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The Prevalence

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Title: The Prevalence


1
The Prevalence Predictors of Foot Ulceration in
Rheumatoid Arthritis
Jill Firth Honorary Rheumatology Nurse
Specialist Smith Nephew Foundation Doctoral
Student
2
Background
  • Lower limb ulceration is often poorly defined in
    research the foot is rarely the primary focus
  • Surprisingly little is known about the prevalence
    aetiology of wounds in this client group
  • Investigation often focuses on relatively small
    samples of patients in secondary care

3
Previous work
  • A review of 139 rheumatology outpatients (53 had
    RA) over half were assessed as having poor
    tissue viability (included past or present
    ulceration, callus, skin nail abnormalities)
    Williams Bowden (2004)
  • A rheumatology foot ulcer clinic treated 149
    patients over 3 years (73 had RA) ulceration
    was most commonly seen in female RA patients with
    longstanding disease many patients had multiple
    episodes of ulceration, not always at the same
    site Davys (2006)
  • A cross-sectional multi-centre study of forefoot
    problems in 285 consecutive RA outpatients in the
    Netherlands overall prevalence of foot
    ulceration was 13 the point prevalence 5
  • Matricali et al (2006)

4
Research Design
  • Postal survey to establish overall prevalence of
    foot ulcers among RA patients on a diagnostic
    register in Bradford (n 1130)
  • Validation of prevalence data
  • Recruitment of open cases randomly selected
    case matched controls to a case control study of
    predictors of ulceration

5
The prevalence data
  • Response rate 78 (n883)
  • Validated point prevalence 3 (n30)
  • Validated overall prevalence 10 (n86)
  • False positive rate 21.21 initially (10.76 with
    use of diagrammatic data)
  • False negative rate 11.76
  • The prevalence data was unchanged if patients
    with diabetes were excluded from the sample as a
    whole

6
Characteristics of affected patients
  • Patients reporting open healed ulceration
  • had significantly longer disease duration
  • reported significantly greater usage of special
    footwear
  • a higher prevalence of foot surgery than ulcer
    free patients

7
Site and frequency of ulceration
  • Most common sites were the dorsal aspect of
    hammer toes (n24) the metatarsal heads (n16)
    medial aspect of 1st MTPJ associated with HV
    (n10) digital ulceration (n6,
  • 3 cases of major vessel disease 3 of
    vasculitis)
  • 33 reported multiple sites of ulceration
  • 47 reported multiple episodes of ulceration
    ranging from 2-30 (median 2 IQR 1-4)

8
Wound management
  • Practice or district nurse - 26
  • Podiatrist 16
  • Nurse podiatrist 21
  • Self management 15
  • Carer 7

9
Are patients with RA at increased risk of foot
ulceration?
  • The point prevalence of foot ulceration in the
    general population was estimated at 2 cases per
    10,000 based upon health professional reporting,
    including patients with without RA
    (Scanlon,2000)
  • This study estimated the point prevalence rate in
    the RA population to be 300 cases per 10,000
  • So you are up to 150 times more likely to
    experience a foot ulcer if you have RA!

10
Why?
  • Known risk factors for foot ulceration in
    diabetes co-exist in RA peripheral neuropathy
    peripheral vascular disease raised plantar
    pressures foot deformity trauma from footwear
  • Additional factors are liable to affect tissue
    viability in RA articular disease systemic
    disease (anaemia, nodules, vasculitis) reduced
    mobility self care capacity impaired
    nutritional status side effects of medication

11
A preliminary case control study
  • Sample 15 cases recruited from postal
    survey 66 controls randomly sampled from
    respondents after case matching (patients with
    diabetes excluded)
  • Methods Clinical examination (10g
    monofilament ABPI Platto PressureStat
    SJC medication pre-ulcerative lesions)
  • Data analysis Step-wise logistic regression to
    test diabetic model potential
    predictors in RA

12
Model selection
  • The Diabetic Model
  • Loss of protective sensation
  • Abnormal ABPI
  • Foot deformity
  • Raised plantar pressures
  • Potential predictors in
  • RA
  • Abnormal ABPI
  • Foot deformity
  • Pre-ulcerative lesions
  • Swollen joint count
  • Current steroid therapy

13
Results
14
Exact logistic regression
  • More accurate where numbers are low or data
    sparse
  • Possible to account for matching
  • Steroids, swollen joint count pre-ulcerative
    lesions retained significance
  • ABPI no longer a significant predictor due to
    small sample size

15
Conclusions
  • Foot ulceration in RA is a relatively common
    problem
  • Its aetiology is still poorly understood a
    multi-centre study of incident cases is needed
  • Further investigation is warranted, particularly
    in terms of aetiology, effective management, the
    identification of risk factors the prevention
    of recurrence

16
With thanks to
  • Professor Claire Hale
  • Dr. Philip Helliwell
  • Dr. Jackie Hill
  • Dr. Andrea Nelson
  • The FASTER team
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