensory perception. This may be because of peripheral sensory neuropathy. Limitations such as consideration of participant height, participant numbers, and inability to analyze results against statin groups are reported. As statins are a life-saving medication, careful consideration should be applied to these results and further research be conducted to determine if these results are applicable to larger populations.

"Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever's disease): a systematic review".

BACKGROUND: Calcaneal apophysitis, also commonly known as sever's disease, is a condition seen in children usually aged between 8-15 years. Conservative therapies, such as taping, heel lifts and orthotic intervention are accepted management practices for calcaneal apophysitis, though there is very little high quality research examining the efficacy of such treatment modalities. Previous narrative literature reviews and opinion pieces provide some evidence for the use of heel raises or orthoses. The aim of this manuscript was to complete a systemic review on the treatment options for calcaneal apophysitis as measured by pain reduction and maintenance of physical activity. METHODS: A search strategy completed by two reviewers examined nine databases from inception to May 2012. Search terms included heel pain, children, adolescent, calcaneal apophysitis, sever's disease, treatment, and management (full text publications, human studies). Systematic reviews, randomised control trials, case series, and case studies were included. The reference lists of the selected articles were also examined. The methodology, quality and risk of bias was examined and assessed using the PEDro scale. RESULTS: Nine articles were retrieved including three clinical trials involving randomisation, two case series, two retrospective case reviews, and two case reports. Effect size calculations and a meta analysis were unable to be completed due to the limited data reported within the literature. Numerous treatment options were reported throughout the literature, though few were examined against a control or alternate treatment option in well-designed trials. The limited evidence indicated that orthoses provided greater short-term pain relief than heel raises. Health practitioners should view these results with caution, as there were apparent methodological problems with the employed study design and limited follow-up of participants. CONCLUSION: There is limited evidence to support the use of heel raises and orthoses for children who have heel pain related to calcaneal apophysitis. Further research is needed to generate higher quality evidence with larger sample sizes, and validated measures of pain and function to establish effective treatment approaches for children with calcaneal apophysitis.

Metatarsus adductus: development of a non-surgical treatment pathway.

Metatarsus adductus (MA) occurs in one to two cases per 1000 births and is the most common congenital foot deformity in newborns. The appearance is that of a curved or adducted forefoot with a normal hindfoot. A systematic literature review was conducted to answer the following question: For a child who presents with MA, what is the most evidence-based conservative treatment option? Thirteen articles were reviewed using the National Health and Medical Research Council levels of evidence and guidelines for clinical practice. Conservative treatment options reported on included the following: no treatment, stretching, splinting, serial casting, sitting and sleeping positions and footwear/orthotics. There was strong evidence supporting no treatment in the case of flexible MA. Some limited evidence was found for the treatment of semi-rigid MA. Clinicians should use these recommendations together with clinical experience when advising parents on treatment of MA.

Heel raises versus prefabricated orthoses in the treatment of posterior heel pain associated with calcaneal apophysitis (Sever's Disease): a randomised control trial.

BACKGROUND: Posterior Heel pain can present in children of 8 to 14 years, associated with or clinically diagnosed as Sever's disease, or calcaneal apophysitis. Presently, there are no comparative randomised studies evaluating treatment options for posterior heel pain in children with the clinical diagnosis of calcaneal apophysitis or Sever's disease. This study seeks to compare the clinical efficacy of some currently employed treatment options for the relief of disability and pain associated with posterior heel pain in children. DESIGN: Factorial 2 x 2 randomised controlled trial with monthly follow-up for 3 months. PARTICIPANTS: Children with clinically diagnosed posterior heel pain possibly associated with calcaneal apophysitis/Sever's disease (n = 124). INTERVENTIONS: Treatment factor 1 will be two types of shoe orthoses: a heel raise or prefabricated orthoses. Both of these interventions are widely available, mutually exclusive treatment approaches that are relatively low in cost. Treatment factor 2 will be a footwear prescription/replacement intervention involving a shoe with a firm heel counter, dual density EVA midsole and rear foot control. The alternate condition in this factor is no footwear prescription/replacement, with the participant wearing their current footwear. OUTCOMES: Oxford Foot and Ankle Questionnaire and the Faces pain scale. DISCUSSION: This will be a randomised trial to compare the efficacy of various treatment options for posterior heel pain in children that may be associated with calcaneal apophysitis also known as Sever's disease. TRIAL NUMBER: ACTRN12609000696291Ethics Approval Southern Health: HREC Ref: 09271B.

Phosphorescence and Structure of a Tetrameric Copper(I)-Amide Cluster.

The colorless copper(I) cluster [CuN(Si(CH(3))(3))(2)](4), which contains a square-planar Cu(4)N(4) core, phosphoresces in CH(2)Cl(2) solution (lambda(max), 512 nm; lifetime, 30 &mgr;s) and in the solid state at room temperature. Its electronic absorption spectrum in CH(2)Cl(2) consists of two intense bands at 283 and 246 nm; these transitions, as well as the phosphorescence, are likely to involve population of MOs reflecting substantial Cu.Cu interactions. Solid [CuN(Si(CH(3))(3))(2)](4) luminesces with approximately the same spectrum as that of the CH(2)Cl(2) solutions. At 77 K, the solid-state luminescence red-shifts slightly (lambda(max), 524 nm) and narrows substantially (fwhm, 2400 cm(-)(1); vs 3500 cm(-)(1) at 300 K); the emission lifetime in glassy Et(2)O solution is 690 &mgr;s. X-ray analysis of crystals of [CuN(Si(CH(3))(3))(2)](4) at 130 and 296 K shows that, although the previously reported structure solution (in space group I2/m, with the molecules on 2/m sites; Eur. J. Solid State Inorg. Chem. 1992, 29, 573-583) is approximately correct, the lattice is actually primitive, P2/n, and the only crystallographically required symmetry element for the molecule is a 2-fold axis. C(24)H(72)Cu(4)N(4)Si(8): monoclinic, space group P2/n, Z = 2. At 130 K, a = 9.285(3) Å, b = 13.393(3) Å, c = 17.752(5) Å, and beta = 90.53(2) degrees. [At 296 K, a = 9.3773(4) Å, b = 13.5836(7) Å, c = 17.814(2) Å, and beta = 90.207(7) degrees.] At 130 K, the Cu and N atoms in the cluster are planar within 0.007 Å, and the Cu-N and Cu.Cu distances are 1.917(4)-1.925(4) and 2.6770(7)-2.6937(7) Å, respectively. Despite the low volatility of the compound, it can be used as a precursor for chemical vapor deposition (CVD) of copper metal, under H(2) carrier gas, with both source and substrate at ca. 200 degrees C. Smaller amounts of Cu metal films are also deposited when the substrate temperature is as low as 145 degrees C (in the dark) or 136-138 degrees C (under Pyrex-filtered Xe arc lamp illumination). Thus, Cu CVD with this precursor shows slight photochemical enhancement.