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Estudio transversal de hallux valgus como consecuencia del uso de tacones, en mujeres entre los 25 y 35 años que trabajan en los bancos Bogotá y Bancolombia en la ciudad de Bucaramanga 

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Estudio transversal de hallux valgus como consecuencia del uso de tacones, en mujeres entre los 25 y 35 años que trabajan en los bancos Bogotá y Bancolombia en la ciudad de Bucaramanga 

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Tipos de personalidades y su relación con el género musical de preferencia. 

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¿Hay una mayor frecuencia de uso de videojuegos violentos en adolescentes que manifiestan conductas violentas?

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Factores de riesgo o de protección para el desarrollo de urticarias agudas en adolescentes de los 12 a los 19 años

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Factores de riesgo o de protección para el desarrollo de urticarias agudas en adolescentes de los 12 a los 19 años

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¿Qué impacto puede lograr el consumo de cannabis en relación al trastorno esquizoiderespecto al género?

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¿Qué impacto puede lograr el consumo de cannabis en relación al trastorno esquizoiderespecto al género?

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3. DESARROLLO DE LA INTELIGENCIA LINGÜÍSTICA EN LA COMPRENSIÓN LECTORA.pdf

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Ingrese consu usuario y contraseÑa para consultar las bases de datos.

Universidad Autónoma de Bucaramanga - UNAB | Avenida 42 No. 48 - 11 | PBX (57) (7) 643 6111 /643 6261 | Centro de Contacto: 018000127395 Bucaramanga - Colombia |Todos los derechos reservados

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Bases de datos Universidad Autonoma de Bucaramanga

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Ingrese consu usuario y contraseÑa para consultar las bases de datos. Universidad Autónoma de Bucaramanga - UNAB | Avenida 42 No. 48 - 11 | PBX (57) (7) 643 6111 /643 6261 | Centro de Contacto: 018000127395 Bucaramanga - Colombia |Todos los derechos reservados

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https://idus.us.es/bitstream/handle/11441/107540/El_Hallux_Abductus.pdf?sequence=1&isAllowed=y

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CREENCIAS RELIGIOSAS Y ACTITUDES HACIA EL USO DEL PRESERVATIVO EN ADOLESCENTES PERUANOS

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https://pubmed.ncbi.nlm.nih.gov/33944542/

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Affiliations

¹ Department of Allergy, Centro Hospitalar Vila Nova de Gaia/Espinho, EPE, Vila Nova de Gaia, Portugal.

² Department of Pediatric, Centro Hospitalar Vila Nova de Gaia/Espinho, EPE, Vila Nova de Gaia, Portugal.

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Affiliations

¹ Department of Allergy, Centro Hospitalar Vila Nova de Gaia/Espinho, EPE, Vila Nova de Gaia, Portugal.

² Department of Pediatric, Centro Hospitalar Vila Nova de Gaia/Espinho, EPE, Vila Nova de Gaia, Portugal.

Abstract

Background. Acute urticaria is a common condition in the pediatric emergency department (ED) and no data is available in Portugal. Objective. We aimed to characterize the prevalence, etiology and management of acute urticaria in children presenting at an ED of a portuguese central hospital and report the follow-up investigation when drug or food allergy was suspected. Methods. Retrospective study of clinical records from children admitted to the ED with acute urticaria during one year period. Results. 250 children were included, mean age of 7.4 ± 4.9 years (0-17 years). The most frequently suspected etiological factors were infections (22%), foods (12%), insect bites (9%) and drugs (8%), of which, upper respiratory tract infections, seafood and β-lactam antibiotics were the most frequent. In 44% of cases, the etiology of urticaria was not determined. After ED discharge, of the 50 patients with suggestive drug or food allergy, only 48% were sent to allergological workup and the allergy confirmed in 6 of them (2.4% of the 250 children). Conclusions. These data suggest that allergy is not the main trigger of acute urticaria in ED children, but when suspected, reference to an allergy department to complete allergological workup was insufficient.

Keywords: Acute urticaria; allergy; children; emergency department; management.

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national center for biotechnology information

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Acute urticaria in children: from pediatric Emergency Department to allergology consultation at a Central Hospital - PubMed

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Background. Acute urticaria is a common condition in the pediatric emergency department (ED) and no data is available in Portugal. Objective. We aimed to characterize the prevalence, etiology and management of acute urticaria in children presenting at an ED of a portuguese central hosp ...

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La urticaria es un conjunto heterogéneo de enfermedades cuya lesión elemental es el habón ¹. El cuadro clínico se manifiesta en diferentes severidades, desde la urticaria y el angioedema hasta la anafilaxia. Según su temporalidad se puede clasificar en aguda (menos de seis semanas) o crónica (más de seis semanas).

La UA afectará al 20% de la población en algún momento de la vida. En España la incidencia de UA es de 18,7% en población general, encontrándose la mayor incidencia entre los 3 y 6 años con un 43,9%. Ambos sexos se afectan por igual 2,3.

La UA es una enfermedad autolimitada, sin embargo, hasta un 5,4% de los pacientes persisten con síntomas más de 2 semanas.
¿Cómo identifico una Urticaria Aguda (UA)? 2
La UA tiene distintas formas de presentación:

78,4% se presenta en sólo con habones

6,6% se presenta sólo con angioedema

15% puede presentar ambas lesiones

44% de los casos se acompaña de dolor abdominal y diarrea

El habón o roncha se caracteriza por ser una lesión solevantada, de forma y tamaño variable, que presenta un centro pálido, rodeada de un halo eritematoso, y que característicamente se resuelve a los 30 minutos a 24 horas. Los habones pueden confluir formando placas y afectar cualquier lugar del cuerpo. La mayoría de los afectados presenta prurito como síntoma principal, pero también pueden presentar ardor ¹.

El angioedema corresponde a un edema de la dermis profunda y del tejido subcutáneo, de presentación aguda. Se caracteriza por presentarse como piel pálida, con poco prurito. Puede afectar cualquier lugar del cuerpo, pero se verá con mayor frecuencia en cara (especialmente labios y párpados), cuello, cabeza, genitales y extremidades. También puede comprometer la mucosa oral, digestiva y respiratoria. Su resolución puede tardar hasta 72 horas ¹.
Tabla 1: Criterios diagnósticos de anafilaxia. ³ Fuente: Adaptación a partir de referencia citada
No es objetivo de este artículo referirse al enfrentamiento específico de la anafilaxia, pero es importante recordar que tiene criterios diagnósticos específicos, que deben ser detectados de forma precoz, y que se resumen en la tabla 1.

Criterios clínicos diagnósticos de anafilaxia

Es muy probable cuando cumple uno de los tres siguientes:

Inicio agudo de una enfermedad (minutos a pocas horas) que comprometa la piel, mucosas o ambas y al menos uno de los siguientes:

a. Compromiso respiratorio (disnea, sibilancias, estridor, hipoxemia)

b. Reducción de la presión arterial o síntomas asociados a disfunción de órganos (hipotonía, síncope, incontinencia, etc)

Dos o más de los siguientes que ocurran de manera rápida tras la exposición a un presunto alergeno (minutos a pocas horas):

a. Compromiso de piel y/o mucosas

b. Compromiso respiratorio

c. Reducción de la presión arterial o síntomas asociados a disfunción de órganos

d. Síntomas gastrointestinales persistentes

Reducción de la presión arterial luego de la exposición a un alérgeno conocido

a. Lactantes 1-12 meses: TAS* < 70 mmHg

b. Niños 1-10 años: TAS < 70 mmHg + (edad años x 2)

c. Adolescentes >11 años: TAS <90 mmHg o caída de 30% de la TAS habitual

*TAS = Tensión arterial sistólica.

¿CUALES SON LAS PRINCIPALES ETIOLOGÍAS DE LA UA EN NIÑOS? 5,6,7.

Causas comunes que gatillan UA en niños incluyen infecciones, fármacos y alimentos. En la mayoría de los casos no lograremos identificar la etiología. Aparentemente las infecciones parecen ser la causa predisponente más frecuentemente documentada en niños con UA (más de 40% de lo casos). En la práctica la mayoría de los pacientes no tienen causas precisas y se clasifican como urticarias idiopáticas.
¿CUÁL ES EL ENFRENTAMIENTO INICIAL DE UNA UA EN NIÑOS?
Un estudio observacional retrospectivo realizado en un departamento de dermatología de un hospital universitario en China entre el 2013 y 2017, documentó que 411 pacientes pediátricos recibieron el diagnóstico de urticaria, de estos, solo en 49 se pudo encontrar causa etiológica y en el 41% de los casos, la causa eran las infecciones. Esta proporción disminuye con la edad.

Otros alérgenos involucrados incluyen: picaduras de insectos, látex, plantas, cosméticos, lociones y detergentes.
Tratamiento farmacológico: Orientado al alivio sintomático
La historia clínica y el examen físico bastan para realizar el diagnóstico de UA. No se recomienda el uso de exámenes diagnósticos de rutina, pero sí intentar identificar el gatillante, y evitarlo.

Es clave descartar la presencia de anafilaxia, considerando sus criterios específicos, de modo de tratar esa condición de la manera más adecuada posible 1,2.

Son la primera línea de tratamiento. Debido a que son de vida media corta y con una mayor tasa de efectos adversos, hay expertos que no recomiendan el uso de antihistamínicos de primera generación y sugieren estrictamente utilizar antihistamínicos de segunda generación, que tienen una vida media más larga y presentan una menor tasa de efectos adversos. Estas recomendaciones se basan en estudios realizados en niños mayores de 12 años y en adultos con urticaria crónica espontánea, donde los resultados no son muy diferentes al comparar los antihistamínicos de primera generación versus los de segunda generación, pero sí presentan se observan diferencias significativas en los efectos adversos, siendo los de primera generación los que más los presentan 1,8,9,10.

Estos mismos estudios recomiendan aumentar las dosis de antihistamínicos en urticaria desde 2 hasta 4 veces la dosis estándar para el peso del niño, desde el inicio de tratamiento, y escalar según los resultados observados 1,9,10.

Un estudio prospectivo observacional, realizado en 98 niños con urticaria crónica espontánea reagudizada, mostró que al cuadriplicar la dosis de antihistaminicos de segunda generación un 97,1% de los casos logra la remisión de los síntomas ¹².

Expertos recomiendan, con un grado de evidencia muy bajo, cursos cortos de corticoides orales (máximo por 10 días), ya que podrían ser útiles en reducir la duración y/o actividad de la enfermedad ¹. Como evidencia indirecta en niños, un estudio clínico randomizado doble ciego realizado en mayores de 18 años concluyó que adicionar prednisona por 4 días a un tratamiento con levocetiricina no era superior que levocetiricina sola en mejorar el prurito ni el tiempo de resolución en UA ¹¹.
SEGUIMIENTO:

Bloqueadores H2 (ranitidina, famotidina)

Su uso está en debate, aunque los efectos adversos son bajos. La recomendación de los expertos es considerar una prueba terapéutica en casos severos de UA o con escasa respuesta a tratamiento habitual 1,2.

Se sugiere que los pacientes con UA sean controlados a las dos semanas de inicio del tratamiento, según evolución del paciente.
RESUMEN
Si el tratamiento se inició con doble dosis de antihistamínicos, y no hay respuesta en 2 semanas, es posible escalar hasta incluso cuadriplicar la dosis ¹.

Si el paciente persiste más de 6 semanas es necesario considerar una urticaria crónica. En estos casos se sugiere derivar a dermatología o inmunología para un estudio específico y considerar realizar pruebas estandarizadas de gatillantes.

La UA es una enfermedad inflamatoria de la piel, cuya lesión elemental es el habón y el síntoma principal es el prurito.

En los niños la etiología principal de las UA son las infecciones virales

Dado que las UA son condiciones autolimitadas, y que su diagnóstico es clínico, no requieren exámenes adicionales

El tratamiento de primera línea para UA infantil son los antihistaminicos de segunda generación, usando hasta 4 veces la dosis estándar.

1. Zuberbier, T., Aberer, W., Asero, R., et al. (2018). The EAACI/GALEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria. Allergy, Vol. 73, 1393‐

2. Marrouche, N.; Grattan, C. (2012). Childhood urticaria. Current Opinion in Allergy and Clinical Immunology. Vol. 12(5), 485-490.

3. Fustiñana, A., Rino, P., Kohn-Loncaira, G. (2019). Reconocimiento y manejo de la Anafilaxia en pediatría. Rev Chil Pediatr. Vol. 90(1), 44-51.

4. Wong, H., Najib U. (2018). Acute Urticaria. Recuperado el 1 de noviembre de 2018, de https://emedicine.medscape.com/article/137362-overview

5. Imbalzano, E., Casciaro, M., Quartuccio, S., Minciullo, P., Cascio, A., Calapai, G., Gangemi, S. (2016). Association between urticaria and virus infections: A systematic review. Allergy and Asthma Proceedings. 37 (1), 18-22.

6. Tang, N., Mao, M., Zhai, R., Chen, X., Zhang, J., Zhu, W., Li, J. (2017). Clinical characteristics of urticaria in children versus adults. Zhongguo Dang Dai Er Ke Za Zhi. Vol. 19(7), 790-795.

7. Shin, M., Lee, S. (2017) Prevalence an Causes of Chidlhood Urticaria. Allergy Asthma Immunol Res. Vol. 9(3):189-190

8. Sharma, M., Bennett, C., Cohen, S., Carter, B. (2014). H1-antihistamines for chronic spontaneous urticaria. Cochrane Database Syst Rev.

9. Ferrer, M., Sastre, J., Jáuregui, I., Dávila, I., Montoro, J., Del Cuvillo, A., Mullol, J., Bartra, J., Valero, A. (2011). Effect of antihistamine up-dosing in chronic urticaria. J Investig Allergol Clin Immunol. Vol. 21(3), 34-39.

10. Pattanaik, D., Lieberman, J. (2017). Pediatric Angioedema. Curr Allergy Asthma Rep. Vol. 17(9), 60.

11. C., Dehours, E., Mallet, J., Houze-Cerfon, C., Lauque, D., Charpentier, S. (2018). Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial. Ann Emerg Med. Vol. 71(1), 125-131.

12. Cornillier, H., Giraudeau, B., Munck, S., Hacard, F., Jonville-Bera, A., D'Acremont, G., Pham, B., Maruani, A. (2018). Chronic spontaneous urticaria in children - a systematic review on interventions and comorbidities. Pediatr Allergy Immunol. Vol. 29(3), 303-310.

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Enfrentamiento diagnóstico y terapéutico de la urticaria aguda en niños

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La urticaria es un conjunto heterogéneo de enfermedades cuya lesión elemental es el habón 1. El cuadro clínico se manifiesta en diferentes severidades, desde la urticaria y el angioedema hasta la anafilaxia. Según su temporalidad se puede clasificar en aguda (menos de seis semanas) o crónica (más de seis semanas).

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https://pubmed.ncbi.nlm.nih.gov/32677690/

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http://www.scielo.org.pe/scielo.php?script=sci_arttext&pid=S2308-05312019000300018&lang=es

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https://www.adicciones.es/index.php/adicciones/article/view/1328

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https://pubmed.ncbi.nlm.nih.gov/33844766/

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https://pubmed.ncbi.nlm.nih.gov/31982366/

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En la pagina 76 y 77 nos habla acera de los efectos nocivos del Tacon

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En la pagina 76 y 77 nos habla acera de los efectos nocivos del Tacon

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https://pubmed.ncbi.nlm.nih.gov/31017245/

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Abstract

Cannabis is the most widely used illegal drug in Spain. Currently, its use is on the rise as risk perception is decreasing, primarily among young people. It is well known that cannabis negatively influences course and prognosis in schizophrenic patients. However, the relationship between cannabis use and development of a psychotic or schizophrenic disorder remains controversial. The study of this topic has been approached using longitudinal cohort studies, which study cannabis use and psychotic or schizophrenic disorders. In addition to the classic Swedish conscript study published by Andreasson et al. 1987, during the past years, six more longitudinal cohort studies have been published. The data demonstrate that there are both temporal and dose-response relationships, and that early initiation of cannabis use is highly correlated with the development of psychotic symptoms. Cannabis consumption can increase the risk of developing schizophrenia in a vulnerable population twofold, to the extent that some studies suggest a causal relationship. The current knowledge base makes it necessary to warn the population about the relationship between cannabis use and the development of psychosis.

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In interventions in episodes of SIP we must bear in mind that a significant proportion will progress to an SMD in the first three years.

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Cannabis, esquizofrenia y cognición, aportes de la conectividad cerebral | Díaz-Soto | Adicciones

# data[].attributes.attachment_link.description
Alamo, C., López-Muñoz, F. y Cuenca, E. (1999). Fundamentos neurobiológicos del trastorno dual: hipótesis etiopatogénicas. De Avances en patología dual. Aspectos diagnósticos, clínicos, terapéuticos y asistenciales. Servicio de Publicaciones. Universidad de Alcalá, Madrid, 143-162. Alonso Solís, A. y Pérez Sola, V. (2016).

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http://scielo.iics.una.py//scielo.php?script=sci_arttext&pid=S1816-89492017000200095&lang=es

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Uso de cannabis y desarrollo de esquizofrenia: ¿cuáles son los vínculos?

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REFERENCIAS BIBLIOGRAFICAS 1. Pulido A., Avilés J., Suárez R. Vasculitis cutáneas. Actas Dermosifiliogr. 2012;103(3):179-191. [ Links ] 2. Cantor-Graae E, Nordstrom LG, McNeil TF. Substance abuse in schizophrenia: a review of the literature and a study of correlates in Sweden. Schizophr Res. 2001;48(1):69-82. [ Links ] 3.

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https://pubmed-ncbi-nlm-nih-gov.aure.unab.edu.co/34344603/

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Ingrese consu usuario y contraseÑa para consultar las bases de datos.

Universidad Autónoma de Bucaramanga - UNAB | Avenida 42 No. 48 - 11 | PBX (57) (7) 643 6111 /643 6261 | Centro de Contacto: 018000127395 Bucaramanga - Colombia |Todos los derechos reservados

# data[].attributes.attachment_link.title
Bases de datos Universidad Autonoma de Bucaramanga

# data[].attributes.attachment_link.description
Ingrese consu usuario y contraseÑa para consultar las bases de datos. Universidad Autónoma de Bucaramanga - UNAB | Avenida 42 No. 48 - 11 | PBX (57) (7) 643 6111 /643 6261 | Centro de Contacto: 018000127395 Bucaramanga - Colombia |Todos los derechos reservados

# data[].attributes.body
https://pubmed-ncbi-nlm-nih-gov.aure.unab.edu.co/6643936/

# data[].attributes.attachment_link.title
Bases de datos Universidad Autonoma de Bucaramanga

# data[].attributes.body
https://pubmed-ncbi-nlm-nih-gov.aure.unab.edu.co/28251259/

# data[].attributes.attachment_link.readable_text
Ingrese consu usuario y contraseÑa para consultar las bases de datos.

Universidad Autónoma de Bucaramanga - UNAB | Avenida 42 No. 48 - 11 | PBX (57) (7) 643 6111 /643 6261 | Centro de Contacto: 018000127395 Bucaramanga - Colombia |Todos los derechos reservados

# data[].attributes.attachment_link.title
Bases de datos Universidad Autonoma de Bucaramanga

# data[].attributes.attachment_link.description
Ingrese consu usuario y contraseÑa para consultar las bases de datos. Universidad Autónoma de Bucaramanga - UNAB | Avenida 42 No. 48 - 11 | PBX (57) (7) 643 6111 /643 6261 | Centro de Contacto: 018000127395 Bucaramanga - Colombia |Todos los derechos reservados

# data[].attributes.body
https://pubmed-ncbi-nlm-nih-gov.aure.unab.edu.co/33814288/

# data[].attributes.attachment_link.title
Bases de datos Universidad Autonoma de Bucaramanga

# data[].attributes.body
https://pubmed-ncbi-nlm-nih-gov.aure.unab.edu.co/24878414/

# data[].attributes.attachment_link.title
Bases de datos Universidad Autonoma de Bucaramanga

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http://adm.meducatium.com.ar/contenido/articulos/8000070014_563/pdf/8000070014.pdf

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Influencia de la ansiedad en diversas patologías dermatológicas 

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Influencia de la ansiedad en diversas patologías dermatológicas 

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https://www.sciencedirect.com/science/article/abs/pii/S0001731006734846

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Resumen

Introducción

El objetivo de este estudio consiste en determinar los niveles de ansiedad de sujetos con enfermedad dermatológica frente a sujetos sanos, así como la diferencia de ansiedad entre distintas patologías dermatológicas.

Material y métodos

Se trata de un estudio descriptivo de una serie de casos donde se seleccionan 152 sujetos, de los que 20 son controles sanos y los 132 restantes son pacientes que acuden a consulta dermatológica. Se dividen en 5 grupos en función de la patología dermatológica por la que acuden a consulta: urticaria crónica, urticaria aguda, psoriasis en placas, dermatitis atópica y varios dermatológicos (donde se icluyen diversos diagnósticos como queratosis seborreica, revisión de nevos, epiteliomas, etc.), donde en principio la ansiedad no influye en estas patologías. Se les administra el inventario de Ansiedad Estado (AE) y Ansiedad Rasgo (AR) de Personalidad de Spielberger (STAI) y se analizan las diferencias de AE y AR entre los diferentes grupos. Se interroga sobre si existe un evento estresante en los seis meses previos al inicio de la patología que pudiera ser el desencadenante de la misma y sobre antecedents de patología psiquiátrica o de diátesis atópica.

Resultados

Se observan diferencias significativas en las medias obtenidas en AE y AR entre los sujetos sanos y el resto de patologías dermatológicas. Se obtienen medias más altas en AE en los sujetos diagnosticados de dermatitis atópica, que es significativa cuando se contrasta con los sujetos con urticaria crónica y los varios dermatológicos. El 48,27 % de los sujetos con psoriasis y el 38,89 % de los sujetos con dermatitis atópica refieren la existencia de un evento estresante en los últimos seis meses frente al 11,54 % del grupo de los varios dermatológicos, y además estos sujetos presentan puntuaciones medias de ansiedad más altas. Un 21,2 % de los 132 sujetos con patología dermatológica refiere antecedentes psiquiátricos, presentando puntuaciones promedio mayores para AE y AR con significación estadística.

Conclusión

Los hallazgos encontrados nos demuestran la comorbilidad de patología psiquiátrica en los pacientes con enfermedades dermatológicas crónicas y los altos niveles de AE y AR, sobre todo en los pacientes con psoriasis y dermatitis atópica.

Abstract

Introduction

The objective of the current study is to determine the levels of anxiety in patients with dermatological diseases compared to healthy subjects and the degree of anxiety in the different cutaneous diseases.

Material and methods

It is a descriptive study of a case series where 152 patients are selected, 20 of whom are healthy controls and the other 132 are patients that attend a Dermatology clinic. The patients are divided into 5 groups based on the cutaneous disorder for which they attend the clinic: chronic urticaria, acute urticaria, plaque psoriasis, atopic dermatitis, and a miscellanous group (includes several diagnoses such as seborrheic keratosis, follow-up of multiple nevi, carcinomas...) where, a priori, anxiety does not influence these disorders. Spielberger State-Trait Anxiety Inventory (STAI) is administered to the participating subjects and the differences in State Anxiety Inventory (SAI) and Trait Anxiety Inventory (TAI) for the different groups are analyzed. Patients were asked to report any stressful event in the six months prior to the appearance of the disease that might have been a trigger, and they were also asked about history of psychiatric disorders or atopy.

Results

We observed significant differences in the means obtained in SAI and TAI in healthy subjects compared to patients. We obtained higher mean scores in SAI in patients diagnosed of atopic dermatitis, that were significant when compared with patients with chronic urticaria or other diseases. Forty-eight percent of patients with psoriasis and 38.89 % of patients with atopic dermatitis report a stressful event in the past six months compared to 11.54% of patients from the group with miscellanous diseases and, additionally, patients with psoriasis and atopic dermatitis have the highest mean scores in the anxiety tests. Twenty-one percent of the 132 patients with cutaneous diseases report a history of psychiatric disorders, showing statistically significant higher mean scores in STAI.

Conclusion

The findings show the comorbidity of psychiatric disorders in patients with chronic cutaneous diseases and the high levels of state and trait anxiety, mainly in patients with psoriasis and atopic dermatitis.

View full text

# data[].attributes.attachment_link.title
Influencia de la ansiedad en diversas patologías dermatológicas

# data[].attributes.attachment_link.description
El objetivo de este estudio consiste en determinar los niveles de ansiedad de sujetos con enfermedad dermatológica frente a sujetos sanos, así como la diferencia de ansiedad entre distintas patologías dermatológicas. Se trata de un estudio descriptivo de una serie de casos donde se seleccionan 152 sujetos, de los que 20 son controles sanos y los 132 restantes son pacientes que acuden a consulta dermatológica.

# data[].attributes.body
https://www.adicciones.es/index.php/adicciones/article/download/178/176

# data[].attributes.body
https://www.researchgate.net/profile/Roser-Amell/publication/288395258_The_therapeutic_adherence_in_psychotic_patients/links/5757264f08ae05c1ec16cfc1/The-therapeutic-adherence-in-psychotic-patients.pdf

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https://www.researchgate.net/profile/Roser-Amell/publication/288395258_The_therapeutic_adherence_in_psychotic_patients/links/5757264f08ae05c1ec16cfc1/The-therapeutic-adherence-in-psychotic-patients.pdf?origin=publication_detail

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https://medicinaclinicaysocial.org/index.php/MCS/article/download/249/257

# data[].attributes.body
https://www.adicciones.es/index.php/adicciones/article/viewFile/1328/1053

# data[].attributes.body
https://dialnet.unirioja.es/descarga/articulo/4830216.pdf

# data[].attributes.body
https://www.researchgate.net/profile/Jorge-Tamayo-3/publication/232768950_MARIHUANA_Y_ESQUIZOFRENIA_un_diagnostico_dual_inocuo_y_terapeutico/links/09e415095573673676000000/MARIHUANA-Y-ESQUIZOFRENIA-un-diagnostico-dual-inocuo-y-terapeutico.pdf

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3395996/pdf/nihms378572.pdf

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https://reader.elsevier.com/reader/sd/pii/S2530312018300584?token=ED2342AB10E0F0F0CC69C261E7F41B5DB2F9950F7AAE1C258D5D254ACADEAB2A84D72C1027ECCC8D762A8C2BB80152AF&originRegion=us-east-1&originCreation=20230322195450

# data[].attributes.attachment_link.authors[].name
Author links open overlay panelHassaan Tohid a, Philip D. Shenefelt b, Waqas A. Burney c, Noorulain Aqeel d

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Psychodermatology: An Association of Primary Psychiatric Disorders With Skin

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The association of nervous system with skin is well documented. Many common psychiatric disorders can involve skin either directly or indirectly. We f…

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https://www.e-ijd.org/article.asp?issn=0019-5154;year=2006;volume=51;issue=1;spage=18;epage=22;aulast=Seyhan

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ORIGINAL ARTICLE

Year : 2006 | Volume : 51 | Issue : 1 | Page : 18-22

Psychiatric morbidity in dermatology patients: Frequency and results of consultations

Department of Dermatology, Inonu University Medical Facultly, Malatya, Turkey Muammer Seyhan, Tuba Aki,
Yelda Karincaoglu, Hamdi Ozcan

Correspondence Address:
Muammer Seyhan
Bilkent-1, E-4, Blok, No. 59 06530 Bilkent, Ankara
Turkey

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/0019-5154.25181

BACKGROUND: Dermatological patients quite commonly depict psychiatric morbidity. PURPOSES: To study the psychiatric morbidity among skin patients of our clinic. METHODS: In the present study, the patients who were treated in the Dermatology Clinic of Inonu University Medical Faculty were evaluated retrospectively. The age, gender, marital status, habits, dermatological and systemic diseases, previously used drugs, current therapy and psychiatric diagnosis of each patient were recorded. FINDINGS: Of 636 patients involved in the study, 15.3% had psychopathological problems, which were depression (32.0%), adjustment difficulty (15.5%), anxiety (13.4%), psychosomatic disorders (10.3%), obsessive-compulsive disorder and conversion (5.1%), dysthymic disorder (4.1%), attention deficit and hyperactivity disorder (2.1%), panic attack (1.0%), premenstrual syndrome, schizophrenia, somatization disorder, insomnia, alcohol dependency, bipolar affective disorder, mental retardation, agoraphobia, social phobia and dementia. The dermatological diseases defined for the patients with psychopathology diagnosis were chronic urticaria (25.8%); psoriasis (15.5%); alopecia areata, totalis and iniversalis (11.3%); acute urticaria, neurodermatitis and Behcet's disease (5.1%); atopic dermatitis and drug eruptions (4.1%); pemphigus (3.1%); angioedema, contact dermatitis and generalized pruritus (2.1%); folliculitis and the others (1.0%). CONCLUSIONS: Psychiatric morbidity has an affect on the course of dermatological diseases. When required, psychiatric consultation should be sought by dermatology clinics and patients should be followed with the cooperation of dermatologists and psychiatrists. LIMITATION: The indoor-based study had not included any control group and any domicillary patient.

Keywords: Psychiatric morbidity, Skin diseases

How to cite this article:
Seyhan M, Aki T, Karincaoglu Y, Ozcan H. Psychiatric morbidity in dermatology patients: Frequency and results of consultations. Indian J Dermatol 2006;51:18-22

How to cite this URL:
Seyhan M, Aki T, Karincaoglu Y, Ozcan H. Psychiatric morbidity in dermatology patients: Frequency and results of consultations. Indian J Dermatol [serial online] 2006 [cited 2023 Mar 22];51:18-22. Available from: https://www.e-ijd.org/text.asp?2006/51/1/18/25181

Psychopathological disorders are highly prevalent among dermatology patients.[1],[2] The relationship between dermatological diseases and psychiatric morbidity can be established as follows: 1) The appearance of skin lesions and the chronic progression of the disease may frequently affect the quality of social and work life of patients, thus, psychiatric morbidity may arise as a complication, 2) less frequently, these skin diseases may result from primary psychological diseases cuh as obsessive compulsive and delusional disorders, 3) both the skin findings and psychiatric complaints may develop secondary to a disease such as systemic lupus erythematosus, 4) some drugs, such as corticosteroids, used in dermatological treatment may trigger psychiatric symptoms, or lithium and some antipsychotic drugs may cause dermatological diseases. [3],[4],[5]

The prevalence of psychiatric diseases in the patients presenting to dermatology clinics has been reported as 25-43%.[3],[6],[7] Stress may aggravate the cutaneous disease in 40-100% of patients.[5] In general, patients prefer the treatment of their dermatological diseases rather than psychiatric disorders and seek dermatologic consultation. Consequently, dermatologists often see patients who also have psychiatric conditions.[6] The most efficient treatment of dermatological diseases is achieved with combined evaluation of emotional factors.[4],[5]

The aim of the present study was to investigate the psychiatric morbidity, consultation rate and results in patients in our clinic.

The study involved the patients hospitalized in Dermatology Clinic of Inonu University. Psychiatric morbidity, consultation rate and results were investigated retrospectively. Their age, gender, marital status, habits, dermatological and systemic diseases, previous drug use, the treatment modality applied after diagnosis, psychiatric diagnosis and recommended psychiatric therapy were recorded. The duration of dermatological diseases were also determined. The patients who had personal and/or family history of psychiatric disorders and/or previous suicide attempt were also recorded.

Of 636 patients, 104 (16.4%) had psychiatric consulations and in 97 of them a psychopathology had been diagnosed. The patients with a psychopathology constituted 15.3% of all the patients and 93.3% of those who received a psychiatric consultation. Of the patients who had a diagnosis of psychopathology, 62 patients (63.9%) were female and 35 patients (36.1%) were male. The age range was 7 to 66 years (mean age: 35.98 ± 15.34). The mean age of the female patients was 37.86 ± 17.44, while the mean age of the males was 34.92 ± 14.68. Two patients (2.1%) were children. Fifty-eight patients (59.8%) were married; 32 patients (33.0%) single; and 5 patients (5.2%) were widow/widower or divorced. When in patient treatments of the patients were evaluated, 11 patients (11.3%) were hospitalized twice before; 6 patients (6.2%) three times; 1 patient (1%) four times, 2 patients (2.1%), five times; and the remaining 77 patients (79.4%) were adulted for the first time. Seven patients who had been hospitalized for a total of three times had received a psychiatric evaluation during their second or the third hospitalizations. Of the three patients with a history of suicidal attempts, two patients had been hospitalized five times and one patient was hospitalized four times. The sociodemographic features of the patients have been presented in [Table - 1]. The occupational distribution of the patients with psychomorbidity was as follows: housewife: 47 patients (48.5%); student: 18 patients (18.6%) [Table - 2]. The most prevalent pathology was depression (31 patients 32.0%), followed by adaptation problem in 15 patients (15.5%), anxiety in 13 patients (13.4%) and psychosomatic disorder(s) in 10 patients (10.3%). The relatively less prevalent psychopathologies were obessive disorders, conversion, dysthymic disorder, attention deficit and hyperactivity. The distribution of these findings has been listed in [Table - 3]. The most prevalent dermatological diagnosis of the patients with psychatric morbidity was chronic urticaria (25 patients, 25.8%). The other dermatological diagnoses were psoriasis in 15 patients (15.5%) and alopecia in 11 patients (11.3%) [Table - 4]. The rates of psyhopathologies accompanying the most prevalent dermatological diseases have been presented in [Table - 5].

The association of psychiatric disorders and dermatological anomalies has long been known.[2],[8] Dermatological diseases have an affect on the daily life, self-confidence and self-respect. In fact, they may lead to questioins on self-image; thus, creating a problem of identity.[8],[9] Dermatologists have observed their patients to be relatively more concerned and worried about the diseases that are related to their physical appearance,[9] as a result of which dermatology patients may be aflicted with disorders such as anxiety, depression and other psychosocial problems.[1]

Woodruff et al[6] have reported a prevalence of 30-40% for the psychiatric problems among the dermatology patients attendins their clinic. On the other hand, Picardi et al[3] have reported 25.2% psychiatric morbidity rate in dermatology patients. In general evaluation of the epidemiological studies, the prevalence of psychiatric morbidity was, found to be 25-43% in outpatient dermatology patients.[1],[6] Among our patients who had been observed in our clinic within a period of 3 years, 16.4% had received psychiatric consultation and among them 93.3% had received a diagnosis of a psychiatric disorder. The psychiatric morbidity rate among those who had been hospitalized was 15.3%. Psychiatric consultation was sought when the psychopathologies had been thought to be probable etiological factor or aggravating factor and when marked psychopathologies were observed. Thus, the consultation offers of our clinic were selective and did not involve all the patient groups. In the study of Aslan et al,[10] in which psychiatric consultation rates during one year were evaluated, dermatology clinic was determined as the one that sought consultations from the psychiatry clinic most frequently with a rate of 25%. The psychiatric consultation order rate by the dermatology clinic was 16%, which was nearly same with that of our study. Despite the lack of a study about the interclinical consultation rates in our hospital, to expression of the consultant physicians of psychiatry clinic, dermatology has been the most frequently consulting clinic to date. In another study from our country, Aktan et al[11] have found 33.4% prevalence of psychiatric disorders accompanying dermatological diseases, which is nearly twice as much as the rate found in our study.

In the study of Woodruff et al,[6] the mean age of female patients was 46.8 years and of male patients, 41.9 years (mean age of all patients: 44.88 years). However, in our study mean age of females was 37.8 years and 35.0 for males, with a general mean of 36.0 years. The prevalence of psychiatric morbidity is higher in female patients and widows, particularly those with eczema, psoriasis, pruritis, urticaria, acne and alopecia with widespread lesions.[2],[6] Picardi et al[3] have found higher psychiatric morbidity rates in females, widows and widowers. There were, however, no differences associated with age and educational level of the patients.[3] In our study, the number of female patients was significantly higher and psychiatric morbidity was more prevalent in married patients. The prevalance of psychiatric morbidity was higher among housewives, students, retired, unemployed and teachers, respectively.

Picardi et al[1] have given a questionnaire to 1389 patients of the dermatology outpatient clinic and ound a psychiatric morbidity rate of 20.6%. The patient group with the higher rate of psychiatric morbidity has been the females with hand and foot lesions. Similarly, in our patient group, various psychopathologies, primarily depression, was detected in female patients, 67.7% of whom were housewives and 40% of these patients had lesions at visible parts of their bodies. In another study, Pulimood et al[12] have found higher rate of psychiatric morbidity in the patients who had received therapy for at least six months, especially steroid therapy.[12] In the present study, the morbidity rate in the patients with dermatological problems of longer than one year was 27.8% while it was 72.2% in those with problems of less than one year. The lower rate of psychiatric morbidity in patients with long-standing disease may be accounted for by patients' eventual psychological adjustment to the disease.

Depression (34%) was the most prevalent finding in the study of Pulimood et al.[12] Chronic urticaria, exfoiliative dermatitis and sexually transmitted diseases were the diseases that led to psychiatric disorders most. In study of Aslan et al[10] among psychological problems associated with physical disorders, depression was the most prevalent and adjustment disorder were the second most prevalent. Woodrufft et al[6] have reported mild to moderate depression (28%), mild anxiety (25%) and severe depression (14%). In their patient group, they have reported patients with a history of psychiatric disorders (40%), patients with a familial history (29%) and patients with an additional systemic disease (29%).[6] Parallel to the results of Pulimood et al , Woodruff et al and Aslan et al ,[10] out results were depression (32.0%), adjustment disorder (15.5%) and anxiety (13.4%). The distribution of psychiatric morbidity in various dermatological disease groups in this study were psychosomatic disorders (25%) and depression (18.8%) in urticaria group; adjustment disorder (40%) and depression (30%) in the patients with psoriasis; and anxiety (36.4%) and adjustment difficulty (18.2%) in the patients with alopecia.

When dismorphic diseases such as acne and psoriasis lead to lesions, particularly of face, the prevalence of depression and suicide attempts have been relatively higher in both genders.[3],[13],[14],[15] In the study of Akay et al[16] from Turkey, depression rate was 58% in the patients with psoriasis, 53% in the patients with lichen planus, while it was 20% in the control group. The rate in psoriasis group was significantly higher compared to that of the control group. Thus, PASI score was parallel to depression score.[16] The dermatological diseases accompanied by psychopathologies were, in the order of prevalence, chronic urticaria, psoriasis and alopecia areata. Chronic and debilitating dermatological diseases like psoriasis may lead to suicide associated with depression.[3],[15] Particularly female patients with dermatological problems on the face and males with dermatological scars have been reported to have higher suicidal tendency. Therefore, young patients with scarring acne who use isotretinoin and the patients with prevalent dermatological diseases such as atopic dermatitis should undergo comprehensive psychiatric evaluation.[13] In our study, three patients with widespread psoriasis had a history of suicide attempt. One of these patients was a female with inverse psoriasis with genital area involvement and was not supported by her spouse. Two other male patients had often been hospitalized with erythroderma and their family and work lives were affected. The study involved patients with dermatological problems requiring hospitalization; thus, there was no patient with acne.

The drugs used in the treatment of dermatological diseases such as steroid and retinoid may lead to psychiatric symptoms.[5] In this study, 31.0% of the patients had used steroids, which may have facilitated the development of psychopathologies. Thus, the patients with psychopathologies requiring steroid treatment should be closely observed. In a questionnaire on 100 patients with eczema, psoriasis and acne, 40% of the patients have reported experiencing difficulties in their social life; 75% in their work life and 80% of the patients have expressed embarrassment.[9] Accordingly, the patients with dermatological diseases and their family should be educated and there must be a well-established patient-doctor relationship. Individual or group therapies should be performed and internet sites and associations should be set up for patients.[3],[9],[17] We think that the communication between the patient groups in our country should be systematically provided. Informing the parents of pediatric patients and providing psychatric consultations are recommended. This recommendation is also valid for the spouses of married patients. In our study, the parents of pediatric patients had also been consulted. Particularly psoriatic and alopecic children are the patients most in need of specially designed psychiatric help.

The recognition of psychiatric disorders by a dermatologist is not adequate in itself. The cooperation of the dermatologist and a psychiatrist in order to increase the life quality of the patients is of utmost importance. A dermatologist's lack of knowledge on the psychiatric morbidity rates in dermatological diseases may delay the diagnosis of psychiatric condition and hinder the treatment. Dermatologists should be more wary and sensitive about the possible psychiatric morbidity in their patients. We think that when the problems noticed by dermatologists are definitely diagnosed, patients can be properly informed and referred to psychiatrists and patients can be followed through the cooperation of dermatologists and psychiatrists.

Tables
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]

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Psychiatric morbidity in dermatology patients: Frequency and results of consultations Seyhan M, Aki T, Karincaoglu Y, Ozcan H - Indian J Dermatol

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ORIGINAL ARTICLE Year : 2006 | Volume : 51 | Issue : 1 | Page : 18-22 Psychiatric morbidity in dermatology patients: Frequency and results of consultations Department of Dermatology, Inonu University Medical Facultly, Malatya, Turkey Muammer Seyhan, Tuba Aki, Yelda Karincaoglu, Hamdi Ozcan Correspondence Address:Muammer SeyhanBilkent-1, E-4, Blok, No.

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El nacimiento del caníbal: Un debate conceptual

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El nacimiento del caníbal: Un debate conceptual* The Birth of the Cannibal: a Conceptual Debate* Yobenj Aucardo Chicangana-Bayona Profesor Asociado del Departamento de Historia, Facultad de Ciencias Humanas y Económicas de la Universidad Nacional de Colombia, Medellín, Colombia. Doctor en Historia de la Universidade Federal Fluminense, Niterói, Brasil.

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https://onlinelibrary.wiley.com/doi/abs/10.1002/acr.22517

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https://academic.oup.com/biomedgerontology/article/71/12/1682/2513750

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Abstract

Footwear plays an important role in protecting the foot. The earliest known footwear, dating from approximately 7,500 BCE, were simple sandals secured around the ankle with rope ( 1), whereas the first direct evidence of footwear covering the foot dates back to 3,500 BCE ( 2). The functional role of footwear was diminished by fashion influences from the 15th century, as features such as high heels and extended toe boxes became popular ( 3). Modern footwear has retained vestiges of these early fashion influences, many of which are thought to be associated with foot pain and deformity ( 4). Consequently, shoe-related foot disorders represent an important public health problem ( 5). Indeed, the annual economic impact of foot problems caused by footwear has been estimated as $3 billion in the United States alone ( 6).

Some styles of women's footwear encompass two key design features, an elevated heel and a constrictive toe box, that are considered to be particularly detrimental to the foot ( 7). Biomechanical studies have revealed that heel elevation increases the pressures under the metatarsal heads ( 8), limits motion of the first metatarsophalangeal joint ( 9), and increases the stiffness of the Achilles tendon ( 10), whereas shoes with a narrow toe box increase pressures on the medial side of the foot and between the toes ( 11). Over time, these changes may contribute to the development of foot pain and deformity. Cross-sectional studies have shown that wearing shoes with an elevated heel is associated with hallux valgus and plantar calluses ( 12), and wearing shoes with a constrictive toe box is associated with hallux valgus ( 12, 13) and foot pain ( 12, 14). Furthermore, studies involving recall of previous footwear use have reported a protective effect of 'good' shoes in relation to foot pain ( 15) and an association between high heel use and hallux valgus ( 5, 16).

Establishing an association between footwear characteristics and foot problems, however, is inherently difficult, as shoe wearing behaviors are likely to vary as a function of both age and period-the interaction of these producing cohort effects ( 17). Footwear selection in women reflects changes across the life course in fashion consciousness, identity and health status ( 18). Furthermore, these age- and life-stage changes in footwear selection are expressed in the context of changing footwear fashions, and their availability and affordability. Therefore, in order to better understand the relationship between footwear and foot problems, it is necessary to adopt a life-course approach to estimate past exposure to potentially detrimental footwear behaviors. Accordingly, the aims of this study were to (i) examine shoe wearing patterns over time in older women in relation to the height of the heel and the shape of the toe box and (ii) evaluate associations between these footwear characteristics and current foot pain and hallux valgus.

Methods

Study Design

The design was an unmatched population-based case-control study using prevalent cases, derived from baseline data from the Clinical Assessment Study of the Foot ( 19). Adults aged 50 years and older registered with four general practices were invited to take part in the study, irrespective of consultation for foot pain or problems. Ethical approval was obtained from Coventry Research Ethics Committee (reference number: 10/H1210/5).

Health Survey Questionnaire

All eligible participants were mailed a Health Survey questionnaire that gathered information on current demographic and socioeconomic characteristics and general health ( 19). Past footwear use was assessed by line drawings depicting four heel heights (A = flat, B = low, C = medium, and D = high) and four toe-box shapes (A = very wide, B = wide, C = narrow, and D = very narrow) ( Figure 1). For each period of their life (divided into decades, commencing with 20-29 years of age), participants were asked to indicate which heel height and toe-box shape they wore most of the time. Foot pain was assessed with the question "Have you had any pain in the last year in or around the foot?" The presence and severity of hallux valgus was documented using a validated line-drawing instrument, with five drawings illustrating a sequential 15-degree increase in the hallux valgus angle ( 20). Participants were asked to select for each foot the drawing that best depicted the severity of hallux valgus in that foot. The score was dichotomized for each foot by classifying the three most severe grades as present and the two least severe grades as absent, and participants were deemed to have hallux valgus if this was present on one or both feet ( 21).

Statistical Analysis

All analyses were conducted using SPSS Version 21 (IBM Corporation, Armonk, NY). Four birth cohorts were created according to year of birth: 1922-1931, 1932-1941, 1942-1951, and 1952-1961. The frequency and proportion of women who reported wearing shoes with high heels and narrow toe box for each decade of their life according to birth cohort were examined. Associations of past footwear use (heel height and toe-box shape worn when participants were aged between 20 and 29 years, and 30 and 39 years) with foot pain in the last year and hallux valgus were examined using logistic regression, with a flat heel and a very wide toe box as the reference categories. To evaluate the effect of cumulative exposure, the association of the total number of decades of wearing high heels or a narrow toe box with foot pain in the last year and hallux valgus were also calculated. Analyses were stratified by age and adjusted for educational attainment as an indicator of socioeconomic status. Additional adjustment for current body mass index (BMI) was considered, as some (but not all) cross-sectional studies have reported inverse associations between BMI and hallux valgus ( 16, 22, 23). However, this was rejected on a priori grounds for two reasons. First, adjusting for BMI in our analysis assumes that the BMI documented when completing the Health Survey is a valid measure of each participant's BMI throughout their adult life. We cannot be certain of this, given the timeframe involved. Second, there is no evidence that BMI influences the selection of footwear. Odds ratios (OR) and 95% confidence intervals (CI) are reported. To estimate the number of cases of foot pain or hallux valgus that could potentially be avoided if footwear risk factors were eliminated, we calculated population attributable fractions (PAF) where significant associations were identified. This involved converting the adjusted ORs to relative risks and calculation of PAF using the formula:

Results

Study Population

The baseline Health Survey questionnaire was initially sent to 9,334 adults aged ≥50 years. During the mailing process, there were 140 exclusions due to deaths, ill health, departures, and incorrect addresses. The exclusions left an eligible baseline-mailed population of 9,194 people from whom 5,109 completed Health Survey questionnaires were received (adjusted response 56%) ( 24). For this analysis, we excluded all men ( n = 2,439) and due to the small number, women aged 90 years and over ( n = 43), resulting in a sample of 2,627 women aged 50-89 years. Characteristics of the sample are reported in Table 1.

Footwear Characteristics According to Decade of Life and Birth Cohort

The proportions of participants who reported wearing shoes with high heels and a narrow toe box for each decade of their life according to birth cohort are shown in Figure 2. The frequency of high heel and narrow toe box use was highest between the ages of 20 and 29 years for all birth cohorts (38% of the whole sample), and then declined across subsequent decades. A birth cohort effect was evident, with those born between 1942 and 1951 being more likely than the other cohorts to wear shoes with high heels and a narrow toe box when aged between 20 and 29 years (OR 1.55, 95% CI 1.29-1.86, p < .001 and OR 2.99, 95% CI 2.49-3.60, p < .001, respectively) and 30 and 39 years (OR 1.36, 95% CI 1.07-1.71, p = .009 and OR 1.43, 95% CI 1.11-1.83, p = 0.006, respectively). However, this birth cohort effect diminished across subsequent decades of life.

Association Between Footwear Characteristics and Foot Pain

Heel height and toe-box shape worn between the ages of 20-29 years and 30-39 years in participants with and without foot pain in the past 12 months are shown in Table 2. There was no association between these footwear characteristics and foot pain in the past 12 months for either decade of exposure. Furthermore, there was no association with the total number of decades of exposure to high heels or a narrow toe box (data not shown). Adjusting for educational attainment did not substantially alter these associations, and similar results were obtained when adjusting for occupation instead of educational attainment (data not shown). Similar patterns were evident when these analyses were stratified by birth cohort (see Supplementary File 1).

Association Between Footwear Characteristics and Hallux Valgus

Heel height and toe-box shape worn between the ages of 20-29 years and 30-39 years in participants with and without hallux valgus are shown in Table 3. There was no association between heel height and hallux valgus for either decade of exposure. However, participants with hallux valgus were more likely to have worn shoes with a narrower toe box when aged between 20-29 years and 30-39 years. Adjusting for educational attainment slightly attenuated these associations and similar results were obtained when adjusting for occupation (data not shown). When these analyses were stratified by birth cohort, similar patterns were evident (see Supplementary File 1). There was no association between the total number of decades of exposure to high heels or a narrow toe box and hallux valgus (data not shown).

Population Attributable Fractions

The PAF for the association between toe-box shape and hallux valgus was calculated for two scenarios: (i) the adoption of a very wide toe box between the ages of 20 and 29 years, and (ii) the adoption of a wide or very wide toe box between the ages of 20 and 29 years. For scenario (i), the PAF was 0.408, indicating that 40.8% of cases of hallux valgus could be attributable to wearing shoes with a wide, narrow, or very narrow toe box. For scenario (ii), the PAF was 0.168, indicating that 16.8% of cases of hallux valgus could be attributable to wearing shoes with a narrow or very narrow toe box. Given the prevalence of hallux valgus in the population was 43%, these calculations indicate that (i) if women wearing shoes with a very narrow, narrow, or wide toe-box between the ages of 20 and 29 years had worn shoes with a very wide toe box, approximately 18 out of every 100 cases of hallux valgus in older women might have been prevented, and (ii) if women wearing shoes with a very narrow or narrow toe box between the ages of 20 and 29 years had worn shoes with a very wide or wide toe box, approximately 7 out of every 100 cases of hallux valgus in older women might have been prevented.

Discussion

The findings of our population-based study suggest that shoe wearing behaviors change over time. Specifically, our results indicate that women tend to wear shoes with a lower heel and a broader toe box as they age. A similar pattern was evident across all birth cohorts and was characterized by a marked reduction in the wearing of styles of footwear with high heels and narrow toe boxes from the age of 40 onwards. Our findings are consistent with Dawson et al. ( 5), who reported a reduction in maximum heel height in shoes 'worn for work' between the ages of 20 and 60 in women aged 50-70 years. This change in behavior may be indicative of a life-course trajectory in which the influence and perceived importance of fashion diminishes over time and is replaced with a greater emphasis on comfort and practicality ( 18, 25).

A birth cohort effect was observed in relation to footwear worn between the ages of 20-29 years and 30-39 years, with those born between 1942 and 1951 being more likely to wear shoes with high heels and a narrow toe box at these ages. This finding may be explained by the styles of footwear that were 'in fashion' during the time period when participants were aged in their 20s. The 1942-1951 birth cohorts were in their 20s in the 1960s, a decade in which stiletto heels became popular. In contrast, the 1922-1931 birth cohorts were less likely to have worn shoes with high heels and narrow toe boxes when aged between 20 and 39 years. This birth cohort was aged in their 20s in the 1940s and 1950s: a period encompassing World War II and the postwar Age of Austerity. During this period, the soles of women's shoes were manufactured from relatively inexpensive materials such as cork, and as a consequence generally had a low heel ( 26).

In contrast to previous studies ( 12, 14, 15), we found no association between footwear characteristics and foot pain, although this can be largely explained by methodological differences. Previous cross-sectional studies involved the examination of current footwear and its association with current foot pain, and incorporated an assessment of the mismatch between foot size and shoe size ( 12, 14). Our study explored the association between previous footwear use and foot pain in the last year, and did not involve any direct measurement of foot or shoe shape. A similar study involving recall of previous footwear use by Dufour et al. ( 15) did report an association with foot pain, although the classification of shoe characteristics was substantially different. In our study, we focused on two specific features of shoes-the height of the heel and the shape of the toe box-while Dufour et al. ( 15) collapsed 11 different shoe types into three categories ('good', 'average', and 'poor') and reported a protective effect of 'good' shoes compared with 'average' shoes. Interestingly, Dufour et al. ( 15) did not find any association between past use of 'poor' footwear and foot pain, although this may be because this category included quite disparate shoe designs (high heels, sandals, and slippers). Irrespective of differences in footwear categorization, establishing a temporal association between previous footwear use and current foot pain is inherently difficult, as foot symptoms are not stable over time ( 27, 28). Furthermore, our foot pain question was broad and would have identified pain resulting from a diverse range of causes in addition to those related to footwear.

We found no association between hallux valgus and heel height of footwear worn between the ages of 20-29 years or 30-39 years, or between the hallux valgus and total number of decades of exposure to high heels. Dawson et al. ( 5) reported that hallux valgus was associated with a significantly lower age at which one-inch heels were first worn, although the mean age difference was small and of borderline significance (mean [ SD] = 14.5 [2.5] vs 15.4 [2.0] years, p = .05). More recently, Nguyen et al. ( 16) found that older women who reported wearing shoes with a heel higher than two inches as their 'usual' footwear between the ages of 20 and 64 were more likely to have hallux valgus; however, this association was also of small magnitude and borderline significance (OR 1.2, 95% CI 1.0-1.5, p = 0.04). Taken together, these findings suggest that there is no strong association between history of wearing high heels and hallux valgus ( 29).

An important finding of our study is the significant association between the use of shoes with a narrow toe box and hallux valgus. Although the cause of hallux valgus is considered to be multifactorial (involving biomechanical ( 30) and genetic ( 31, 32) factors), constrictive footwear may contribute to its development by holding the hallux in an abducted position, leading to soft tissue and osseous remodeling over time ( 29). We found a graded increase in the risk of hallux valgus with increasing narrowness of the toe box in footwear worn between 20 and 29 years of age, and to a lesser extent, at ages 30 and 39 years. This observation is suggestive of a critical period in which exposure to constrictive footwear may lead to permanent structural change. Although the prevalence of hallux valgus across the lifespan has not been examined in detail, it is uncommon in children ( 33) and exhibits a strong linear association with age beyond 30 years ( 34).

Key strengths of this study include the large, population-based sample, clearly defined evaluation of footwear characteristics and the use of a validated measure of hallux valgus. However, our findings need to be interpreted in the context of several methodological limitations. First, the accuracy of retrospective self-report of footwear use over such a long time period cannot be confirmed and is likely to be subject to recall bias. Although the footwear questions preceded the hallux valgus questions in the health survey, it is possible that women with hallux valgus may have attributed their condition to inappropriate footwear and were more likely to recall wearing constrictive footwear than those without. Second, our footwear assessment tool was limited to two key features: heel height and toe-box shape. These features were selected as they have the most plausible association with hallux valgus. However, we acknowledge that there are several other footwear characteristics that may also be of relevance to the development of foot problems ( 35). Finally, inferring temporal relationships between past footwear use and foot problems is inherently problematic. This is particularly the case for foot pain, the natural history of which is characterized by intermittent episodes of onset and resolution ( 27, 28). A stronger case for temporality can perhaps be made for the association between constrictive footwear and hallux valgus, as the condition is uncommon in the 20- to 29-year age range and develops gradually. However, we cannot be certain that exposure to narrow toe-box footwear preceded the development of hallux valgus, particularly in the 30- to 39-year exposure period.

The key public health implication of our study is that avoiding constrictive footwear, particularly between the ages of 20 and 29 years, may contribute to the prevention of hallux valgus. For example, the PAF calculations indicate that approximately 18 out of every 100 cases of hallux valgus in older women might have been prevented if all women had worn shoes with a very wide toe box between the ages of 20 and 29 years. This 'best-case' scenario is admittedly an unrealistic goal given the limited availability of such footwear and the competing demands of fashion. However, if women wearing shoes with a very narrow or narrow toe box between the ages of 20 and 29 years had worn shoes with a very wide or wide toe box-a more achievable outcome-the PAFs suggest that approximately 7 out of every 100 cases of hallux valgus in older women might have been prevented. Given the high prevalence of hallux valgus in this population ( 33) and the economic burden associated with surgical treatment of the condition ( 6), this potentially represents a substantial public health benefit.

In conclusion, this study provides evidence that women tend to wear shoes with a lower heel and broader toe box as they age, but that the wearing of constrictive footwear between the ages of 20 and 39 years may be a critical period for the development of hallux valgus in later life. These findings add to the body of literature pertaining to the potentially harmful effects of footwear and suggest that advising younger women to minimize their use of constrictive shoes may have long-term benefits on foot health.

Funding

This work is supported by an Arthritis Research UK Programme Grant (18174) and service support through the West Midlands North CLRN.

Conflict of Interest

The authors have no conflicts of interest to declare.

Acknowledgments

The authors would like to thank the administrative, health informatics and research nurse teams of Keele University's Arthritis Research UK Primary Care Centre, and the staff of the participating general practices. H.B.M. is a National Health and Medical Research Council of Australia Senior Research Fellow (ID: 1020925). M.J.T is funded by a National Institute for Health Research (NIHR) School for Primary Care Research Launching Fellowship.

References

Author notes

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/3.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

# data[].attributes.attachment_link.title
Epidemiology of Shoe Wearing Patterns Over Time in Older Women: Associations With Foot Pain and Hallux Valgus

# data[].attributes.attachment_link.description
Footwear plays an important role in protecting the foot. The earliest known footwear, dating from approximately 7,500 BCE, were simple sandals secured around the ankle with rope ( 1), whereas the first direct evidence of footwear covering the foot dates back to 3,500 BCE ( 2).

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https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-017-0229-y

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Abstract

Background

Foot symptoms in rheumatoid arthritis (RA) derive from a combination of inflammation, altered foot mechanics, deformity and secondary skin lesions. Guidelines recommend regular review of patients' feet, but the extent to which the general population of RA patients report foot symptoms and access foot care has not been established. The aims of this study were to determine the prevalence, impact and care of foot problems in all patients with RA in one geographical area and identify factors associated with accessing foot care.

Methods

Cross-sectional survey of a random sample of patients with RA, who resided within a single community-based National Health Service (NHS) podiatry service. The questionnaire collected demographic data (age, gender, local deprivation score), clinical data (disease duration, arthritis medications, disability (Health Assessment Questionnaire (HAQ)), current foot problems, foot care accessed (podiatry, orthotics and/or orthopaedics) and care received, measures of impact (Foot Impact Scale) and ability to work.

Results

Of 1003 total eligible patients in the target population, 739 were posted survey packs. Of these 413 (56%) replied. Responders and non-responders had similar age (63.5 yr. vs.61.5 yr), gender (74.1%F vs. 75.2%F), and highest deprivation category (13.3% vs.15.9%). Of the responders 92.1% reported current foot problems: articular 73.8%, cutaneous lesions 65.4%, structural 57.6%, extra-articular 42.6%. Responders' median (IQR) disease duration 10 (5-20) years, HAQ 1.5 (0.75-2.0), FIS IF 10 (6-14) and FIS AP 16 (7-23) and 37.8% reported impacts on work. While 69.5% had accessed foot care there were differences in the route of access (by gender and whether independent or NHS provision) and were older (64.9 yr. vs 60.4 yr. p = 0.001), had longer disease duration (12 yr. vs 7 yr. p < 0.001) and had a greater proportion of females (72.2% vs 61.7% p  = 0.04) than those who had not accessed care.

Conclusions

Current foot problems were reported by 92.1% of the study sample and substantially impacted on life and work. While overall access to foot care was higher than anticipated, routes of access differed and extent of current problems suggests the provision of effective, timely and targeted care is a pressing need.

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Background

Foot involvement is so common in early rheumatoid arthritis (RA) that it is part of the well-described clinical picture at presentation [ 1]. Continuing foot involvement in patients with longstanding RA has been estimated as 30% to 90% [ 2, 3, 4] but no formal survey has been reported in a random selection of a geographically defined RA population. Clinical issues involving the feet include articular features such as joint pain, stiffness and swelling; extra-articular features such as bursae, nodules and numbness; structural deformities such as hallux valgus and toe deformities; and cutaneous lesions such as callosities, nail pathologies and ulceration [ 4, 5, 6, 7]. Foot problems can lead to reduced walking distance, impaired health-related quality of life and an increased risk of falls [ 8, 9, 10]. Despite recent advances in the medical management of RA, prospective longitudinal studies report that even in patients classified as being in remission, up to 40% have continuing disease features in the feet [ 2, 11]. Although national guidelines and expert opinion call for timely and appropriate foot care [ 12, 13, 14], provision of dedicated foot care services for inflammatory arthritis is variable and service provision has been reported to be poor [ 15, 16, 17]. Furthermore, the non-pharmacological management of foot problems in patients with RA can involve a variety of interventions such as treatment for cutaneous lesions, provision of foot orthoses, prescribed footwear and orthopaedic surgery. These treatments can be delivered by a variety of clinicians within both primary (community) and secondary (hospital) care settings such as podiatrists, orthotists and orthopaedic surgeons. Additionally, foot care in the UK can be provided within the National Health Service (NHS) and independent health care sector (outside NHS provision). Overall access to and utilisation of foot care services is reported to be relatively low compared to foot health care needs and inequitable, being more likely to be taken up by affluent older women [ 18, 19, 20].

However, the evidence base quantifying the prevalence of foot problems and access to foot care in patients with RA has uncertainty, as it rests on observational hospital-based studies using convenience sampling strategies or surveys of self-selecting groups using restricted outcome measures [ 4, 6, 21]. Although these studies have provided valuable insights their findings cannot be extrapolated to the general RA population. Furthermore, they may not account for regional variation of foot care service provision for patients with RA [ 15]. In addition, the clinical features of foot problems in RA and a description of care received have not been documented in detail.

In order to establish the prevalence and impact of foot problems and access to foot care in patients with RA a survey is required of a large group of patients with RA, randomly selected from a defined population which has equitable access to both primary and secondary based foot care services and including assessment of the full range of impact. Here we report such a survey using an RA population-based sample in a well-defined geographical area to determine the prevalence of self-reported foot problems, assess their impact (based on previous qualitative work [ 22], identify the proportion of patients who have accessed foot care (podiatry, orthotics and/or orthopaedics) within the study geographical area.

Methods

Study population

The study design was an RA population-based, cross-sectional survey of patients conducted in Bristol, United Kingdom. Bristol has a mixed population with a broad range of social affluence and deprivation [ 23]. Rheumatology services for the city of Bristol and surrounding areas are provided by two NHS hospitals with rheumatology services and long-term follow-up of RA patients similar to those in other parts of England [ 24]. NHS orthotics and orthopaedic services are provided at both hospitals. A single community-based service provides NHS podiatry care to a well-defined local population based on their registration with primary care general practices all of which feed into one or both hospitals. The general practices are within the geographical boundary of the Bristol Clinical Commissioning Group (CCG) which is responsible for NHS services for the city of Bristol. The target population for this study was patients diagnosed with RA [ 25] attending for rheumatology medical care at either hospital, over the age of 18 years, and registered for primary care within the community service geographical boundary. Thus the target population was all adult patients with a consultant diagnosis of RA residing within the Bristol CCG geographical area. Hospital databases were accessed to facilitate identification of patients within the target population. Within the study geographical area patients are universally diagnosed with RA in specialist care (hospital based consultants). As the hospital databases cannot select on geographical area, patient details were reviewed to ensure they were within the defined community service boundary. A total of 2335 patients were registered for rheumatology medical care at the two hospital sites. Of these, 1003 RA patients (target population) were within the community service geographical boundary and therefore met the study eligibility criteria.

The study subjects were selected by random sampling from departmental databases of the target population at both hospitals. Patients were sent an invitation letter, a questionnaire and a FREEPOST return envelope. If no response was received within 3 weeks this was repeated. If any patients had a pending rheumatology appointment within the next month, they were not contacted until after that appointment. This was to reduce the potential for the invitation on accessing foot care to influence the patient's imminent consultation, and thus alter the response to the survey on discussions about feet during consultations.

The sample size requirements for this study were difficult to estimate as the extent of variation in access to foot care (and possibly foot care needs) was unknown a priori. Based on existing published rates [ 4, 20, 21] the chosen target of 400 patients would enable the proportion of patients reporting foot problems or with specialist foot care need or history to be estimated with a margin of error not greater than 5 percentage points and confidence limits of at least 95%.The chosen target was also based on the expectation that there would be a maximum of 5 to 6 main determinants of access to foot care, which would be identified by multivariate analyses with adequate precision [ 26]. Questionnaires were distributed to RA patients in randomly assembled batches and this continued until the number of questionnaires returned reached the chosen target of 400 returned response sets. Research ethics committee approval was obtained (Central Bristol Medical Research Ethics Committee, 11/SW/0327) and informed consent was inferred by the return of completed questionnaires.

Study questionnaire

The study questionnaire collected clinical and general demographic data, presence and impact of foot problems, foot care accessed and a description of foot care received. Responders were classified as having accessed foot care (AFC) if they reported to have accessed/utilised podiatry, orthotics and/or orthopaedics. Conversely, responders who had not accessed any of the defined foot care services were classified as not accessed foot care (NAFC). The content of the questionnaire was developed from data generated from one-to-one interviews with patients with self-reported foot problems [ 22], a narrative review of the literature in relation to studies reporting foot problems [ 27], validated questionnaires measuring the impact of foot problems in RA (Foot Impact Scale (FIS)) [ 28], and a measure of general disability (Health Assessment Questionnaire (HAQ)) [ 29, 30]. A convenience sample of 10 patients commented on the content of the study materials and provided valuable feedback to inform the final format of the questionnaire.

Scoring the scales

The FIS comprises two subscales, FIS Impairment / Footwear (FIS IF) and FIS Activities / Participation (FIS AP). FIS IF scores ≤ 6 are considered mild, 7-13 moderate and ≥ 14 severe measures of foot related impairment. FIS AP scores ≤ 9 mild, 10-19 moderate and ≥ 20 severe are considered for measurements of activity limitation [ 5]. Full guidance on the scoring of the FIS (for example how to deal with missing data) has not been published; a pre-determined, pragmatic approach was therefore required in relation to scoring the scale. For this study a minimum of 90% of all questions had to be completed for the scores to be admissible (FIS IF > 18 and FIS AP > 27 questions completed). Missing values were given the average of the individual patient's score for the other questions. If any returned FIS questionnaires were not sufficiently completed to meet the defined admissible criteria, the incomplete FIS scores were excluded from analysis. HAQ scores were admissible if there was at least one response in at least 7 sections and the missing section was given the average score of the individual patient's score for the other sections [ 29].

Social deprivation

The Index of Multiple Deprivation (IMD) 2007 for England was used as a measure of local deprivation. IMD scores were obtained from postcodes utilising GEOConvert software ( http://geoconvert.mimas.ac.uk, accessed 09/10/13). IMD scores were taken for the whole study sample and were converted into categories. Category 1 of least deprived (most affluent) was defined as the lowest 20% of numerical scores recorded in the study, Category 2 represents the second fifth (21%- 40%), and up to category 5 most deprived (least affluent (81-100%). These categories are therefore an index of comparative local deprivation within the study sample [ 31].

Statistical analysis

Descriptive statistics were used to characterise the study sample. Continuous variable data were expressed either as means, standard deviations (SD) or as medians with their inter-quartile range (IQR), depending on the underlying distribution. For categorical data, proportions were calculated and expressed as percentages.

Univariate analyses were conducted to compare the general and clinical characteristics of responders who accessed foot care (AFC) and responders who had not accessed foot care (NAFC) since being diagnosed with RA. Continuous variable data were expressed either as means, standard deviations (SD) and compared using independent sample t-tests, or as medians with their inter-quartile range (IQR) and compared using the Mann-Whitney U test, depending on the underlying distribution. For categorical data, proportions were calculated and expressed as percentages and, where appropriate, compared using the Chi-squared test applied to the original numbers. P values < 0.05 were considered statistically significant.

Multivariate analyses were undertaken to determine the statistical significance of contributory factors as independent variables influencing access to foot care (AFC/NAFC) as the dependent variable. Binary logistic regression was selected as the method for multivariate analyses. Initial selection of the independent variables included in the logistic regression model was conducted after univariate analyses identifying differences (non-foot related) between the AFC group and the NAFC group (NAFC). Logistic regression analyses were then performed to assess the predictive ability of each independent variable by controlling for the effects of the other independent variables in the model. Analyses were conducted utilising binary entry (block entry) whereby all the independent variables were entered in to the model simultaneously. Incomplete data sets (missing data) were excluded from logistic regression analyses using case pairwise deletion. Predictor variables associated with the outcome with p  ≤ 0.05 were selected as variables in a series of logistic regression models. The statistical analyses were conducted using SPSS 19.0 (SPSS Inc. Chicago, Illinois).

Results

Participants

Of the 1003 patients, within the target population, 739 were posted a questionnaire before the target sample size was achieved and 415 returned. Of these 295 were returned directly and 120 after a reminder, giving an overall response rate of 56.2% (Fig. 1). Two returned surveys were inadmissible due to large quantities of missing data and 413 were available for analysis.

Flow diagram of study recruitment

Some information was available on the 324 non-responder study subjects in relation to gender, age, local deprivation scores and hospital site. The characteristics of the responders and non-responders to the questionnaire are summarised in Table 1. Responders were slightly younger than non-responders (63.5 years v 61.5 years) but a similar proportion were male (25.9% responders v 25.3% non-responders). There was only a small difference in overall local deprivation scores between responders and non-responders. Additionally response rates were very similar for both hospital sites. Responders were consequently regarded as being adequately representative of the target RA population in the analyses.

Clinical characteristics responders

A wide range of disease duration and current disability was reported (Table 2). The majority of responders were taking medications for their RA ( n = 394, 95.4%) and one half was taking more than one category of arthritis medication ( n = 210, 50.8%). Impact of foot problems was substantial with 178 (44.5%) reporting moderate foot related impairment and 105 (26.3%) reporting severe foot related impairment (FIS IF). The impact of foot problems in relation to activity levels and participation in valued activates (FIS AP) was 110 for moderate impact (27.5%) and 161 (40.3%) for severe. Of the 413 responders 254 (61.5%) were working, of these 156 (61.4%) reported foot problems impacting on their ability to work. The majority ( n  = 312, 75.7%) of responders reported having had a foot examination.

Almost all respondents reported they had experienced foot problems at some time being diagnosed with RA (Table 3). The majority of responders ( n = 377, 91.2%) reported the presence of one or more foot problems currently and over half reported ( n = 215, 52.1%) 5 or more foot problems. The rates of current foot problems in women and men were similar ( n = 279, 90.0% v n  = 91, 85.8%).

Table 3 Reported foot problemsa

Of the 413 responders, 287 (69.5%), had accessed foot care (AFC) and 140 (48.8%) had accessed two or more services. The general, clinical and foot related characteristics of the AFC group and the NAFC group are presented in Additional file 1 (online). Overall the AFC group were slightly older and had longer disease duration than the NAFC group (64.9 years v 60.4 years, p = 0.01; 12 years v 7 years, p < 0.001). Additionally a higher proportion of females had accessed foot care compared to males (F 72.2% v M 61.7% p = 0.04). The proportions from more deprived areas (IMD score categories 3, 4 and 5) were similar for both groups (AFC 36.2% v NAFC 39.7% p  = 0.363).

Although disability was statistically significant in univariate analyses (AFC 1.62 v NAFC 1.12 p = 0.005), HAQ scores included lower limb disability and these were therefore omitted from multivariate analyses. As an assumption of logistic regression analyses requires independent variables are independent of the dependent variable of interest [ 32]. Logistic regression analyses revealed increased odds (OR) of AFC in those with longer disease duration (OR = 1.04, 95% CI 1.02-1.07) and in those who were older (OR = 1.02, 95% CI 1.01-1.04). Although these results demonstrate disease duration and age to be independent factors of access to foot care the effect for both was mild. The strongest predictor of AFC was female gender, with an odds ratio of 1.72 (95% CI 1.06-2.88). Social deprivation did not make a statistically significant contribution to the model (OR 0.87, 95% CI 0.70-1.09). Table 4 presents the results of univariate and logistic regression analyses.

The AFC group reported a wide range of foot care received (Table 5). Device prescriptions were the most frequent care category reported. Of the 72 patients who had undergone foot surgery, 54 (75.0%) reported their foot problems had improved after surgical intervention.

Of the AFC group, 204 (71.1%) had accessed podiatry (NHS and/or independent sector), 192 (66.7%) orthotics and 92 (32.1%) orthopaedics and 140 (48.8%) had accessed two or more services (Table 6). Over half of the podiatry group had accessed independent sector podiatry care (with or without NHS care) ( n = 107, 52.5%). No information was available on exclusive use of independent sector care. Of the patients who had accessed podiatry, nearly half ( n  = 95, 46.5%) had self-referred including 39 (19.1%) who had accessed independent sector foot care (i.e. outside the NHS). There were differences in access routes for each service according to gender. Women were more likely than men to access podiatry (NHS and/or independent sector) care through self-referral (29.7% v 20.0%) and from hospital clinicians (26.6% v 17.4%) whereas men were more likely to be referred by their GP (41.3% v 22.2%). The proportions of patients self-referring for independent sector podiatry care was similar for both genders. In contrast the proportion of women referred to orthopaedics by hospital based clinicians was higher than GP initiated referrals (F 71.4% v F 20.7%). Access routes to orthotics were broadly similar for gender.

Table 6 Gender and routes of access to foot care servicesa

Discussion

This study achieved an overall response rate of 56%, similar to other postal surveys of patients with RA conducted in the UK [ 4, 33]. Responders and non-responders were similar in relation to hospital site, gender, age; and social deprivation. Additionally the general and RA characteristics of responders were similar to other postal surveys of patients with RA conducted in the UK [ 7, 33, 34, 35]. Thus the responders to this survey are likely to represent the target population, and the target population may reflect the general diagnosed RA population.

These results show that patients with RA in this study experience a wide range of foot problems and the great majority currently have one or more foot problems. The prevalence of foot pain, numbness and ulceration reported in this study were broadly similar to but slightly lower than earlier surveys based on selected populations [ 4, 7]. However, this study provides the broadest description of foot problems reported in a random sample of a defined population of patients with RA to date.

Foot impact scores were slightly lower than previous studies [ 5, 36, 37]. However, these data represent the overall impact of foot problems of all patients with RA in a defined geographical area as opposed to selected samples such as patients attending a specific clinic. The FIS scores in this study show the impact of foot problems to be considerable in a wide population sample of patients with RA. However, the findings of an earlier qualitative study indicated not all issues of the impact of foot problems (e.g. work related disability) are captured in the FIS [ 28]. Work related disability in patients with RA has been widely described [ 38, 39, 40] and this study provides new insights identifying the specific and substantial impact of foot problems on work related disability.

An annual review of patients' feet and access to foot care services is recommended in national guidelines [ 12]. However, surveys of rheumatology departments have shown the provision of dedicated foot care services for patients with inflammatory arthritis is variable [ 15, 16, 17]. Additionally, the conduct of foot examinations in clinical practice can also be variable as the foot is omitted from standard measures of disease activity such as the Disease Activity Score [ 41] and consequently foot problems may be ignored in clinical consultations [ 2, 11]. The majority of responders in this study recalled having undergone a foot examination, although only a third reported to having had a foot examination in the preceding 12 months. The accuracy of patients recalling the time when foot examinations were conducted can be questioned. Nonetheless this study suggests patients perceive the time interval of when foot examinations were conducted to be variable and potentially not complying with national guidelines [ 12].

Based a review of the literature and local service evaluation, it was estimated that many patients within the study geographical area would not have accessed foot care. However, the proportion of patients who had accessed foot care was higher than anticipated. It is possible repeated interactions with clinicians may overcome barriers to utilisation of health care services and thus patients with RA may be more likely to access additional services including foot care. Indeed patients with RA being regular users of health care provided by a wide range of clinicians has been reported [ 42]. However, access to and utilisation of health care services in general terms is complex. A number of predisposing factors such as general characteristics (age, gender, social deprivation), clinical characteristics (type of health condition acute or long term, additional morbidity) experience and satisfaction of care received are reported to influence individuals in their decisions to access health care or not [ 43]. Furthermore, patients' reasons for accessing and utilising foot care services are complex [ 22]. In spite of the higher than expected access rates, many patients from both the AFC group and NAFC group reported current foot problems. The proportion of patients who had accessed podiatry was similar to an earlier postal survey of patients with RA [ 4]. However, in a longitudinal cohort study of patients with early RA, only 30% of study participants reported to have accessed podiatry and 4% orthopaedics [ 20]. This may be accounted for by the differences between this random RA-population sample compared to an early arthritis cohort.

In multivariate analyses age and disease duration were independently associated with having accessed foot care, but not strongly. Foot problems are reported to affect one in four older people [ 44]. It therefore is possible to postulate patients with RA who are older and have longer disease duration are more likely to develop foot problems and therefore seek foot care. However, severity and clinical progression of RA varies from patient to patient. Thus the mild influence of age and disease duration as possible determinants of accessing foot care would seem reasonable. Female gender was the strongest independent predictor of AFC. This is not an unexpected result as it has been reported foot problems may be more prevalent in women [ 45, 46], and utilisation of health care has been widely reported to be higher in women [ 47, 48, 49]. This study has identified broad characteristics of which patients are likely to access foot care in in Bristol, UK. For example women were more likely to self-refer and men more likely to be advised by clinicians to seek treatment. Knowing that female patients are more likely to access foot care does not necessarily reflect greater clinical need.

In the UK, podiatry services are provided within both the NHS and independent health care sectors. Of the responders who had accessed podiatry services one half reported to have accessed independent sector foot care. A recent UK based survey of 217 patients with RA who had accessed podiatry care showed that the majority (76%) had used independent sector care [ 21]. It could be inferred that patients consider their foot problems to be an important health care need that they are willing to self-fund. Conversely, patients may elect to self-fund their foot care due to lack of NHS provided foot care, barriers to accessing care and/or experience of care received [ 22].

Of the AFC group, a range of care interventions was reported. Foot care "devices" was the most common care category reported suggesting clinicians consider them beneficial. However, despite having accessed foot care, the majority of patients reported current foot problems and substantial impact. These data therefore raise questions regarding effectiveness and/or continuity of foot care received. However, data in relation to the clinical significance of foot problems at the time foot care was accessed is not available. Firm conclusions regarding the effectiveness of foot care received cannot be drawn directly from these data, as that would require contemporaneous clinical examination of the feet.

The number of podiatrists within the independent sector specialising in inflammatory arthritis within the geographical area of this study is unknown. However, non-specialists' knowledge of national guidelines for the management of foot problems in rheumatic diseases shows wide variation [ 50]. In order for patients to receive timely and effective care non-specialist clinicians need to have the clinical skills to identify and refer patients who require specialist review. The role of specialist podiatrists as members of hospital based multidisciplinary teams' managing diabetic foot disease is well established in the UK [ 51]. In contrast, the number of podiatrists as members of rheumatology multidisciplinary teams in the UK is variable [ 15]. Provision of foot care services for patients with RA could reflect the diabetes model. Indeed close collaboration between clinicians for access and management of foot problems in RA has long been advocated [ 52].

Overall, this study has provided data in relation to: (i) a description of the general and RA characteristics of a large random sample of all RA patients residing within a defined geographical area; (ii) estimated the reported prevalence and impact of current foot problems; (iii) identified the proportion of patients who have accessed foot care services; (iv) provided a description of foot care patients received. These data are from a community based random sample of all patients with RA in a defined geographical area. How and whether or not patients in the general RA population access foot care may be variable and potentially influenced by different patterns of foot care service provision. How these data reflect the situation in other geographical areas could be the focus of further investigation.

Strengths and limitations

Is a strength of this study that the patient population was a random sample of all patients within a defined geographical area, the sample size was large and responders were an accurate representation of the target population of adult patients with RA. Additionally, almost all the returned questionnaires were admissible (minimal missing data), indicating patients found the survey items easy to understand and complete. There are some limitations to this study. While the prevalence of one or more current foot problems in patients with RA by self-report was very high, it would be useful to know to what extent patient self-report is accurate. The clinical categorisation of foot problems and the proportion of patients who might benefit from immediate foot care could be identified by direct clinical examination of the feet. Data relating to the prevalence of foot problems in non-responders is not known and there is potential for non-responder bias. However, in this study the general characteristics of responders and non-responders that might cause such bias, such as the proportions of responders from areas of deprivation, were very similar.

Conclusion

Self-reported foot problems were present in 91% of a random sample all of adult patients with RA in Bristol and they substantially impacted on patients' lives. Additionally foot problems were important issues for patients. While overall access to foot care was higher than anticipated, the extent of current problems suggests that the provision of effective, timely and targeted care a pressing need. Clinicians need to have the clinical expertise in foot assessments and knowledgeable of the clinical management of foot problems. Additionally foot care needs to be co-ordinated and tailored to individual patient's needs in order to improve outcomes for patients.

Abbreviations

CCG:

Clinical commissioning group

FIS:

Foot impact scale

HAQ:

Health assessment questionnaire

IMD:

Index of multiple deprivation

NHS:

National health service

RA:

Rheumatoid arthritis

UK:

United Kingdom

References

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Acknowledgements

The authors thank the patients who participated in the study; Dr. Paul Creamer and clinical teams for assisting with recruitment staff at North Bristol NHS Trust and University Hospitals Bristol NHS Foundation Trust rheumatology departments, Bristol, United Kingdom (UK); Enid Quest and Caroline Swales for their advice as patient research partners on this study.

Funding

This work was supported by the National Institute for Health Research UK Clinical Doctoral Research Fellowship Award (grant number CATCDRF09/) to OW. This paper presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the National Health Service (NHS), the NIHR or the Department of Health, UK.

Availability of data and materials

Additional files: Additional file 1 General, clinical and foot related characteristics of the AFC and the NAFC groups. The data sets used and analysed during the current study are available from the corresponding author on reasonable request.

Author information

Authors and Affiliations

1. Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK

Oonagh Wilson, Sarah Hewlett & Jon Pollock

2. School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK

James Woodburn

3. School of Clinical Sciences, University of Bristol, Bristol, UK

John Kirwan

Contributions

All authors contributed to the study conception and design. OW and JK identified the study sample. OW conducted all data collection and takes responsibility for the integrity of the data and data analysis. All authors contributed to data analyses, interpretation of the data and intellectual content of the manuscript and approved the final submission.

Corresponding author

Correspondence to Oonagh Wilson.

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Ethics approval and consent to participate

Research ethics committee approval was obtained (Central Bristol Medical Research Ethics Committee, 11/SW/0327) and informed consent was inferred by the return of completed questionnaires.

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Not applicable.

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The authors declare they have no competing interests.

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Wilson, O., Hewlett, S., Woodburn, J. et al. Prevalence, impact and care of foot problems in people with rheumatoid arthritis: results from a United Kingdom based cross-sectional survey. J Foot Ankle Res 10, 46 (2017). https://doi.org/10.1186/s13047-017-0229-y
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DOI: https://doi.org/10.1186/s13047-017-0229-y

Keywords

Feet

Rheumatoid arthritis (RA)

Prevalence

Foot care

RA population survey

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