Podiatry Review July/August 2011

The Ins tute of Chiropodists and Podiatrists

ISSN 1756-3291

Vol. 68 No. 4 - July/August 2011

Features within this issue l l l

Independence

Conference Photos Chairman’s Address President’s Address

Initiative

Individualism

July/August 2011 Podiatry Review

Contents 1. Editoria

The Institute of Chiropodists and Podiatrists Podiatry Review Editor Roger Henry F.Inst.Ch.P. DChM editor@iocp.org.uk Sub-Editor Robert Sullivan M.Inst.Ch.P.

2. Rambling Roads 3. Diabetes UK News Dear Reader

4. Part 2 Clinical Guidelines for the recognition of melanoma of the foot and nail unit.

Traditionally this issue of Podiatry Review is concerned with giving you, the reader, a flavour of our A.G.M., conference, lectures, dinner dance and the chiropodial and medical trade show.

8. Article on Dementia

This year, the 56th A.G.M. etc was held at Beaumont House Windsor, which had extensive grounds and superb facilities. It engendered a learning atmosphere at the lectures and a fun time at the dinner dance.

See the letters and photographs herein.

BSc(Hons)Pod, PG Dip. TP Surg.

Subeditor@iocp.org.uk

11. Chairman’s Address

Press and Public Relations Officer Fred Beaumont Hon.F.Inst.Ch.P., D.Ch.M Tel: 0191 297 0464

12. President’s Address

Editorial Assistant Bernadette Willey bernie@iocp.org.uk Editorial Committee Mrs. F. H. Bailey M.Inst.Ch.P Mr. R. Beattie Hon.F.Inst.Ch.P., LCh., HChD Mr. W. J. Liggins F.Inst.Ch.P, FpodA, BSc(Hons) Mrs. A. Yorke, M.Inst.Ch.P Mr. J. W. Patterson, M.Inst.Ch.P., BSc(Hons)

DChM, MSc

Advertising Please contact the Editor for all matters pertaining to advertising editor@iocp.org.uk Published by The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside PR9 0TL Tel: 01704 546141

15. Peer Review Section Centre CPD Article Haematiolgy (part 1) 19. Designing a Clinical Audit 21. A.G.M. Postbag 26. A.G.M. Traders 27. A Day in the Dissection Lab Getting Under The Skin by Gillian Webster, M.Inst.Ch.P. 28. CPD information 30. Branch New 33. Classified 34. Diary of events 36 National Officers

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Now, what is of interest and note in this issue of Podiatry Review? Firstly part 2 of Ivan Bristow, from Southampton University, and colleagues’ treatise, Clinical Guidelines for the recognition of Melanoma of the Foot and Nail.

I have put in notes on Patricia Pope’s RGN lecture on dementia, which I found fascinating. It was well worth the trip to the Windsor conference for those lectures alone.

The pull-out CPD section is on Haematology by Judith Barbara-Brown, MSc BSc(Hons) PGCE D Pod M MChs, for which once again we thank her. Judith was presented with the Basham prize at our conference and well deserved it.

South Wales branch member, Gillian Webster, has given us an account of her ‘day in a dissection lab’ which I found interesting and am sure our readers will do also. Thank you Gillian. We always welcome articles, news, anecdotes from our members, if any of you wish to write in please do so.

The peer-reviewed articles in this issue are l

Designing a Clinical Audit, waste in the manufacture of chairside orthotics by Deirdre O’Flynn.

l

Primus Metatarsus Supinatus, also called Rothbarts Foot, by Brian A. Rothbart, DPM, PhD, DNM.

So I think you could say that there is something for everybody in this issue of Podiatry Review.

I am going on holiday tomorrow, so keep your fingers crossed for nice weather.

All the best Roger Henry Editor, Podiatry Review

Rambling Roads The Medical Protection Society ‘Casebook’ Vol. 19.2pp 12-14 carries an article on tunnel vision in diagnosis, much of which is relevant to podiatrists. The author, Sara Williams, makes the point that in one study approximately 6% of errors were those of reasoning and not of lack of knowledge. She goes on to list behaviours which can lessen the risk of diagnostic errors including the old saw of ‘if you hear hooves expect a horse, not a zebra’ indicating that one should think of common possibilities first. She also suggests adopting an attitude of transparency with the patient, documenting differential diagnoses and to always be prepared to question the initial diagnosis if the condition fails to respond. This is very close to home for a colleague whose father developed an indolent plantar ulcer which failed to respond to treatment and was diagnosed by the treating podiatrist as neuropathic.

Subsequent tests revealed that the patient was an unrecognised type 1 diabetic and that the rapid diagnosis and resultant treatment was indeed timely.

‘Clinical Medicine’ Vol. 11.2 features a paper by Griffths et al. on the implementation of an interprofessional patient record at Sheffield Teaching Hospitals Trust. Having established the process of creating the record in accordance with national standards the plan was implemented after appropriate staff training. Key results included 96% compliance with a single record, 99% compliance with maintaining the record in chronological order, 99% compliance of entry by all staff and 95% compliance of undue repetition. The point is made that the written interprofessional record is a vital step towards the forthcoming electronic patient record.

A concern of the electronic medical record (EMR) is that privacy might be compromised. However, on a more positive note, New Scientist 30th April notes that Dr. Abel Kho and colleagues of North Western University Chicago have designed a computer programme to analyse EMRs. The information gained from identifying patients with specific disorders at a rate of 73% to 98% accuracy could replace the time consuming methods currently used to recruit suitable patients to research studies.

In Bauerfeind Life magazine 2010/2011, Prof. Dr. Markus Walther, deputy Medical Director and senior consultant at the Centre for Foot and Ankle Surgery in MunichHarlaching discussed the effects of foot misalignment. In answer to questions, he stated that the most common foot misalignment was bunions. Women were six to ten times more likely to be affected than men. He felt that shin splints and knee problems could be attributed to foot misalignment and that suitably designed orthoses could be used to correct these problems.

On the subject of hallux valgus, the well-known podiatrist Hylton Menz from La Trobe University, Melbourne has been taking part in a co-operative study with researchers at the Arthritis U.K. Primary Care Centre at Keele University.

Assistive Technologies Issue 78 April/May reports on the study which involved 2,831 people aged 56 years or older, of whom 36% suffered from hallux valgus with female > male ratio and older > younger ratio. Dr. Menz was quoted as saying “Our findings indicate that hallux valgus is a significant and disabling condition that affects overall quality of life. Interventions to correct or slow the progression of the deformity offer patients beneficial outcomes beyond merely localised pain relief.”

The same journal reports on the research carried out by Dr. Jacky Finch at Salford University Gait Laboratory on two artificial toes dating from before 600BC. The question approached was did the artificial Egyptian toes represent true prostheses, or were they simply applied after death as a part of the mummification ritual? Two volunteers who had lost their right hallux were recruited to wear precise replicas of the original prostheses – one found in the Cairo museum, the other the “Greville Chester” toe in the British Museum - in replicas of Egyptian sandals. One of the volunteers was able to walk well in both artificial toes, and although no significant pressure elevation was noted, both volunteers said that they found the hinged Cairo toe particularly comfortable. The findings strongly suggest that the toes were capable of functioning as replacements for the lost toe, hence they are true prostheses, and the credit should therefore, as Dr. Finch puts it, “be laid firmly at the feet of the Egyptians.”

Power and Hopyian present an article “Exposing the evidence gap for complementary and alternative medicine to be integrated into science based medicine” in the Journal of the Royal Society of Medicine Vol. 104 No. 4. The paper deals with why calls for more clinical trials which have already demonstrated no benefit in the claimed treatment are invalid, why focusing on ‘packages of care’ does not negate the evidence gained from RCTs of a given treatment and why examination of ‘non-specific effects’ does not accurately reflect true placebo effects. Reading the article in its entirety would benefit those practitioners who have patients who believe in ‘complementary medicine’ and who wish to understand precisely why blinded RCTs are the best method available for examining the validity of methods of treatment. The final paragraph in the article is telling: “At this time of a drive for efficiency savings in the health services, it is especially important that expenditure should be directed to effective interventions and not be wasted on ineffective ones.”

New Scientist 7th May notes that nearly 20,000 Americans a year are hospitalised for accidental overdose of paracetamol. The problem is seen as consumer ‘comfort’ with ‘over the counter’ painkillers such that potential toxicity goes unrecognised. It is suggested that a red stop sign indicating maximum dose and a warning concerning liver damage should be applied to all containers of acetaminophen.

Achilles Hele

Diabetes UK project encourages people to improve NHS care

D

iabetes UK is helping involve people in improving their diabetes care, through a recentlycompleted two-year project, which has led to a permanent online resource for healthcare professionals.

The scheme, ‘User Involvement in Local Diabetes Care’, worked with three NHS organisations to involve people with diabetes in improving their care. Each group was made up of around 25 local people living with diabetes.

The project was funded by NHS Diabetes.

What has the scheme achieved?

In Hammersmith and Fulham The user group increased awareness of patient education in the service redesign process, produced a Diabetes Personal Care Charter and launched a mentoring programme.

In Lincolnshire The user group produced a leaflet for newly diagnosed people about what to expect from diabetes services, reviewed diabetes information on the local NHS website and produced a regular newsletter about diabetes.

In North Mersey The user group worked with a social marketing team to improve attendance rates for retinal screening, developed guidelines on home blood glucose monitoring, gave advice to paramedics and changed the advice given to patients by ambulance crews. They also looked at how

NHS savings could be made by addressing overprescribing medication for people with diabetes.

What next?

The three groups that took part in the ‘User Involvement in Local Diabetes Care’ project show that it is possible to involve people with diabetes in the care they receive.

Online resource for healthcare professionals Diabetes UK has now developed practical advice and tools for healthcare professionals to follow so that they can involve patients in diabetes care.

This resource is the Making Involvement Happen website, which was shaped by what has been learned from the project.

Involving patients more important than ever “Patients are the greatest untapped resource and if there is any time we need to involve them, it is now!" said David Jones, Diabetes UK User Involvement Manager.

“Tackling the NHS future funding challenge - to create better services and better value for patients, the NHS and the taxpayer - will only be achieved, and publicly supported, if all roads to its delivery are travelled in partnership with patients who use the services.

“The emphasis on involving users is more important than ever, with the planned changes to commissioning structures outlined in the Health and Social Care Bill 2011.”

Call for Clearer Food Labelling

D

iabetes UK, along with the British Heart Foundation, Children’s Food Campaign and Which?, has written to Secretary of State for Health Andrew Lansley calling for clear and easy-tounderstand food labels to allow people to tell quickly and easily what’s in the food they’re buying.

The organisations have come together, ahead of an EU vote on 5 July, to urge that UK representatives call strongly for mandatory front-of-pack (FOP) labelling which includes information on energy, fat, saturated fat, sugar and salt.

Being overweight or obese is a major risk factor for Type 2 diabetes and cardiovascular disease, as well as increasing the risk of developing several cancers.

Unhealthy diets can lead to poor diabetes management and subsequently increase the risk of developing serious complications, including heart disease, stroke, blindness, kidney disease and amputation.

Stella Valerkou, Diabetes UK Senior Policy Officer, said, “Nutrition labelling helps people to understand the nutritional content of the food they are buying, and can empower them to make healthier food choices, helping to prevent Type 2 diabetes, heart disease and cancer.

Independent research shows that consumers value information about these nutrients on the front of the pack, and information about all five is already displayed widely in the UK. Clear mandatory FOP food labelling is an important part of creating an environment which helps make healthy choices, easy choices.”

Clinical guidelines for the recognition of melanoma of the foot and nail unit Part Two Ivan R Bristow1 David AR de Berker2, Katharine M Acland3, Richard J Turner4 and Jonathan Bowling4 1 School of Health Sciences, University of Southampton, SO17 1BJ, UK 2 Bristol Dermatology Centre, Bristol Royal Infirmary, Bristol, BS2 8HW, UK 3 St. Johns Institute of Dermatology, St. Thomas’ Hospital, London, SE1 7EH, UK 4 Department of Dermatology, Oxford Radcliffe Hospital, Oxford, OX3 7LJ, UK `Differential diagnosis: Melanoma or haematoma?

The most common clinical presentation to cause uncertainty is subungual bleeding. The history can be of great value. A subungual bleed will normally have arisen within a day or two and may be associated with an episode of trauma, or more commonly, a period of vigorous activity or sport where no trauma is recollected. Having been noted, it will not change greatly, although the clinician will note a distal drift with time if they review over a period of several months [30] (Figure 4). Associated with this drift a small transverse groove will often emerge from beneath the nail fold about 2 months after the cause of the bleed.

This represents a step disturbance of nail plate production, precipitated by the same episode that caused the bleed, but emerging later as it requires the nail to grow by the length of the proximal nail fold before the sign is manifest. Clinical photography is of great value in documenting the exact form and dimensions of pigmented marks within the nail unit. It is best done at the outset, where change over 3 months can provide very useful clues. A source of pigment that clears proximally as it progresses distally will almost always be subungual blood.

Longitudinal melanonychia reflects melanin pigment created during nail plate generation incorporated within the nail plate as it is formed by the matrix (Figure 5). Subungual bleeding (or subungual haematoma) represents blood beneath the nail, which in some instances may be trapped within pockets of nail plate and be carried with it as the nail grows. Both longitudinal melanonychia and subungual bleeding have a range of benign and malignant causes (see Table 4). Clinically they can be distinguished on a series of points (Table 5), where some of these points can be clarified with dermoscopy. The dermatoscope is a hand held instrument that combines a x10 lens with an internal light source. It can be held directly against the nail plate and periungual skin to examine pigment and other characteristics [31]. When used in combination with clear jelly, a continuous medium is established between the light source and the reflective pigments of the nail plate by avoiding an air interface. This greatly improves the amount of information available to enable the clinician to analyse the source of pigment [32]. There are occasions when a malignancy beneath the nail will bleed such that the presence of blood does not rule out malignancy and associated features need to be considered [30,31].

One of the biological rules of the nail unit is that functioning melanocytes are limited to the matrix and nail folds, but not found in the nail bed. This means that if pigment change occurs within a structurally normal nail or nail bed, with no continuity with the nail folds or matrix, then it is not likely to be melanocytic and hence cannot be a melanoma. This leads to 2 simple rules:

1. Pigment arising solely within the nail bed with normal matrix and nail folds is not likely to be a melanoma 2. Where melanoma involves the nail bed, there will be a history of the disease starting in the nail matrix or nail fold.

The shape of the outline of the pigmentation is also a useful clue.

Blood may present as small irregular pools within the nail bed, with adjacent puddles or drops of purplish brown discolouration.

By contrast, longitudinal melanonychia arises as a well organised band of similar width throughout the longitudinal axis, arising in the matrix and extending to the distal edge.

An anecdotal clinical observation is that traumatic causes of subungual bleeding are associated with a proximal white transverse band in many instances [33]. This is more common for trauma to digits of the hand than the foot. The band is likely to represent a physical disturbance to nail production associated with the episode of trauma which in turn will make the nail less translucent for a brief zone. This white band is not seen in melanocytic causes of nail discolouration.

What is the likely cause of the longitudinal melanonychia?

The longitudinal melanonychia most likely to represent malignancy is that arising as a solitary pigmented streak in a white person with fair colouring and of middle age or older. In a dark skinned person, benign nail pigmentation becomes increasingly common with age and is typically found in varying degrees of intensity on several digits. In all instances, there needs to be careful evaluation to determine the cause of the pigmentation [30,34]. If no satisfactory benign explanation can be found, then they should be reviewed by a Dermatologist to consider the need for biopsy. The most common causes are drugs, trauma, fungal infection (Figure 6) and inflammatory diseases such as lichen planus which may be manifest elsewhere on the skin. Both squamous cell carcinoma and melanoma would be considered

Figure 4. Subungual Haematoma. Demonstration of haematoma by clear nail growth proximally

during assessment. In rare instances, the pigment is exogenous, such as that produced by potassium permanganate. This can be demonstrated by scraping the surface of the nail. Where there is onycholysis, the same may apply to the undersurface of the nail.

This is particularly the case where there is colonisation by pseudomonas which can lend a green to black appearance.

Other details for consideration include the pattern of the pigment within the longitudinal streak and whether there is any spread of the pigment onto adjacent skin. Dermoscopy is helpful in both instances and where the pigment is heterogeneous in both the longitudinal and transverse axes (Figure 7), the likelihood of melanoma is greater [31]. Detection of pigment on the nail folds or digit pulp can also be easier with dermoscopy. Where present, it is referred to as Hutchinson's sign after the surgeon of that name noted it in the early historic accounts of subungual melanoma and referred to it as a "melanotic whitlow" conferring a poor prognosis. It is to be distinguished from the "pseudo-Hutchinsons sign" which is the appearance of periungual pigment leant by the melanin within the nail being visible through the translucent edges of the proximal nail fold as it dwindles to a cuticle [35].

Evolution of the pigmentation is diagnostically useful, but not reliable as a means of ensuring that the source of pigment is benign. Whereas blood may be distinguished from melanin over

Figure 5. A single nail exhibiting both longitudinal melanonychia and haematoma. A: Longitudinal melanonychia arising in the nail matrix from the melanocytes. B: Subungual haematoma limited to the nail bed with poorly defined rounded borders.

a period of a few months, the characterisation of a benign or malignant source of melanin is less easy. Pigment that does not change is not necessarily benign, however the longitudinal melanonychia that increases in width or variety of pigment is more likely to represent malignancy than one that is static. One exception to this is longitudinal melanonychia in children where the pigment arises in a subungual naevus which changes as the child matures [34]. Quite dramatic nail pigmentation can evolve quickly from a benign lesion and biopsy would rarely be undertaken in this group. A further exception is the evolution of a pigmented streak that comes to be associated with other pigmented streaks on other nails of the hands and feet. This indicates a systemic process and is common in dark skinned races, those taking certain drugs and in a condition termed Laugier Hunziker syndrome. Laugier Hunziker syndrome is increased patchy pigmentation of mucosae of the mouth and/or genitals, associated with multiple homogenous pigmented longitudinal bands in the nails. It is common for this problem to present with one nail in the first instance and hence the value in making a proper examination of all nails and other areas as appropriate [36].

Multiple pigmented bands in dark skinned people may also initially be noted in one nail alone, but are soon detected in others.

The abnormal nail plate associated with pigment

A nail plate that is structurally altered presents a different scenario. Where there is a longitudinal melanonychia associated with loss of nail integrity this raises concern and needs immediate assessment. In other instances, the pigment may be broken up or scattered within a creamy yellow nail plate. Where there is no preceding history of longitudinal melanonychia, this may represent a pigmented onychomycosis with damage to the nail plate. This can be difficult to assess. Unlike melanocytic pigment which starts in the matrix, the pattern of onychomycosis usually extends from the distal free edge with proximal progression. Early reassurance can be given if the pigmented change and dystrophic nail can all be trimmed away with no disturbance of surrounding skin and there is no sign of a more proximal origin to the pathology. Suspicion of fungus should always be explored by mycological assessment and in particular culture. There is a wide variety of potential organisms [37,38]. Some of the pigmented fungi are non-dermatophytes and may represent a therapeutic challenge likely to be surmounted only if the pathogen is known.

Table 4 Causes of melanonychia compared with those of subungual bleeding Melanonychia

Subungual bleeding

Benign racial melanonychia

Direct trauma

Laugier Hunziker

Indirect microtrauma-end on repetitive trauma

Inflammation

Haemorrhagic tendency lowering threshold for effects of trauma. e.g.

• Lichen planus

• warfarin

• Chronic paronychia

• leukaemic

• Trauma/friction

• thrombocytopaenia

• Radiation Medication e.g.

Subungual tumour

• Minocycline

• squamous cell carcinoma

• Chemotherapy

• wart

• HIV disease or medication

• exostosis • melanoma • pyogenic granuloma

Addison’s disease Peutz Jegher Subungual naevus Benign melanocyte activation Melanoma Bowen’s disease (in situ squamous cell carcinoma) Onychomycosis

Levit has used a modification of the ABCD rule developed for detection of suspicious pigmented lesions on the skin and applied it to the nail unit [39]. First is A for Age, in the 5th to 7th decade of life. B stands for a Band (longitudinal streak) that is brown or black and measures 3 mm or more. C stands for Change in the nail band or lack change in the nail morphology in spite of presumed adequate treatment. D stands for the Digit most commonly involved, which for the foot would be the big toe. E stands for Extension of the pigment onto the adjacent skin or nail fold, known also as Hutchinson's sign and F stands for Family history of melanoma or dysplastic naevus. All these points are reasonable and may guide the practitioner to seek advice (Table 6). They may in turn help the dermatologist when deciding to do a biopsy, although all the other points raised in the preceding text would be considered in taking this step. However, a final diagnosis of melanoma will depend on the histology.

Amelanotic tumour of the nail unit

Amelanotic melanoma arises in the nail unit as it is does at other acral locations, at a rate higher than other body sites. The lack of overt pigment appears to delay the diagnosis further, which in turn affects prognosis [25]. There may sometimes be small pigmented tints to an otherwise pink or granulomatous mass [31].

The differential diagnosis of amelanotic melanoma is considered for all pyogenic granuloma, which is a common benign diagnosis presenting as a vascular nodule. Pyogenic granuloma is usually found on the fingers or toes, bleeds easily and does not readily remit. In Dermatological practice, a pyogenic granuloma would normally be surgically removed. This provides histology to ensure that it was not a melanoma at the same time as resolving the clinical complaint. In biological terms, pyogenic granuloma has much in common with the granulation tissue of ingrowing toenail. Amelanotic melanoma presenting as a granulating mass of the nail fold can be interpreted as an ingrowing nail. This is a well recognised pitfall in podiatry and a potential cause of delayed diagnosis which compromises prognosis [40-43]. Where practice entails cauterising or simply dressing fleshy granulomatous masses of the extremities there is a significant risk of leaving a malignancy undiagnosed. In the authors' experience patients with advanced amelanotic melanoma of the hand or foot often say "they treated it with dressings for the last X months and it just wouldn't heal". Although this article is examining presentation and diagnosis of acral melanoma, squamous cell carcinoma can also present this way and hence the value in asking for histological assessment of any lesion that does not resolve in 2 months, but which oozes or bleeds or has no clear diagnosis.

Concern is greatest when the tumour causes disturbance of nail

Figure 6. Fungal infection of the nail caused by Fusarium sp. Causing a longitudinal melanonychia

integrity as it arises in the nail matrix and destroys the specialised nail matrix epithelium such that it can not produce nail.

In conclusion, NUM is best detected early if all clinicians and patients have a low threshold for asking for advice early. In particular this means avoiding prolonged periods of conservative management of change in the nail or periungual tissues that are limited to one digit and do not respond promptly to appropriate treatment. For less advanced lesions, where there is only altered pigment, if such pigmentation is limited to a single digit and cannot confidently be attributed to a single episode of subungual bleeding then expert advice should be sought. In all instances, although general practitioners are a good source of general assessment, they typically do not have any experience of NUM. We would recommend assessment by a Dermatologist.

Referral

If a melanoma is suspected, the normal route for referral would be to a general practitioner. Occasionally, direct referral to the dermatology department may be possible, but local policies will dictate this. Under current NICE guidelines in the UK, patients with suspected melanoma should be seen by a specialist within two weeks of presentation. As a diagnosis of melanoma is relatively uncommon and can only be made after a full professional assessment and biopsy, practitioners should be cautious and not speculative when giving any advice to the patient about potential diagnoses to prevent any unnecessary alarm and concern. A point to emphasise to all patients is that it is important to know the diagnosis of what is being treated. If that diagnosis

Table 5 Features of longitudinal melanonychia compared with those of subungual bleeding-all features are generally true, but there can be individual exceptions Melanoncyhia

Subungual bleeding

The duration of history is from 3-6 months upwards to 20 years or more.

The duration of history is rarely more than 6 months and is typically shorter.

A history of trauma is quite common.

A history of trauma or precipitating activity is quite common Lateral margins may be irregular.

Lateral margins within the nail are mainly straight and longitudinally oriented.

Pigment rarely extends from beneath the nail plate.

Where margins merges with the nail fold, pigment may spread onto nail fold (Hutchinson’s sign).

There may be a proximal transverse groove and/or transverse white mark within the nail.

There are rarely any detectable transverse features

Haemorrhage may be broken up into a number of zones.

In the absence of clinical tumour, nail plate pigmentation is in continuity with a single zone.

Dermoscopy reveals

Dermoscopy reveals • continuous pigment between proximal nail fold and distal free edge • in the transverse axis, pigment may vary„whereas in the longitudinal axis it remains largely constant • There may be longitudinal flecks of darker pigment within the background pigment of the nail • Pigment is mainly brown black

• Pigment may not be continuous in the longitudinal axis, with clear nail at either the proximal or distal margin.

• Pigment may vary in any axis.

• Droplets of blood may be seen separated from the main zone of pigmentation.

• Blood may be seen as a discrete layer of material on the lower aspect of the nail plate at the free margin.

• Pigment may be purple black, with increasing red hues at margins. It is rarely brown.

Figure 7. Dermoscopy of the nail plate demonstrating heterogenous streaks in the longitudinal and horizontal axes Table 6 The ABCDE of nail melanoma after Levit [39] A Age Range 20-90, peak 5th - 7th decades.

Band (nail band): Pigment (brown-black). Breadth > 3 mm.

Border (irregular/blurred).

C Change: rapid increase in size/growth rate of nail band. Lack of change: failure of nail dystrophy to improve despite adequate treatment.

D Digit Involved: Thumb > hallux > index finger > single digit > multiple digits.

E Extension: Extension of pigment to involve proximal or lateral nail fold (hutchinson’s sign) or free edge of nail plate.

F Family or personal history: Of previous melanoma or dysplastic nevus

is not clear, or becomes unclear due to unusual clinical response to development, then both patient and the practitioner need the benefit of a clear diagnosis.

Summary points • Melanoma can occur on any part of the foot, including the nail unit, in all ethnic groups and skin types.

• Early recognition and diagnosis can significantly improve prognosis.

• Melanoma of the foot is frequently misdiagnosed, especially when lesions are amelanotic or arise within the nail unit.

• The use of the “ABCDE” and “CUBED” acronyms may improve practitioner's assessment of unusual lesions.

• Any skin or nail lesion arising on the foot with an unclear diagnosis, which deteriorates or fails to heal within two months despite treatment or exhibits unusual features should be reassessed, and referred if considered appropriate.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-inChief of this Journal of Foot and Ankle Research.

Competing interests

The authors declare that they have no competing interests

Authors’ contributions

The paper was initially drafted by IB and DB. RT, KA and JB reviewed the manuscript and made suggested amendments. All authors provided images and read and approved the final manuscript.

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17. Hamidi R, Cockburn MG, Peng DH: Prevalence and predictors of skin selfexamination: prospects for melanoma prevention and early detection. Int J Dermatol 2008, 47:993-1003.

18. Buttner P, Garbe C, Bertz J, Burg G, D’Hoedt B, Drepper H, Guggenmoos-Holzmann I, Lechner W, Lippold A, Orfanos CE, et al: Primary cutaneous melanoma. Optimized cutoff points of tumor thickness and importance of clark’s level for prognostic classification. Cancer 1995, 75:2499-2506.

19. Malignant Melanoma. [http://www.aad.org/public/publications/pamphlets/sun_malignant.html].

20. Strayer S: Diagnosing skin malignancy: Assessment of predictive clinicalcriteria and risk factors. J Fam Pract 2003, 52:210-218.

21. Albreski D, Sloan SB: Melanoma of the feet: misdiagnosed and misunderstood. Clin Dermatol 2009, 27:556-563.

22. Bristow I, Acland K: Acral lentiginous melanoma of the foot: a review of 27 cases. J Foot Ankle Res 2008, 1:11.

23. Metzger S, Ellwanger U, Stroebel W, Schiebel U, Rassner G, Fierlbeck G: Extent and consequences of physician delay in the diagnosis of acral melanoma. Melanoma Res 1998, 8:181-186.

24. Bennett DR, Wasson D, MacArthur JD, McMillen MA: The effect of misdiagnosis and delay in diagnosis on clinical outcome in melanomas of the foot. J Am Coll Surg 1994, 179:279-284.

25. Soon SL, Solomon AR Jr, Papadopoulos D, Murray DR, McAlpine B, Washington CV: Acral lentiginous melanoma mimicking benign disease: the Emory experience. J Am Acad Dermatol 2003, 48:183-188.

26. De Giorgi V, Sestini S, Massi D, Panelos J, Papi F, Dini M, Lotti T: Subungual melanoma: a particularly invasive “onychomycosis”. J Am Geriatr Soc 2007, 55:2094-2096.

27. Saida T, Miyazaki A, Oguchi S, Ishihara Y, Yamazaki Y, Murase S, Yoshikawa S, Tsuchida T, Kawabata Y, Tamaki K: Significance of dermoscopic patterns in detecting malignant melanoma on acral volar skin: results of a multicenter study in Japan. Arch Dermatol 2004, 140:1233-1238.

28. Bristow IR, Bowling J: Dermoscopy as a technique for the early identification of foot melanoma: a review. J Foot Ankle Res 2009, 2.

29. Banfield CC, Redburn JC, Dawber RP: The incidence and prognosis of nail apparatus melanoma. A retrospective study of 105 patients in four English regions. Br J Dermatol 1998, 139:276-279.

30. Braun RP, Baran R, Le Gal FA, Dalle S, Ronger S, Pandolfi R, Gaide O, French LE, Laugier P, Saurat JH, et al: Diagnosis and management of nail pigmentations. J Am Acad Dermatol 2007, 56:835-847.

31. Phan A, Dalle S, Touzet S, Ronger-Savlé S, Balme B, Thomas L: Dermoscopic features of acral lentiginous melanoma in a large series of 110 cases in a white population. Br J Dermatol 2010, 162:765-771.

32. Gewirtzman AJ, Saurat JH, Braun RP: An evaluation of dermoscopy fluids and application techniques. Br J Dermatol 2003, 149:59-63.

33. Bowling J, McIntosh S, Agnew K: Transverse leukonychia of the fingernail following proximal nail fold trauma. Clin Exp Dermatol 2004, 29:96-96.

34. Tosti A, Piraccini BM, de Farias DC: Dealing with melanonychia. Semin Cutan Med Surg 2009, 28:49-54.

35. Baran R, Kechijian P: Hutchinson’s sign: a reappraisal. J Am Acad Dermatol 1996, 34:87-90.

36. Sterling GB, Libow LF, Grossman ME: Pigmented nail streaks may indicate Laugier-Hunziker syndrome. Cutis 1988, 42:325-326.

37. Parlak AH, Goksugur N, Karabay O: A case of melanonychia due to Candida albicans. Clin Exp Dermatol 2006, 31:398-400.

38. Perrin C, Baran R: Longitudinal melanonychia caused by trichophyton rubrum.

Histochemical and ultrastructural study of two cases. J Am Acad Dermatol 1994, 31:311-316.

39. Levit EK, Kagen MH, Scher RK, Grossman M, Altman E: The ABC rule for clinical detection of subungual melanoma. J Am Acad Dermatol 2000, 42:269-274.

40. Cahill S, Cryer JR, Otter SJ, Ramesar K: An amelanotic malignant melanoma masquerading as hypergranulation tissue. Foot Ankle Surg 2009, 15:158-160.

41. Gosselink CP, Sindone JL, Meadows BJ, Mohammadi A, Rosa M: Amelanotic subungual melanoma: a case report. J Foot Ankle Surg 2009, 48:220-224.

42. Lemont H, Brady J: Amelanotic Melanoma Masquerading as an Ingrown Toenail. J Am Podiatr Med Assoc 2002, 92:306-307.

43. Winslet M, Tejan J: Subungual amelanotic melanoma: a diagnostic pitfall. Postgrad Med J 1990, 66:200-202.

44. Green A, McCredie M, Giles G, Jackman L: Occurrence of melanomas on the upper and lower limbs in eastern Australia. Melanoma Res 1996, 6:387-394.

7

All About Dementia Patricia Pope, Dementia Specialist Memory The hippocampus of the brain sorts and stores memory in 3 different areas, all three memory banks are unique and specific to certain tasks. Let us look at the three different types of memory: Procedural Located in the dorsolateral striatum , this memory bank is active from age 3-4 months. Often referred to as “subconscious” memory, the abilities located here are automatic to us, once learned. l

Routine tasks.

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Facial recognition.

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Gestures or body language.

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Visual recognition.

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Musical skills.

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Sounds.

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Facial expressions.

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Social skills.

Episodic In the neocortex is our memory that “records” our life story. Active from around age 4 years, this memory stores emotional events that happen to us. We can replay the events at will. Emotion is attached to the memory and will come out with the story. l

Events/experiences.

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Likes/dislikes.

Semantic Finally in the para-hippocampal cortices is our intellectual memory. l

Vocabulary.

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Mathematical ability.

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Reasoning.

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Languages.

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Comprehension.

Remember… it is very rare to lose all three memory banks, ascertain the one that is lost and communicate with the remaining memories!

Causes of Dementia Alzheimer’s Disease An organic brain disease with no known cause or treatment, strikes indiscriminately in all ages, races and educational levels. First area affected is Semantic memory so intellectual skills, such as comprehension, reasoning and vocabulary are lost.

Other key factors: l

Reality shift, 14 – 24 years of age. The person believes they are in this age range, and the rest of their life has not occurred. They want to see the people that were important to them at this time, be in the home they lived in at this time, wear the clothing they wore then, do the things they did then. Priorities will shift to those they held during this time.

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Visual interpretation deficit. Cannot see white objects on or in a field of white. Black appears to be a hole. Pattern does not belong to the objects but is something to be picked up. Shine is always water, so high gloss surfaces do not work well. Shadows are threatening. Mirrors make rooms look larger or more confusing.

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Lack of recognition of hunger and thirst.

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Hallucinations.

Dementia with Lewy Bodies Abnormal protein deposits in the brain disrupt normal brain function. Same root cause as Parkinson’s Disease, but in Parkinson’s the damage is localized to the area of the brain associated with movement and coordination, in DLB the damage is in the entire brain. l Sleep disturbance. The person with DLB cannot enter deep sleep, but rather stays in the dreaming phase. This causes sleep disturbances and waking patterns in the night. Staff must chart the individual’s pattern and design all cares, medication and nutrition/hydration, around that pattern. The person will have noticeable peaks and troughs through out a 24 hour period. Allow this to occur naturally and work around it. Periods of lucidity. Fluctuation in cognition is distinctive to DLB. The person will have lucid times. Again, there will be a pattern. Chart the pattern and adapt care. Some research says hydration is linked to this symptom, with the brain functioning better the more hydrated it is. l Parkinsonian symptoms. Within 12 – 18 months, following the dementia onset, the person with DLB starts to have the symptoms of Parkinson’s. l Hallucinations. More bizarre than in Alzheimer’s. l Sensitive to neuroleptics. Haldol, Stelazine, Clopixal, all should be avoided.

Pick’s Disease Caused by a build up of the abnormal protein called tau, this disease strikes in the frontal lobe of the brain, affecting personality.

Usually Pick’s is an early onset dementia, 40 % is hereditary linked to Chromosome 17. l Inappropriate remarks. No loss in vocabulary. l Sugar obsession. l Lack of impulse control. l Obsessions and compulsions. l Aggression. l Sexual fixation. l Retain math skills.

Wernicke-Korsakoff Syndrome Caused by a deficiency of vitamin B1, or thiamine, the brain does not receive enough glucose and therefore energy to function. Wernicke is the earlier stage of the disease, which left untreated, will result in Korsakoff’s Psychosis. The most common underlying cause is alcoholism, as the diet suffers and lack of B1 is a result. May also be associated with malnutrition, famine and chronic eating disorders. l Confabulation. l Leaning gait when walking l Telescoping events. l Rapid eye movement. l Unable to form new memories. l Hallucinations.

Vascular Dementia Caused by a disruption in blood supply to the brain, which in turn causes death of brain tissue. There are many causes of Vascular Dementia, CVA and Multi infarct, being the two most common, however Binsanger Disease is thought to be more prevalent than previously recognised. l Depression l Physical symptoms of a stroke. l Lack of emotional stability. l A marked stepped deterioration in cognitive function. l Loss of tasks from procedural memory.

Person Centred Care in Dementia - Check List

What do they want to do?

Which memory has been lost?

How can I give that reality to them?

Which form of dementia is present?

What form of communication do I use?

Where is the service user’s reality?

How can I provide the least restrictive care?

Who do they think I am?

What props can I use to divert?

Where do they think they are?

What environmental clues can I give to lessen fear?

Take off the white coat, know the person, enter their reality, use every day objects to promote understanding and compliance.

Still recommending... tins of beans, water Introducing the bottles?

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Chairman’s Address This is my first written address since you, the membership, honoured me by electing me to be your new Chairman; a position which I shall carry out with all my energy and to the best of my ability. I pledge myself to continuing the process of change begun by Heather Bailey, our President, and my predecessor, Robert Beattie. I am fortunate in having a superb team of vigorous National Officers and Area Council Executive Delegates who are also very active in supporting the Institute.

It is important for me to point out that nothing can be done, or is done on behalf of the membership without the consent of the entire Executive Committee, who then share collective responsibility. It might be of interest to detail exactly how decisions are made on your behalf, and how those decisions are put into action. The strategy of the Institute is discussed within the Executive Committee and frequently tactics are touched on. Very often ideas are developed through contact outside the formal meetings during breaks and dinner when more relaxed brain storming sessions take place. Each National Officer, elected by the membership selects their subcommittee members from within the Executive Committee - the President and Chairman being ex officio members of all subcommittees. If certain individuals from amongst the membership have particular skills then they may be co-opted to subcommittees. This is particularly relevant to the Board of Education for example, where our university lecturers have an important role. The Chair - and Vice Chair if relevant - of the subcommittee then develop written plans, tactics and systems for application within their own area of responsibility. Having been agreed by their subcommittee members they are then put to the Executive Committee as a whole. As might be expected, there is much debate both within the subcommittees and the Executive Committee before planning is accepted and passes into action. Plans having been agreed by the Executive Committee, the subcommittees are then empowered to develop the plans and put them into place with the assistance of the staff at Southport, whose experience and support is invaluable. A progress report is provided at the next Executive Committee meeting which takes place after 3 months, and fine tuning can be carried out and reported accordingly. During the whole of this process, the opinions of the membership are sought formally via the Area Council Delegates and informally through contact at the various branches and conferences that take place up and down the countries in which the membership reside.

Planning for the future includes vigorous promotion of both the Institute as a professional body, and you, the member, as the first stop when any matter pertaining to the feet is concerned. If any member has experience of the media, they are invited to play a role. Membership numbers will continue to be expanded through our own Associate courses and from students at the existing schools as well as attracting members through our excellent insurance and other facilities. New ‘hands-on’ courses are planned by the Board of Education. Have you ever asked yourself “Why am I a podiatrist?” There are many answers to this question;

how-ever, I suspect that amongst the most popular are the desire to serve in a caring profession, the desire to enjoy a certain respect in society, an interesting way of life and finally a desire to earn a reasonable income. All these elements of being a professional can be enhanced by an increase in scope of practice and I urge you to attend the relevant courses since expansion of practice and additional techniques are the way to ensure your future and that of the profession. Despite the general gloom concerning national cut backs, now is a very good time indeed to be a podiatrist and a better time to be a member of the Institute.

The web site will be expanded and will carry CPD programmes which can be carried out at any time to suit you.

Advice on practice and minimum standards is also carried on the web site, and the members’ only discussion forum is available for questions, answers and comments. As far as possible all elements of the Institute will become either selffunding or financially neutral so that the fiscal future of the Institute can be secured and reserves built up for the future.

The next conference in Liverpool will revert to the previous date format as requested by you the members, and even at this early stage it promises to be even better than recent A.G.M.s with interesting and relevant CPD. The staff at Southport and our new Vice-Chairman are working hard to ensure that no member will be unable to attend for purely financial reasons, so please book the dates in your 2012 diaries now. I have always been impressed by the democratic structure of the Institute, which is unique amongst the bodies representing the profession; add to this the systems in place to care for the needs of our members and associates across the entire service industry from Foot Care Professionals to podiatric surgeons and we see in the Institute, a truly inimitable body.

The overweening hubris of King Louis XIV of France which ultimately led to the French revolution and its accompanying Terror was encapsulated in his statement of ‘L’Estate C’est Moi’.

It is vitally important for the membership to be reassured that all of the National Officers are approachable and will respond to questions and suggestions either through the Area Council Delegates or directly. I will attempt over the next 12 months to visit as many branches as I am able but please do contact me if you wish to do so. The natural democracy of the Institute determines that no one individual, be they a National Officer, nor any group of individuals, be they a sub-committee or be they the Executive itself are the Institute. The Institute is its Associates, Members and Fellows; indeed,’ L’Estate C’est Vous’.

W. J. Liggins Chairman Institute of Chiropodists and Podiatrists

11

President’s Address May, 2011 Dear Fellows, Delegates and Members, It is my pleasure to wish you a very warm welcome to the 56th Annual General Meeting of the Institute of Chiropodists and Podiatrists here in Windsor.

Within weeks of last year’s A.G.M. the National Officers, Executive committee members and Secretariat took part in business planning workshops which continued throughout the summer and autumn. Those who took part benefited personally and more importantly the Institute gained significantly.

New approaches to our business practices have been set up, with clearer accounting methods proving to be the asset we had expected to help plan the future of the Institute and, in my opinion, this should have been done a number of years ago.

Our business practices must continue to develop, we cannot rest on our laurels, and time must be set aside for business planning. By using technology we will reduce wastage of our most valuable resource which is manpower and therefore money which can be put to better use elsewhere. The gap between where we were and where we should have been in our efficiency was wide and widening. This is now being addressed and we are working on other areas but still lag behind in the use of our web site which is undervalued and under used.

Dissemination of information to and from the membership should be via the web site rather than spending valuable secretarial time in photocopying and more in postage. The calendars are there to be used to display branch meetings and CPD activities; the Members 1

Forum is there to be used for discussion.

Please note that organisations without our democratic credentials do not allow open forums for their members on their web sites.

The revised Code of Ethics has joined the Minimum Standards of Clinical Practice on the open site and in the Members Area are a number of documents to help you in your practice the Articles of Association and Membership By-Laws are areas which still need bringing into the 21st century. The modernisation of these documents does not mean changing the ethos of the IOCP as by tradition we have always represented across the whole of the profession and this is perhaps more important today than ever before.

Following government reports it is clear that selfregulation by professional bodies, with the stature of the IOCP, confirms this is the way forward for protection of the public, where legislation is limited only to those who are HPC registered. The IOCP participates in meetings across all political areas which affect our profession.

Under the guidance of Robert Sullivan, the incoming Chair of the Board of Education, the Podiatry Review has taken a leap forwards to be peer reviewed, which is necessary for the educational output of any educational organisation which is seen from outside the membership.

The outgoing Board of Education has worked closely

over the past year with the incoming Chair and Vice Chair of Education in producing new practical training and CPD, the first in a series of CPD discs is now available and can be purchased at the IOCP stand here at the A.G.M. This training format will be developed further, providing high quality CPD at an affordable price for you to study at home.

I was delighted to accept invitations to attend Midland Area, North West Area and Southern Area Council seminars during the past twelve months and to meet members and listen to their views. My thanks go to those area officials who do so much to produce CPD on your behalf.

Following last June's successful outing, the IOCP stand will make another appearance at the Kettering Foot Health event run by Professional Events on June 21st and 22nd of this year to promote us to prospective members. Malcolm Holmes and I will be there, along with members who have volunteered their time to field enquiries. The IOCP will also be represented by Martin Harvey at the Primary Care event at the NEC, Birmingham on 25th and 26th of this month.

These and other promotional events take a huge amount of officers time so to help with this in the coming year we will be approaching members to attend events in their area.

My congratulations go to those who have completed their degree in Podiatric Medicine and Masters in Podiatric Surgery.

My thanks go to the Secretariat; Jill, Bernie, Julie and Sarah for their continued hard work and good humour while coping with the increased workload of the past year.

To the National Officers, Executive Committee and Coopted Members of the Executive Committee I give my most grateful thanks for the work they have done on our behalf during the past year.

I also thank John Patterson who now steps down - but not away too far -from the roles of Vice Chairman of the Board of Education and Lead Tutor at Sheffield.

Finally my most grateful thanks go to a man who has given me his support and encouragement to develop the role of President and his loyalty to the members of the Executive Committee, his care and compassion to the staff and Secretariat, Robert Beattie, as he steps down from the office of Chairman of the IOCP after nine years.

Heather Bailey

Dear Madam President, Executive and fellow members, I would like to take this opportunity to say thank you for your nominations and support. My first task and by far the easiest, is to pay tribute to my two predecessors, who in their own unique ways did Stirling jobs for the Institute; Roger Henry, who for many years worked tirelessly behind the scenes and travelled far and wide on our behalf and Stephen Gardiner who took over last year at a time of financial concern for not only the IOCP but the country as a whole and started to put into place various new strategy’s to take us forward.

I will re-iterate what I said in my resume; The country is still facing challenging times re the economic situation, so too is the IOCP and some unpopular decisions may have to be agreed upon, however I strongly believe if, as an organization, we all pull together, we can and will get through these uncertain times.

I look forward to serving the best interests of the members and the Institute now and for the long term future prospects.

Jacquie Drane, Honorary Treasurer 1

1

Peer Review Section

PEER REVIEW SECTION Robert Sullivan BSc (Hons), Dip.Pod.Med, PgC .L.A, PgD.Pod.Serg, FSSChP, FIChPA, MRSM, M.Inst.ChP.

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nother Annual General Meeting has come and gone, and the membership has appointed a new Board of Directors. Incoming are Mr. Bill Liggins as Chair of the Executive Committee, with Mr. Malcolm Holmes as Vice Chair. Mrs. Jacquie Drain is our new Honorary Treasurer, and Mr. Martin Harvey and I, take over the ViceChair and Chair of Education respectively. Mrs. Heather Bailey remains as Our President.

Your risk of getting skin cancer is real. The good news is that you can reduce your risk by following these simple skin cancer prevention tips to help you protect your family and yourself. l

Generously apply a broad-spectrum, water-resistant sunscreen with a Sun Protection Factor (SPF) of 30 or more to all exposed skin. “Broad-spectrum” provides protection from both ultraviolet A (UVA) and ultraviolet B (UVB) rays. Reapply approximately every two hours, even on cloudy days, and after swimming or sweating.

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Wear protective clothing, such as a long-sleeved shirt, pants, a wide-brimmed hat, and sunglasses, where possible.

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Seek shade when appropriate. Remember that the sun's rays are strongest between 10 a.m. and 4 p.m. If your shadow appears to be shorter than you are, seek shade.

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Use extra caution near water, snow, and sand because they reflect and intensify the damaging rays of the sun, which can increase your chances of sunburn.

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Get vitamin D safely through a healthy diet that may include vitamin supplements. Don't seek the sun.

The other article on Primus Metatarsus Supinatus, also called Rothbarts Foot, which is a mechanical problem and cause of musculoskeletal pain, presents a good, well informed, read.

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Avoid tanning beds. Ultraviolet light from the sun and tanning beds can cause skin cancer and wrinkling. If you want to look tan, consider using a self-tanning product, but continue to use sunscreen with it.

Both of these articles were submitted to our peer review panel that were positive about them. In relation t to the student article, the reviewers felt that this author shows promise and should be encouraged to continue writing and developing a literary presence.

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Check your birthday suit on yourHer birthday.

If you contribution notice anything changing, growing, or bleeding on your skin, see a dermatologist. Skin cancer is very treatable when caught early.

We aim, where possible, to attract good scholarship to our peer review section, and this issue sees the publication of one established writer and the entry of a new comer. Deirdre O’Flynn is a mature student soon to graduate from Queen Margaret University. We hope to see more new authors coming forward over the coming months, and bringing you their works. As Deirdre is the first of our student members to publish in our journal, I am hopeful her inclusion will inspire others to submit articles.

In this issue we have an article about waste in the manufacture of chairside orthosis. This article shows the steps necessary wishes to carry out an audit. The same If I can writeif one so can you.

It is formula can be applied to any audit. I hope that the inclusion of this article gives us all a little food for thought in these economically challenging times. Please note that this audit protocol is written by one of our student members who is in her final year at Queen Margaret University, Edinburgh.

We on the peer review

All that remains is to wish you all a happy summer and some advise from he Irishsaid:Cancer Research on safe fun in the This is what sun:-

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Enjoy the summer and be safe. Keep those articles coming!

Robert Sullivan,

Look out for some of these reviewed articles in Sub-Editor, Podiatry Review 1

“enjoy these articles, and

Peer Review Section

Primus Metatarsus Supinatus (Rothbarts Foot): A common cause of musculoskeletal pain Biomechanical vs Neurophysiological Model Brian A. Rothbart, DPM, PhD, DNM Abstract The talar bone (seated on top of the foots heel bone), goes through a series of growth changes that reshapes the contour of the forefoot. At approximately week five post ovulation, the talar head is untwisting around its longitudinal axis [1012]. If this torsional growth in the talar head ends prematurely, the 1st metatarsal, proximal phalanx and hallux (e.g.1st ray) remain in supinatus (structurally elevated and inverted). Postnatally, when standing; gravity pulls the elevated 1st ray downward to the ground. As the 1st ray collapses to the ground, the body shifts into a kyphotic posture. As a result, weight bearing joints become mal-aligned and postural muscles compensate by tightening. In time, these joint and muscle changes lead the patient into chronic, debilitating musculoskeletal pain, foot to jaw.

Introduction Postural distortions (poor posture) have been linked to chronic muscle and joint pain by many authors. However, the cause of the postural distortions is still highly debated with multifaceted etiologies being suggested [1-8].

Rothbart [9] described a previously unrecognized foot structure in which the 1st ray (first metatarsal, proximal phalanx and hallux) are structurally elevated and inverted. Rothbart terms this foot structure Primus Metatarsus Supinatus (PMS), now commonly called Rothbarts Foot, which he links to the development of a kyphotic posture.

This paper discusses: the embryogenesis of PMS, the series of postural shifts resulting from PMS, and the link between these postural shifts and chronic musculoskeletal pain.

Fig. 1

Talar Torsion Linked to Primus Metatarsus Supinatus Sewell [13] was the first to publish on the substantial variances in the torsion of the talar head. Straus [14] reported similar angular variances in this torsion, ranging from 26 degrees to 43 degrees, McPoil et al [15] from 24 degrees to 51 degrees, and Sarrafian [16] from 30 degrees to 65 degrees (see Figure 1). Tax [17] and Hlavac [18] proposed that talar torsion may determine the structural position of the Fig. 2 forefoot. Daniel [19], in an in vitro cadaver study, demonstrated that angular changes in the structure of the talar bone visibly changed the shape of the forefoot.

Rothbart suggests that if talar torsion is less than 35 degrees; this results in a planter grade foot. That is when the subtalar joint is placed in its anatomical neutral position, the entire forefoot rests on the ground. (See Figure 2).

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Rothbart also suggests that if the talar torsion is greater Fig. 3 than 35 degrees, when the subtalar joint is in its anatomical neutral position, the 1st metatarsal and hallux do not rest on the ground.

Instead, they are twisted inward and upward relative to the 2nd metatarsal. Rothbart terms this foot structure as Primus Metatarsus Supinatus (Rothbarts) Foot. (See Figure 3) PMS typically has a flexible inner longitudinal arch (higher when sitting, lower when standing). Gait analysis reveals a strong supinatory strike at heel contact (accounting for the lateral heel wear patterns) and abnormal pronatory rotation (inward and downward) at mid-stance. This unlocks the forefoot and allows the elevated 1st metatarsal and hallux (driven by gravity) to fall to the ground. Thus the elevated 1st metatarsal and hallux are not manifested when standing or walking.

Fig. 4

Fig. 5

This structural alteration becomes apparent when the foot is placed in its anatomical neutral position (subtalar joint congruity) (See Figure 4) and can be quantified using biovectors (calibrated wedges) underneath the feet.

Biovectors are used to quantify, in millimeters, the distance between the ground and the elevated 1st metatarsal head (See Figure 5).

Peer Review Section This distance is referred to as the Primus Metatarsus Supinatus value (PMSv). This measuring technique was found to have a high inter and intra rater reliability in a double blind study conducted at Georgia University [20].

Ascertaining the PMSv in infants under four years of age is difficult and prone to error due to the budding longitudinal fat pad and the late ossification of the navicular bone (typically around the age of four). However, as the longitudinal fat pad attenuates and the navicular bone ossifies, PMSv becomes as easy to accurately ascertain as taking a radial pulse. PMSv between 11mm and 24mm are pathognomonic of PMS and are frequently used in the differential diagnosis.

PMS and the Development of the Kyphotic Posture PMS is a common precursor to the development of the kyphotic posture. Two distinct models have been suggested that explain this link.

The BioMechanical Model In a strong gravitational field (i.e., mother earth), PMS forces the weight-bearing foot to roll inward, forward and downward (pronate) until the 1st metatarsal rests on the ground. It is theorized that this pattern of foot pronation shifts the bodys center of gravity forward and downward, which in turn, pulls the innominates forward and downward. This can unlevel Fig. 6 the pelvis and result in a functional leg length discrepancy [21]. As these displacements cascade up the axial framework, scoliotic and kyphotic curves increase and may become unstable. The thoracic cage twists and the shoulders protract [22].

Typically, the head is thrust forward, the maxilla moves anteriorly (relative to the mandible) resulting in a Class II malocclusion [23].

This gravity-induced skeletal collapse was originally termed BioImplosion [23], but now is more correctly referred to as a kyphotic posture (See Figure 6).

The BioMechanical Model was first introduced by Root in the mid 1950s to explain lower body mechanics and then later expanded by Rothbart to include upper body mechanics. [32] The BioMechanical Model provides a very logical and intuitive explanation on how PMS leads to a kyphotic posture.

The Neurophysiological Model An introduction to the Neurophysiological Model can be shown by the following exercise, which visually depicts the interconnection between the extremities and the brain. That is, changing motion or position in one part of the body (such as the feet) changes motion or position in other parts of the body, all this being coordinated through the central nervous system (brain).

Sitting at your desk, lift your right foot off the floor and draw clockwise circles with the foot. While maintaining this foot motion; in a counter clockwise direction, draw the number 6 in the air with your right hand. The foot will automatically change directions (clockwise to counter-clockwise).

The Foot to Brain Connection [26-29] The Neurophysiological Model that Rothbart suggests is a foot to brain connection that dramatically affects the posture:

The plantar surfaces of the feet are embedded with millions of fast acting touch receptors (Meissners corpuscles). In a closed kinetic chain, at any given moment, certain areas of the foot are touching the ground. At each point of contact, the Meissner corpuscles are being stimulated.

When a group of Meissner corpuscles are simultaneously stimulated, it is referred to as a pattern of stimulation. Rothbart has found that in PMS (a twisting or excessively pronating foot), the patterns of stimulation are distorted compared to the patterns of stimulation in a non-twisting foot. That is: l

In a non-twisting foot, the Meissners corpuscles a re stimulated evenly across the heel and ball of the foot (e.g., a nondistorted pattern of stimulation).

l

In PMS, the Meissners corpuscles are stimulated al ong the outside of the heel and inside of the ball of the foot (e.g., a distorted pattern of stimulation).

Fig. 8

Fig. 7

Patterns of stimulation which are formed in the feet send signals to the cerebellum.

These signals provide the cerebellum with a picture of where the body is in space (e.g., the bodys posture). Based on these signals, the cerebellum is constantly readjusting the bodys position in order to maintain an upright and stable posture. l

Patterns of stimulation formed by a nontwisting foot send non-distorted signals to the cerebellum. From these nondistorted signals, the cerebellum automatically maintains a non-distorted posture.

l

Patterns of stimulation formed by a PMS send distorted signals to the cerebellum.

From these faulty signals, the cerebellum automatically maintains a kyphotic posture.

Rothbart (2009) suggests that the higher the big toe is elevated off the ground (e.g., as the severity of PMS increases), the greater the foot twists. The greater the foot twist, the greater the distortion in the patterns of stimulation and resulting signals to the cerebellum.

The more distorted the signals, the worse the kyphotic posture.

The neurophysiological model was introduced by Rothbart in 2002. He developed this new paradigm because the biomechanical model did not explain what he was seeing clinically through his use of proprioceptive insoles. That is, by applying proprioceptive (non supporting) stimulation under the feet, dramatic postural changes were achieved.

The Neurophysiological Model explains how non- supportive type insoles can dramatically change posture and suggests that the only way to effectively eliminate chronic muscle and joint pain is to change the distorted patterns of stimulation to a nondistorted pattern. The cerebellum automatically responds by reversing the kyphotic posture towards a non-distorted posture.

The biomechanical model implies that rigid or semi-rigid orthotics must be used to support the feet if one wishes to reverse the kyphotic postures resulting from PMS. But, this implication belies the effectiveness of the newer generation of propioceptive insoles [25] which do not support the feet, but which do reverse the kyphotic postures resulting from PMS (See Figures 7 and 8).

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Peer Review Section Fig. 9

Resulting Muscle and Joint Pain A non-distorted posture maintains correct alignment and healthy cartilage within the weight-bearing joints, so they remain healthy, mobile and pain free.

The muscles function optimally and do not become overly tight or stretched.

Conversely, the kyphotic posture, resulting from PMS, has been linked to joint inflammation and muscle hypertonicity: When the weight bearing joints are out of alignment (e.g., kyphotic posture), the bodys weig ht is distributed unevenly across these joints (ankles, knees, hips, back, neck and jaw). This uneven weight distribution results in uneven wear patterns within the cartilaginous caps (See Figure 9). The joints become arthritic (osteodegenerative arthritis) and eventually painful.

The kyphotic posture resulting from PMS has also been linked to increased muscle tightness (hypertonicity). That is, the body overuses muscles across positionally unstable joints to maintain an upright posture. This constant reliance on muscles to stabilize the joints is very fatiguing on the body and may be an important factor in the development of Fibromyalgia and Chronic Fatigue Syndrome.

Visceral components have also been noted in some patients with kyphotic posture [31]. In theory, because the internal organs hang on th e skeletal framework, torsion of the skeleton can produce compression and/or torsion on the viscera. To use another example from engineering, if a building severely settles, the doors and windows may jam, plumbing problems may arise and the roof may leak. Similarly, it is not surprising for patients with an anterior rotation of the pelvis to have a tipped uterus and/or suffer from gastrointestinal or urogenital problems. And it is not surprising for patients with a severe forward head position to have sinus and occlusal problems.

Summary PMS is a very common embryological foot structure which functionally excessively pronates (twists). This excessive foot pronation results in a kyphotic posture. One explanation on how this occurs is offered by the BioMechanical Model. Gravity distorts the bodys posture similar to the way it disrupts the stability of a building with an unstable foundation. Another explanation is offered by the Neurophysiological Model: Distorted patterns of stimulation are generated by a twisting foot. These distorted patterns result in distorted signals to the cerebellum. Acting on these distorted signals, the cerebellum automatically maintains a kyphotic posture. Both models result in the same clinical picture: the weight bearing joints become malaligned. The postural muscles compensate for this joint mal-alignment by tightening up across these joints. This combination of joint mal-alignment and increased muscle tightness can lead the patient into a lifelong struggle with musculoskeletal pain. Thus it can be easily understood that our posture is a major factor in our overall health and wellbeing. People with non-twisting feet usually have naturally good posture, less joint and muscle pain and fewer visceral problems than people with the PMS foot structure (which causes twisting feet) and the resulting kyphotic posture.

Diagram Descriptors Figure 1 Angular variances in the torsion of the talar he ad (red and blue arrows) Figure 2 Complete unwinding of the talar head (black arrow) results in a plantargrade foot (no structural elevation or twist in the 1st metatarsal and big toe Figure 3 Retention of talar supinatus (black arrow) results in the structural elevation and inward twist of the 1st metatarsal and big toe (proximal phalanx and hallux) Figure 4 When the foot is placed in its anatomical neutral position (subtalar joint congruency), the structural elevation and inward twist of the 1st metatarsal and big toe become visible Figure 5 Rothbarts Foot can be quantified using BioVectors underneath the foot. Triangular wedges are placed underneath the first metatarsal and hallux. The degree of supinatus (elevation of the first metatarsal and hallux) can be read directly off the BioVector (calibrated wedge) Figure 6 Kyphotic Posture. The most common postural disto rtional pattern linked to Rothbarts Foot. Figure 7 17 year old Downs female note the shoulder protraction and dramatic forward position of the head Figure 8 Note the dramatic improvement in posture which occurs almost instantaneously when the patient stands on the proprioceptive insoles (retraction of shoulders, reversal of forward head position) Figure 9 Osteodegenerative Arthritis of the knee. The medial joint space (white arrow) is narrowed due to compression of the cartilage. This is thought to result from a postural distortion that shifts the bodys weight through the inside of the knee.

1

References 1. Wheaton C. Mandibular Rest Position: Relationship to Occlusion, Posture and Muscle Activity. In: New Concepts in Craniomandibular and Chronic Pain Management.

London: Mosby-Wolf. pp. 163-75;1994.

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3. MacConkey D. The relationship of posture and dental health. International Journal of Orofacial Myology. Vol 17. No 3:8-10;1991.

4. Irvin R E. Is normal posture a correctable Origin of common, chronic, and otherwise idiopathic discomfort of the musculoskeletal system? In Vleeming A, Mooney V, Dorman T, Snijders C, Edits. Second Interdisciplinary World Congress on Low Back Pain, San Diego. pp. 425-460;1995.

5. Cathie A. The influence of the lower extremities upon the structural integrity of thebody. 1950. In: Postural Balance and Imbalance. Peterson B, ed. Indianapolis: American Academy Of Osteopathy. pp. 50-53;1983.

6. Fink M, Wahling K, Stiesch-Scholz M, et al. The functional relationship between the craniomandibular system, cervical spine and sacroiliac joint: a preliminary study.

Cranio 21: 202-08;2003.

7. Donatelli R. The Biomechanics of the Foot and Ankle, 2nd Edit. Philadelphia: F A DavisCo. Pg. 55-59;1996.

8. Nicolakis P, Nicolakis M, Piehslinger E, Ebenbichler G, et al. Relationship between craniomandibular disorders and poor posture. Cranio April 18(2):106-12;2000.

9. Rothbart B A, 2002. Medial Column Foot Systems: An Innovative Tool for Improving Posture. Journal of Bodywork and Movement Therapies (6)1:37-46;2002.

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13. Sewell R S. A study of the astragalus (talus). Part IV. Journal Anatomy Physiology, Vol 40:152;1906.

14. Straus W L. Growth of the human foot and its evolutionary significance. Contributions in Embryology 19:95;1927.

15. McPoil T, Cameron J A, Adrian M J. Anatomical characteristics of the talus in relation to forefoot deformities. Journal American Podiatric Medical Association 77(2):1987.

16. Sarrafian K S. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional.

2nd Ed., Lippincott Williams & Wilkins, Feb 1993.

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18. Hlavac H F. Compensated forefoot varus. Journal Podiatric Medical Association 60(6):229-233;1970.

19. Daniels T R, Smith J W, Ross T I. Varus Malalignment of the Talar Neck. Its Effect on the Position of the Foot and on Subtalar Motion. Journal Bone Joint Surgery; 78:1559 1567;1996.

20. Cummings G S, Higbie E J. A weight bearing method for determining forefoot posting for orthotic fabrication. Physio Research Intern, Vol 2(1):42-50;1997.

21. Rothbart B A. Relationship of Functional Leg-Length Discrepancy to Abnormal Pronation. Journal American Podiatric Medical Association 96(6):499-507;2006.

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23. Rothbart B A. Vertical Facial Dimensions Linked to Abnormal Foot Motion. Journal American Podiatric Medical Association, 98(3):01-08, May. 2008.

24. Rothbart B A, Yerratt M. An Innovative Mechanical Approach to Treating Chronic Knee Pain: A BioImplosition Model. The Pain Practitioner (formerly American Journal of Pain Management) 4(3):13-18;1994.

25. Rothbart B A. Tactile therapy shirts patients toward equilibrium. Biomechanics. Vol XII, No 10:61-68;2005.

26. Winston D B, James P C, Stinear C M, Fleming M K, et. al. Functional Connectivity Between Secondary and Primary Motor Areas Underlying HandFoot Coordination.

Journal Neurophysiology 98:414-422;2007.

27. Emmanuel G, LehĂŠricy S, Pochon J P, TĂŠzenas duMontcel S, et.al. Foot, Hand, Face and Eye Representation in the Human Striatum. Cerebral Cortex, Vol.13(2):162169;2003.

28. Paus R, Theoharides T C, Arck P C. Neuroimmunoendocrine circuitry of the brainskin connection. Trends in Immunology, Vol.27(1):3 2-39;2006.

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Continued ProfessionalDevelopment

The Institute of Chiropodists and Podiatrists

Continuing Professional Development This article is one of a series of educational documents that can be inserted into your portfolio and be a contribution towards your personal CPD learning.

Haematology (part 1)

by Judith Barbaro-Brown MSc BSc(Hons) PGCE, DPodM, MChs

B

lood is a type of connective tissue consisting of cells and fragments surrounded by a liquid matrix, which circulates through the heart and blood vessels. The cells and cell fragments are the formed elements, and the liquid is the plasma. The formed elements make up about 45% and plasma makes up about 55% of the total blood volume. The total blood volume in the average adult is about 4 - 5 litres in females and 5-6 litres in males. Blood makes up about 8% of the total weight of the body.

Cells require constant nutrition and waste removal because they are metabolically active. Most cells are located some distance from nutrient sources such as the digestive tract and sites of waste disposal such as the kidneys. The cardiovascular system, which consists of the heart, blood vessels, and blood, connects the various tissues. The heart pumps blood through blood vessels, which extend throughout the body, and the blood delivers nutrients and picks up waste products.

transports other substances. For example, the precursor to vitamin D is produced in the skin and transported by the blood to the liver, and then to the kidneys for processing into active vitamin D. The active vitamin D is transported in blood to the small intestines, where it promotes the uptake of calcium. Another example is lactic acid produced by skeletal muscles during anaerobic respiration. The lactic acid is carried in blood to the liver and converted into glucose.

Finally, many of the substances necessary for maintenance and protection must be transported throughout the body.

Maintenance

Blood plays a crucial role in maintaining homeostasis. Many of the hormones and enzymes that regulate body processes are found in blood, as are buffers, which help keep the blood's pH within its normal limits of 7.35-7.45. The osmotic composition of blood is also critical for maintaining the normal fluid and electrolyte balance.

Because blood can hold heat, it is involved with temperature regulation, transporting heat from the interior to the surface of the body, where the heat is released. When blood vessels are damaged, the blood clots that form are the first step in tissue repair and the restoration of normal function.

Protection

Cells and chemicals of the blood constitute an important part of the immune system, protecting against foreign substances, such as microorganisms and toxins. Blood clotting also provides protection against excessive fluid and cell loss when blood vessels are damaged.

Plasma

Functions

The functions of blood can be categorized as transportation, maintenance, and protection. Many of these functions can be placed in more than one category, e.g., for blood cells to protect against microorganisms, they must be transported to sites of infection.

Transportation

Blood is the primary transport medium of the body. Oxygen enters blood in the lungs and is carried to cells; and carbon dioxide, produced by cells, is carried in blood to the lungs from which it is expelled. Ingested nutrients, electrolytes, and water are transported by the blood from the digestive tract to cells, and waste products are transported from cells to the kidneys for elimination in urine. In addition to transporting gases, nutrients, and waste products, blood

Plasma is a pale yellow fluid that consists of about 91% water and 9% other substances, such as proteins, ions, nutrients, gases, and waste products. Plasma is a colloidal solution, which is a liquid containing suspended substances that do not settle out of solution.

Most of the suspended substances are plasma proteins, which include albumin, globulins, and fibrinogen. Albumin makes up 58% of the plasma proteins and is important in the regulation of water movement between tissues and blood. Because albumin does not easily pass from the blood into tissues, it plays an important role in maintaining the osmotic concentration of blood. Globulins account for 38% of the plasma proteins. Some globulins, such as antibodies and complement, are part of the immune system, whereas others function as transport molecules. Fibrinogen constitutes 4% of the plasma proteins and is responsible for the formation of blood clots. In addition to the suspended molecules, plasma contains a number of dissolved components, such as ions, nutrients, waste products, gases, and regulatory substances.

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Continued ProfessionalDevelopment Plasma volume remains relatively constant. Normally, water intake through the digestive tract closely matches water loss through the kidneys, lungs, digestive tract, and skin. Oxygen enters blood in the lungs and carbon dioxide enters blood from the tissues. Other suspended or dissolved substances in the blood come from the liver, kidneys, intestines, endocrine glands, and immune tissues such as the spleen. These other substances are also regulated and maintained within narrow limits.

Formed Elements

About 95% of the volume of the formed elements consists of erythrocytes, or red blood cells. The remaining 5% consists of leukocytes, or white blood cells, and cell fragments called platelets (thrombocytes). In healthy adults, leukocytes are the only formed elements possessing nuclei, whereas erythrocytes and platelets have few organelles and lack nuclei.

Leukocytes are named according to their appearance in stained preparations. Leukocytes containing large cytoplasmic granules are granulocytes, and those with very small granules that cannot be seen easily with the light microscope are agranulocytes. The three types of granulocytes are named according to the staining characteristics of their cytoplasm: neutrophils, eosinophils, and basophils. There are two types of agranulocytes: monocytes, and lymphocytes.

Many cancer therapies affect dividing cells such as those found in tumours. An undesirable side effect of such therapies, however, can be the destruction of non-tumour cells that are dividing, such as the cells in red bone marrow. After treatment for cancer, growth factors are used to stimulate the rapid regeneration of the red bone marrow.

Although not a cure for cancer, the use of growth factors can speed recovery from the cancer therapy.

Some types of leukaemia and genetic immune deficiency diseases can be treated with a bone marrow transplant containing blood stem cells. To avoid problems of tissue rejection, families with a history of these disorders can freeze the umbilical cord blood of their newborn children. The cord blood contains many stem cells and can be used instead of a bone marrow transplant.

Erythrocytes Erythrocytes are about 700 times more numerous than leukocytes and 17 times more numerous than platelets. Males have about 5.2 million erythrocytes per cubic millimetre of blood (range: 4.2-5.8 million), whereas females have about 4.5 million/mm3 (range: 3.65.2 million). Erythrocytes cannot move of their own accord and are passively moved by forces that cause the blood to circulate.

Production of Formed Elements

The process of blood cell production, called heamatopoiesis or heamopoiesis, occurs in the embryo and fetus in tissues such as the yolk sac, thymus, spleen, lymph nodes, and red bone marrow. After birth, heamatopoiesis is confined primarily to red bone - with some lymphoid tissue helping in the production erythrocytes. In young children, nearly all the marrow is red bone marrow. In adults, however, red is confined to the skull, ribs, sternum, vertebrae, proximal femur, and proximal humerus. The red marrow in other locations is replaced by yellow marrow.

Hemocytoblast Proerythroblast

Myeloblast Lymphoblast

Polychromatic erythroblast

Progranulocyte

Megakaryocyte Lymphocyte

Erythrocytes

Megakaryoblast Monoblast

Monocyte

Basophil Neutrophil Eosinophil

Thrombocytes Granulocytes

Agranulocytes Leukocytes

All the formed elements of the blood are derived from a population of stem cells located in the red bone marrow. Stem cells are precursor cells capable of dividing to produce daughter cells that can differentiate into other cell types. The heamopoietic stem cells produce the cells that give rise to the various types of blood cells: pro-erythroblasts, from which erythrocytes develop; myeloblasts, from which granulocytes develop; lymphoblasts, from which lymphocytes develop; monoblasts, from which monocytes develop; and megakaryoblasts, from which platelets develop. The development of each cell line is regulated by a specific growth factor.

That is, the type of formed element derived from the stem cells and how many formed elements are produced are determined by the growth factor.

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Structure Normal erythrocytes are biconcave disks about 7.5 Âľm in diameter with edges that are thicker than the centre of the cell. Compared with a flat disk of the same size, the biconcave shape increases the surface area of the erythrocyte. The greater surface area makes the movement of gases into and out of the erythrocyte more rapid. In addition, the erythrocyte can bend or fold around its thin centre, decreasing its size and enabling it to pass more easily through small blood vessels.

Erythrocytes are highly specialized cells that lose their nuclei and nearly all their cellular organelles during maturation. The main component of the erythrocyte is the pigment protein haemoglobin, which occupies about one third of the total cell volume and accounts for its red colour. Other erythrocyte contents include lipids, adenosine triphosphate (ATP), and the enzyme, carbonic anhydrase.

Function The primary functions of erythrocytes are to transport oxygen from the lungs to the various tissues of the body and transport carbon dioxide from the tissues to the lungs. A proximately 98.5% of the oxygen transported in the blood from the lungs to the tissues is transported in combination with the haemoglobin in the erythrocytes, and the remaining 1.5% is dissolved in the water part of the plasma.

If erythrocytes rupture, the haemoglobin leaks out into the plasma and becomes non-functional because the shape of the molecule changes as a result of denaturation. Erythrocyte rupture followed by haemoglobin release is called haemolysis.

Carbon dioxide is transported in the blood in three major ways: approximately 7% is transported as carbon dioxide dissolved in the plasma, approximately 23% is transported in combination with blood

Continued ProfessionalDevelopment proteins (mostly haemoglobin), and 70% is transported in the form of bicarbonate ions. The bicarbonate ions (HC03) are produced when carbon dioxide (C02) and water combine to form carbonic acid (H2C03), which dissociates to form hydrogen (H+) and bicarbonate ions. The combination of carbon dioxide and water is catalysed by an enzyme, carbonic anhydrase, which is located primarily within erythrocytes.

Haemoglobin

Haemoglobin consists of four protein chains and four heme groups.

Each protein, called a globin, is bound to one heme. Each heme is a red-pigment molecule containing one iron atom. A number of different types of globin exist, each having a slightly different amino acid composition. The four globins in normal adult haemoglobin consist of two alpha (Âľ) chains and two beta (Ă&#x;) chains.

no oxygen is called deoxyhaemoglobin. Oxyhaemoglobin is bright red, whereas deoxyhaemoglobin has a darker red colour.

Haemoglobin also transports carbon dioxide, which does not combine with the iron atoms but is attached to amino groups of the globin molecule. This haemoglobin form is carbaminohaemoglobin.

A relatively-recently discovered function of haemoglobin is the transport of nitric oxide, which is produced by the endothelial cells lining the blood vessels. In the lungs, at the same time that heme picks up oxygen, in each Ă&#x; -globin a sulphur-containing amino acid, cysteine, picks up a nitric oxide molecule to form S-nitrosothiol.

When oxygen is released in tissues, so is the nitric oxide, which functions as a chemical signal that induces the smooth muscle of blood vessels to relax. By affecting the amount of nitric oxide in tissues, haemoglobin may play a role in regulating blood pressure because relaxation of blood vessels results in a decrease in blood pressure.

Life-span of Erythrocytes

Under normal conditions about 2.5 million erythrocytes are destroyed every second, representing 0.00001% of the total 25 trillion erythrocytes contained in the normal adult circulation. In addition, these 2.5 million erythrocytes are being replaced by of an equal number of erythrocytes every second.

The process by which new erythrocytes is produced is called erythropoiesis, and the time required for the production of a single erythrocyte is about 4 days. Stem cells, from which all blood cells originate, give rise to pro-erythroblasts. After several mitotic divisions, pro-erythroblasts become early (basophilic) erythroblasts.

Early erythroblasts give rise to intermediate (polychromatic) erythroblasts. As haemoglobin is synthesised it accumulates in the cytoplasm. Intermediate erythroblasts continue to produce haemoglobin, and then most of their ribosomes and other organelles degenerate. The resulting late erythroblasts have a reddish colour because about one third of the cytoplasm is now haemoglobin.

Embryonic and fetal globins appear at different times during development and are replaced by adult globin near the time of birth.

Embryonic and fetal haemoglobins are more effective at binding oxygen than is adult haemoglobin. Abnormal haemoglobins are less effective at attracting oxygen than is normal haemoglobin and can result in anaemia.

Iron is necessary for the normal function of haemoglobin because each oxygen molecule that is transported is associated with an iron atom. The adult human body normally contains about 4 g of iron, two thirds of which is associated with haemoglobin. Small amounts of iron are regularly lost from the body in waste products such as urine and faeces Females lose additional iron as a result of menstrual bleeding and therefore require more dietary iron than do males Dietary iron is absorbed into the circulation from the upper part of the intestinal tract. Acid from the stomach and vitamin C in food increase the solubility of iron in the alkaline environment of the small intestine, thus facilitating the absorption of iron in the small intestine.

Iron absorption is regulated according to need, and iron deficiency can result in anaemia.

The late erythroblasts lose their nuclei by a process of extrusion to become immature erythrocytes, which are called reticulocytes, which become mature erythrocytes when the remaining ribosomes degenerate. Mature erythrocytes and reticulocytes are released from the bone marrow into the circulating blood, which normally consists of mature erythrocytes and 1-3% reticulocytes.

Cell division requires the vitamins folate and B12, necessary for the synthesis of DNA. Haemoglobin production requires iron.

Consequently, a lack of folate, B12, or iron will interfere with normal erythrocyte production.

Production is stimulated by low blood oxygen levels, typical causes of which are low erythrocyte numbers, decreased or defective haemoglobin, pathologies relating to the lungs, increased altitudes, or cardio-vascular problems. Low blood oxygen levels stimulate production be increasing the formation of the glycoprotein erythropoietin by the kidneys. The erythropoietin stimulates red bone marrow to produce more erythrocytes by increasing the number of proerythroblasts formed and by decreasing the time required for erythrocytes to mature. Conversely, if blood oxygen levels increase, less erythropoietin is released, and erythrocyte production decreases.

Various types of poisons affect the haemoglobin molecule. Carbon monoxide (C0) such as occurs in incomplete combustion of gasoline binds to the iron of haemoglobin, forming the relatively stable carboxyhaemoglobin. As a result of the stable binding of carbon monoxide, haemoglobin cannot transport oxygen, and death may occur. Cigarette smoke also produces carbon monoxide, and the blood of smokers can contain 5% - 15% carboxyhaemoglobin.

Erythrocytes normally stay in the circulation for about 120 days in males and 110 days in females. These cells have no nuclei and therefore cannot produce new proteins. As their existing proteins, enzymes, cell membrane components, and other structures degenerate, the erythrocytes become old and abnormal in form and function. Erythrocytes can also be damaged in various ways while passing through the circulation.

When haemoglobin is exposed to oxygen, one oxygen molecule can become associated with each heme group. This oxygenated form of haemoglobin is called oxyhaemoglobin. Haemoglobin containing

Old, damaged, or defective erythrocytes are removed from the blood by macrophages located in the spleen, liver, kidney, and other lymphatic tissues. Within the macrophage, lysosomal enzymes break

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Continued ProfessionalDevelopment open erythrocytes and begin to digest haemoglobin. Globin is broken down into its component amino acids, most of which are reused in the production of other proteins. Iron atoms also are released for recycling. The heme groups are converted to biliverdin and then to bilirubin, which is released into the plasma. Bilirubin binds to albumin and is transported to liver cells. This bilirubin is called free (indirect) bilirubin even though it binds to albumin. The free bilirubin is taken up by the liver cells and is conjugated, or joined, to glucuronic acid to form conjugated (direct) bilirubin, which is more water-soluble than free bilirubin. Some of the conjugated bilirubin escapes back into the blood and is excreted by the kidneys. Most of the conjugated bilirubin becomes part of the bile, which is the fluid secreted from the liver into the small intestine. In the intestines, bacteria convert bilirubin into the pigments that give the faeces its characteristic brownish colour. Some of these pigments are absorbed from the intestine, modified in the kidneys, and excreted in the urine, contributing to the characteristic yellowish colour of urine. A yellowish staining of the skin and sclerae by bile pigments, associated with a build up of bilirubin in the circulation and interstitial spaces, is known as jaundice.

Leukocytes

Leukocytes, or white blood cells, are clear or whitish coloured cells that lack haemoglobin but have a nucleus. In stained preparations, leukocytes attract stain, whereas erythrocytes remain relatively unstained.

Leukocytes protect the body against invading microorganisms and remove dead cells and debris from the body Most leukocytes are motile, exhibiting amoeboid movement, which is the ability to move like an amoeba by putting out irregular cytoplasmic projections.

Leukocytes leave the circulation and enter tissues by diapedesis, a process in which they become thin and elongated and slip between or in some cases through the cells of blood vessel walls. The leukocytes can then be attracted to foreign materials or dead cells within the tissue by chemotaxis. At the site of an infection, leukocytes accumulate and phagocytise bacteria, debris, and dead cells; then they die. The accumulation of dead leukocytes, along with fluid and cell debris, is called slough. The five types of leukocytes are neutrophils, eosinophils, basophils, lymphocytes, and monocytes.

Neutrophils

Neutrophils are the most common type of leukocytes in the blood, and have small cytoplasmic granules that stain with both acidic and basic dyes. Their nuclei are commonly tri-lobed but a number of lobes varies from two to five. Neutrophils are often called polymorphonuclear neutrophils, or PMNs, to indicate that their nuclei can occur in more than one (poly) form (morph). Neutrophils usually remain in the circulation for about 10-12 hours and then move into other tissues, where they become motile and seek out and phagocytise bacteria, antigen-antibody complexes (antigens and antibodies bound together), and other foreign matter. Neutrophils also secrete a class of enzymes called lysozymes, which are capable of destroying certain bacteria. Neutrophils usually survive for 1-2 days after leaving the circulation

Eosinophils

Eosinophils contain cytoplasmic granules that stain bright red with eosin and acidic stain. They are motile cells that leave the circulation to enter the tissues during an inflammatory reaction. They are most common in tissues undergoing an allergic response and their numbers are elevated in the blood of people with allergies or certain parasitic infections. Eosinophils apparently reduce the inflammatory response by producing enzymes that by producing enzymes that destroy inflammatory chemicals such as histamine. Eosinophils also phagocytise antigen-antibody complexes formed during the allergic response, although they are not as important in this function as neutrophils.

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Basophils Basophils are the least common of all leukocytes, and contain large cytoplasmic granules that stain blue or purple with basic dyes.

Basophils, like other granulocytes leave the circulation and migrate through the tissues, where they play a role in both allergic and inflammatory reactions . Basophils contain large amounts of histamine, which they release within tissues to increase the inflammation. They also release heparin, which inhibits blood clotting.

Lymphocytes The smallest leukocytes are lymphocytes, most of which are slightly larger in diameter than erythrocytes. The lymphocytic cytoplasm consists of only a thin, sometimes imperceptible, ring around the nucleus. Although lymphocytes originate in bone marrow, they migrate through the blood to lymphatic tissues where they can proliferate, producing more lymphocytes. The majority of the body's total lymphocyte population is in the lymphatic tissues: the lymph nodes, spleen, tonsils, lymph nodules, and thymus. Although they cannot be identified using standard microscopic examination, a number of different kinds of 1ymphocytes play important roles in immunity. For example, B-lymphocytes can be stimulated by bacteria or toxins to divide, forming cells that produce proteins called antibodies. The antibodies can attach to the bacteria and activate mechanisms that result in destruction of the bacteria. T-lymphocytes protect against viruses by attacking and destroying cells in which viruses are reproducing. In addition, T-lymphocytes are involved with the destruction of tumour cells and tissue graft rejections.

Monocytes Monocytes are typically the largest of the leukocytes. Monocytes normally remain in the circulation for about 3 days, leave the circulation, become transformed into macrophages and migrate through the various tissues. They Phagocytise bacteria, dead cells, cell fragments and other debris within the tissues. An increase in the number of monocytes is often associated with chronic infections. In addition, macrophages can break down phagocytised foreign substances and present the processed substances to lymphocytes, which results in activation of the lymphocytes.

Platelets Platelets, or thrombocytes, are minute fragments of cells consisting of a small amount of cytoplasm surrounded by a plasma membrane.

The surface of platelets has glycoproteins and proteins that allow platelets to attach to other molecules, such as collagen in connective tissue. Some of these surface molecules, as well as molecules released from granules in the platelet cytoplasm, play important roles in controlling blood loss. The platelet cytoplasm also contains actin and myosin that can cause contraction of the platelet.

Platelets are roughly disc-shaped and average about 3 Âľm in diameter. Even though they are about 40 times more common in the blood than leukocytes, platelets often are not counted in typical blood smears because they tend to form clumps and become difficult to distinguish.

The life expectancy of platelets is about 5-9 days. Platelets are produced within the marrow and are derived from megakaryocytes, which are extremely large cells with diameters up to 100 Âľm. Small fragments of these cells break off and enter the circulation as platelets.

Platelets play an important role in preventing blood loss in two ways: (1) the formation of platelet plugs, which seal holes in small vessels; (2) the formation of clots, which help seal off larger wounds in the vessels.

Peer Review Section

Designing a clinical audit Deirdre O’Flynn, BSc Student Queen Margaret University, Edinburgh Introduction This audit is to evaluate the level of waste orthotic sheet material discarded inappropriately in NHS podiatry clinics. This category of waste is analysed and calculated to find out how much this wastage of orthotic sheet materials may incur extra costs to the NHS.

Aims: The aim is to analyse and calculate the wastage from a range of sheet orthotic materials. These materials include Poron, Leather board, Thermoplastic and closed cell rubber which are manufactured into custom made chair side orthotics in a NHS 3rd year student podiatry clinic. The cost of this waste is calculated in order to make sure that there is not a high volume of unnecessary waste and to find out if it would be more cost effective to implement different approaches to eradicate wastage therefore saving money.

There are no set standards or guidelines to be found at present on the cost of wastage of insole materials within the NHS. In the case of this specific area of audit it has been discovered that very little investigation has been undertaken. No evidence was found regarding the cost from the wastage of sheet insole material in the manufacture of chair side orthotics. Due to the current lack of literature it warrants the need for this research to be undertaken. The purpose of this audit is to emphasise an area in podiatry practice where money can be saved.

Literature Review: A search was undertaken in a number of databases Cochrane library, NHS, Google scholar, Pub Med, British Medical Journal(BMJ) , Cinahl, BioMed Central using the search terms waste materials NHS, NHS podiatry budget, recycling insole materials , orthotic materials, Insoles, disposal, wastage, waste management, recession and cost effectiveness. A search in the library journals and articles was also conducted. Additionally Information was provided from podiatry lecturers. After thorough and comprehensive investigation relating to this research some literature was found Brocklesby and Wooles (2009).

Brocklesby and Wooles (2009) undertook a cost comparison between the manufacture of in house chair side orthoses using sheet material to pre fabricated orthotics. A substantial cost advantage was shown with the use of prefabricated insoles.

Cummings and Reid (2004) found that chair side 1st phase orthotics had many benefits. When patients were transferred from a specialist biomechanics clinic to community podiatry clinics for treatment waiting lists were reduced, podiatrists working in community clinics were able to keep knowledge and skills of biomechanics up to date and which contributed to CPD. Both documents wrote about the advantages and disadvantages of chair side orthotics which attributed to this literature review nevertheless neither of these documents spoke about the wastage of insole material.

In 2005, the NHS estates: focused on ways that waste can be prevented by cutting needless consumption without this having an affect on the quality of healthcare which is being delivered.

This document discusses the benefits in terms of cost saving for the NHS by implementing a strategy to improve the amount of

waste generated. One of the areas targeted was the individual practice of the staff. It is imperative that the staff are made aware that reductions in levels of waste generated will be made when the correct use and disposal of materials is adhered too. Clinical governance is a standard that all NHS employees must adhere to.

The NHS clinical governance website states health professionals are involved in audits and projects to improve and promote good clinical practice. The clinical governance website discussed cost effectiveness within a NHS clinic and utilising the limited resources of the health service with vigilance and caution which was very relevant to the audit.

The evidence which was found supported a full and extensive literature review for this audit. It is apparent from the published literature researched that there is a requirement for research to be undertaken in the wastage of insole material within the NHS.

Methodology: There are no set standards or guidelines for this audit to be measured against therefore there is a need to set up a guideline to adhere to when measuring or weighing the amount of waste material.

A permission letter to be sent to the Podiatry clinic at (wherever) requesting the permission for the audit to take place.

A permission letter to be sent requesting the use of electronic weighing scales over a two week period.

Method: This audit will involve a registered practitioner observing 3rd year students in a NHS podiatry clinic over a period of two days for two weeks. The students will be observed on the wastage made from the manufacture of insole orthotics using sheet materials over 9 hours a week for two weeks surmounting to 18 clinical hours. At the beginning of each session sheets of new materials are weighed and provided to the students. Students will be requested to place the wastage of orthotic material in bins provided while being observed by the registered practitioner. At the end of each clinical session the wastage of material will be segregated into each separate material before being weighed in grams and the data will be recorded in the table provided See Appendix 3. The materials to be weighed are leather board, poron, closed cell rubber 3mm and 5mm also thermoplastic 3mm and mm. The recording of data will take an additional hour after each session.

The inclusion criteria are any amount of sheet orthotic material that the student podiatrist considers as waste. The lecturers’ waste, if they have helped a student and have waste material left over.

The exclusion criteria are additional double sided sticky tape that may be adhered to the wasted material or other non relevant materials to the audit.

Study Design: A quantitative analysis will be undertaken in this design. This analysis will be used because it gathers numerical data rather then thoughts and feelings which would be more relevant to the audit.

1

Peer Review Section

Ethical considerations:

Costings – Sheet Materials used.

The student podiatrist’s who participate in this audit will not be identified. No student will be named and their method of practice will not be identified and recorded in the audit.

Materials

Cost per sheet/

Quantity

Cost

Poron

£11.65

x4

£46.60

Thermoplastic 3mm

£1.27

x4

£5.08

Thermoplastic 6mm

£2.58

x4

£10.32

1. Letters and student briefing: Writing the permission letters and informing students and staff on the placement of waste material into bins provided.

1 hour.

Leatherboard

£3.93

x4

£15.72

Closed cell rubber 3mm

£13.19

x2

£26.38

2. Data collection: 3rd year student podiatrist’s will be requested to participate in the event which will be held on a Wednesday morning from 9am until 12 noon and a further full day Friday 9am until 4pm excluding lunch which is from 12 noon until 1pm in the student podiatry clinic at InchKeith house. Each clinical session is 3 hours and will total 9 hours per week which over the two week period will total 18 hours.

3 hours x 3 clinical sessions = 9 hours x 2 weeks = 18 hours.

Closed cell rubber 6mm

15.42

x 2 sheets

£30.84

Data Analysis: A registered podiatry practitioner will observe the 3rd year podiatry students when manufacturing the insoles while also weighing and recording the data collected.

Timetable of work:

3. Data analysis and calculations: Insole waste material will be collected by the auditor at the end of each clinical session and it will be separated into the material types where it will be weighed, recorded and the cost totalled. This collection of data will take 1 hour multiplied by 3 clinical sessions.

1 hour x 3 clinical sessions = 3 hours x 2 weeks = 6 hours.

Total number of hours to brief staff, analyse and gather the data = 25 hours.

Costings - Data collection, analysis - Hourly pay = £10.85 Data

Time

Calculations

Cost

Permission letters and briefing of staff

1 hour

£10.85 x 1

£10.85

Data collection

9 hours per week x 2 weeks

£10.85 x 9 x 2 £195.30

Data analysis and calculations

3 hours per week x 2 weeks

£10.85 x 6

Plastic Bin

£65.10 £2

Two envelopes with stamps

66p x 2

£1.32

Electronic Scales Scales

Borrowed – permission letter written

Travel expenses

No Cost

Writing up the audit Total

7 hours per day for 5 days

£10.85 x 7 x 5 £379.75 £654.32

Total

£134.94

Overall total cost

£789.26

Study Limitations: Additional materials unrelated to the audit may be disposed of in the bin provided. Some of the orthotic material could have sticky tape adhered to it which would interfere with calculations adding extra weight. Students could possibly be more aware of the auditor watching them and may be cautious placing waste materials in the bin for fear of being criticised.

Dissemination of results: The results of the study will be disseminated through ‘the Foot’ journal. This is international peer reviewed journal. This journal was chosen because primary research papers include biomechanics, orthoses and prostheses which is relevant to the audit. This journal is highly recognised and is the official journal of American college of foot & ankle orthopaedics and medicine The foot (2011).

References: NHS Scotland. 2007. Education resources clinical governance.

[Online].Available from: http://www.clinicalgovernance.scot.nhs.uk/section2/introduction.asp [Accessed March 24th 2011].

NHS Trust. 2007. Waste Management Policy. [Online]. Available from: http://www.5boroughspartnership.nhs.uk/library/documents/5bpt12was te1.pdf [Accessed April 1st 2011].

NHS Estates. 2005. Waste prevention discussion. [Online]. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publica tionsPolicyAndGuidance/DH_4119684 [Accessed April 1st 2011].

Cummings, M. Reid, D. 2004. Clinical audit to access the use of a chair side 1st phase orthotic system in a community clinical setting.

Podiatry Now. December. [Online].Available from: http://74.125.155.132/scholar?q=cache:nb31wcH8YGoJ:scholar.googl e.com/+podiatry+material+wastage&hl=en&as_sdt=0,5&as_vis=1 [Accessed 20th of March 2011].

Brocklesby, S. Wooles, C.2009. Cost comparison: Orthoses- an audit.

In-house manufacture from sheet materials vs prefabricated Orthoses.

Podiatry Now. June. 2009. [Online].Available from: http://www.apcrc.nhs.uk/Service_Evaluation/Feature-orthoses-anaudit.pdf [Accessed April the 1st 2011].

The foot. 2011. The international journal of clinical foot science.

[Online] Available from: http://www.thefootjournal.com/home [Accessed 22th of March 2011].

A.G.M. Postbag

Dear all I had the privilege and good fortune to represent the Northern Ireland Regional Branch as delegate at the 2011 A.G.M. in Windsor. What a picturesque part of England, just beside the river with willows, punts and colourful barges, not to mention the odd paddle steamer - a painters paradise! The venue Beaumont House dates back to the 17th century and is set in 40 beautiful acres of landscaped grounds. The restored Neo Classical Chapel being a delight to behold.

The Conference Centre was well laid out and home to a very successful and concise conference. The Trade Shows were excellent as were the lectures and a great nights fun was had by all at the dinner dance.

Here's to next year in Liverpool they certainly will be hard pressed to equal, never mind better, this one! Thank you for a marvellous weekend, best wishes to all.

Kind regards, Colin Craig, Northern Ireland Regional Branch Dear editor, I am writing to express my thanks and appreciation to David Crew and the team for an excellent conference this year. The quality of the lectures, and the overall accommodation and helpful staff at Beaumont House made the weekend most enjoyable. It was nice to meet up again with friends and colleagues. Looking forward to Liverpool in 2012.

Denise Willis, Chester North Wales Staffs and Shrops Branch

Dear Bernie, On behalf of the Sussex Branch I should like to thank publicly David Crew and his team for organising the A.G.M. at Windsor last week. It was a very pleasant venue and the ambience was good throughout. Catching up with old friends and making new ones always makes one feel good.

The lectures and workshops were appreciated by all not least of which the last two on Dementia - It was the end of the Conference, we were all getting tired, but Pat Pope kept us all rivetted to the end. In fact I hadn't signed up for the last one (sorry!) but I just had to go back to listen to it.

May I take this opportunity of thanking you and all the team at Head Office for all the hard work you put in beforehand to ensure the proceedings run smoothly.

With my very best wishes, Valerie Probert-Broster, Sussex Branch Secretary Dear editor, Congratulations to all those involved with organising this years’ A.G.M. There is a huge amount of work required to arrange a Conference like ours with a professional Trade show.

1

Dear editor, Just a few words about the Conference, The venue is truly magical - vast, just getting to my room was a workout! Met many a lost “sole” wandering the corridors! The quality of the talks and workshops were outstanding. The conference management team were invisible for the great majority of the time. Great job by all concerned.

Many thanks Michael Franklin, South Wales, Monmouth and Gloucester Branch

The choice of venue was excellent, though I believe was a little challenging for some members to arrive by rail. The hotel facilities were top-notch however, including the sound system in the Conference Hall – all the speakers could be clearly heard.

I probably ate too much – even the fish and chips were good, and as a northern lad I know a thing or two about that… but a few lengths in the pool eased the conscience.

Ahem… best not mention the beer prices though! The lectures were interesting and informative and should be seen not just as ‘cpd points’ but a real opportunity to educate ourselves. This year I came prepared for the Trade show with a shopping list. I’m like a kid in a sweet shop among those shiny probes and files at Chiropody Express.

The Dinner Dance is always an opportunity to let ones hair down – it’s surprising how much entertainment can be elicited from a crème brulée… those on our table will understand!

In summary, a great few days meeting old friends and making new ones. Looking forward to Liverpool.

Jon Ollivier, Teesside Branch

Dear Mr. Crew Thank you for inviting me and Naheed to open the A.G.M. at Beaumont House on Friday morning. We enjoyed meeting you and your colleagues and learning a little more about your work.

I hope the conference went well and that you enjoyed your stay in Old Windsor.

With my best wishes for the future.

Yours sincerely Asghar Majeed, Deputy Mayor

Dear editor, I would like to thank Malcolm and David for organising this year’s conference in Windsor.

Malcolm in particular deserves a medal for organising the trade show, workshops and the lectures which were superb.

For those not aware next year’s A.G.M will be in Liverpool which is Western branch’s stomping ground. As Liverpool is renowned for hosting live music events I am hoping we can get a live band for the Saturday night dinner dance. As a disco is not live music and leaves much to be desired for a dinner dance.

See you all next year in Liverpool.

Michelle Taylor, Western Branch Dear editor I write to express my thanks to David Crew and team for organizing our 2011 A.G.M. Conference. The Old Windsor location provided a suitably dramatic setting; the spacious estate by the Thames and within a short gallop from Runnymead.

Our accommodation was good, though a compass might have been helpful – it was quite a maze of buildings and garden paths; fortunately the Trade Exhibition was well laid out, accessible and extensive. The lectures were of a high standard, providing helpful insights into new joint therapies, interprofessional perception and, not to forget, the subtleties of various dementias.

It was encouraging to talk with friends and make new contacts and especially gratifying to see new Officers elected to the Executive, as we all face significant challenges and opportunities. It was good to join the standing ovation for our much appreciated Robert Beattie, after his speech.

A brief quote from the Bard to conclude: “the quality of Mersey is not strained…” Yes, next year we meet in Liverpool.

Yours sincerely Paul Simons, Birmingham Branch

Dear editor, I had decided to attend the A.G.M. in Windsor as it is a beautiful city, I combine it with a break with my wife which include popping into London for some retail therapy.

At the last moment due to circumstances, our branch, Chester were allowed to have two delegates attend, so as I was already going, Denise, Branch Secretary, asked me to be one, along with herself. Good move…

I popped up the one in Glasgow in 2009 however as a delegate it took on a different dimension and the politics of the Institute does interest me a little. The hotel was fabulous in comfort and location. The lectures I got to attend were useful and informative. The actual A.G.M. was an eye opener and to witness the wheels of the Institute in motion

and grasping a better understanding of how final decisions are made was interesting. Ultimately these decisions are the ones that will affect my relationship with the Institute…

The Dinner Dance was fun and abject apologies to anyone I may have talked rubbish to as the Speckled Hen flowed. As for the dancing…! Bill is definitely a budding Thespian and lost me after the second sentence as Shakespeare but it was very entertaining and missed his calling as a stand up… Two halls of trade shows with good attendance by suppliers with various show offers was a good place for some ‘work’ retail therapy.

But one of the highlights for me was putting names to faces and chatting to folk I had heard of but didn’t know. I would like the thank all who organised the huge event that seemed to run flawlessly for an enjoyable four days.

And Bernie for sending certificates for CPD and excelling at Dancing, Chatting, Entertaining(!) and having the worse hangover.

Mostly I would like to thank Denise for being a brilliant Branch Secretary and asking me to be delegate.

Liverpool next year folks, get your party gear on…

Phil Yeomans, Cheshire North Wales Branch

Dear editor Once again, another fabulous Annual General Meeting, Conference, Trade Show and Dinner Dance. Beaumont House was a perfect setting, apart from the early morning planes, it was extremely tranquil with extensive well kept grounds. Staff were very attentive and helped wherever they could. As I seemed to have been nominated as general ‘gofer’ for the weekend it certainly kept me fit sprinting from one end of the complex to the other carrying numerous boxes containing goodness knows what! I thought my wife was joking when she told me to allow 15 minutes to get to a certain room! I would like to thank the organisers who I believe were mainly David Crew, Malcolm Holmes and Julie Aspinwall. Jill and Caroline did a wonderful job with the table decorations they looked superb when we walked in.

I am already looking forward to Liverpool next year and look forward to seeing even more of you. Our A.G.M. really is a fabulous way to fulfil CPD requirements with first class lectures and also to stock up on supplies with the traders who are more than willing to answer any questions you may have as well as mixing with peers and swapping ‘notes’. If you have never been - try it!

Stephen Willey, Sheffield Branch Dear editor, I thoroughly enjoyed this years A.G.M. The venue was excellent and the running of everything was well organised. The CPD was varied and interesting.

Special thanks to those holding National Office - I will relay to my branch just how much work is put in on their behalf. Well done to all others that organised the A.G.M. Ann Richardson, Hants and Dorset Dear editor Many thanks for all the hard work at the A.G.M. The venue was lovely and so was the food! I found the weekend stimulating and informative. I felt I learnt a great deal especially in Dementia, Silicones and Lazers and took notes to feed back to my branch. It was also great to be able to chat to others and learn from their experiences and to find we all have similar problems and ethical issues in practice. All in all the event was well organised except for

some minor issues for example, less mobile people found some of the bedrooms a long walk away but this was rectified by the management, who changed their rooms, where possible.

Fiona C. Grove, Nottingham Branch

Dear editor, I just wanted to write to express my thanks and appreciation to all those involved with the organization of the recent A.G.M./Conference in Windsor. As always I found the whole event interesting and enjoyable, especially so as I was involved with the business part of the proceedings. The venue was super with wonderful helpful staff and the lectures that I attended were first class.

It was the first year for me to be presenting something at conference, in the form of one of the workshops (padding and strapping) and I want, also, to thank the people on that workshop for their great participation and input (as well as those behind the scenes who helped me to organize it) - (they know who they are!) Also a big thank you to Algeos who kindly supplied the products used in the workshop.

It was as ever, very good, to see colleagues and friends and to catch up.

Thanks again Suzie Ostler, Sheffield Branch

Dear editor, Old Windsor - Memories of an A.G.M. I’ll never forget.

Firstly, as always there was the intense friendly, informality that I have been swamped with at every A.G.M. for the past ten years or so. The trade show itself was up to usual standards. A comprehensive cross section of suppliers who were quite happy with the turnout, pleasant surroundings and ample refreshments. It is nice that the trade exhibition and the seminars/workshops are

open to members of other organisations not just IOCP members. That sends out a friendly welcome.

From a traders point of view, it importantly provides a wide field of potential customers.

Another reason the day was unforgettable was because our car broke down en route and after almost being ripped off by one garage for non existent repairs we found Garry in Old Windsor who enabled us to get to Conference on time and ordered new business cards from us in the bargain!

Congratualtions again this year. H.O. staff and the branch organisers were as helpful as they could possibly be.

Des Currie, Printer

The Institute of Chiropodists and Podiatrists would like to thank the following Traders who supported our 56th A.G.M. at Royal Windsor.

Additional thanks go to Canonbury for sponsoring the President’s Reception, Shucco for sponsoring the delegates brochure, and Algeos for sponsoring the workshop.

Algeos Bailey Instruments Barrier Healthcare Blue Zinc IT C & P Medical Trading Canonbury Chiropody Express Currie International Cutera Ltd Cuxson Gerrard D.L.T. Chiropody DB Shoes Hilary Supplies Laderma Health Medical Aesthetics Group Omega Laser Systems Patterson Medical Plinth 2000 RC Supplies Reed Medical Shucco Swann Morton Talar Made Tomorrow Options

A Day in the Dissection Lab - Getting Under The Skin by Gillian Webster, M.Inst.Ch.P. Have you ever wondered just what the internal anatomical features of the feet we treat are really like?

If you trained in the private sector the chances are you will have never seen the internal anatomy of the foot or any other part of the human body in anything but a textbook. Those practitioners who took a full time degree at University would have had to do quite a number of hours of dissection and anatomy giving a sound underpinning knowledge of the underlying structures of the foot.

This lack of physical anatomy and physiology training concerned me for many years after I started practicing. Although I felt my knowledge of the structures of the foot was pretty good, as I have progressed and increased my skills over the years I realised that this was an area that was certainly lacking and needed re-evaluating so when I recently had the opportunity to attend a CPD day in a dissection lab, I grabbed the chance to attend. This would at the very least give me the opportunity to really get under the skin and examine these unique structures that we have to treat on a daily basis. I have to say I looked forward to this day enthusiastically but with trepidation, as I really was not sure what to expect.

Having completed my training within the private sector, I had no physical anatomy experience other than with patients. All my “under the skin” anatomy was from some particularly good textbooks and CDs but this could never be comparable to actual hands on anatomy so I felt this training day was one absolutely not to be missed. Run by The London Massage Company the course was held in central London. For legal reasons relating to access to anatomical specimens we were only informed of the location on booking and I am unable to disclose the actual location of this course in this text.

The day was lead by Jane Johnson-a Chartered Physiotherapist, with many years experience in her profession and in teaching.

Our day would involve examining prepared embalmed cadavers.

The majority of practitioners attending were sports massage therapists or massage therapists but the day was still very relevant to podiatrists.

To the uninitiated the dissection lab looks somewhat uneventful with lots of metal trolleys covered up with metal covers. The most obvious thing I noticed as I approached the lab was the overwhelming smell of formaldehyde. By the end of the day the last thing I ever wanted to smell again was that pungent odour but I did get accustomed to it. It actually reminded me of Phenol.

However, in saying that if I ever had the opportunity to attend another dissection course I would jump at the chance.

In each of the metal containers were various specimens, whole bodies, torsos, limbs etc, some of which were for us to examine.

To get us used to the idea of handling the specimens we started off with examining bones, looking at scapula and humorus bones.

Nothing to do with feet but then I was on a course that related to sports massage so we were looking at the whole body.

I found it quite interesting to see the variety in shape and size of bones and the wear on some of the shoulder joints.

Once accustomed to handling bones we followed our workbooks and began to examine the prepared cadavers looking for different landmarks and revising our muscles. Jane’s enthusiasm was infectious and as the day progressed our confidence really grew.

As we were a mixed group of practitioners we had a wide variety of cadavers to examine, choosing between torsos, legs, arms and feet. Apart from being a podiatrist I am also a holistic therapist so looking at the muscles of the upper back were of special interest to me as well as the feet. We looked at the superficial and deep muscles of the chest and back, the origins and the insertions of the muscles of the arms and legs and examined the pelvis. I was amazed at how small the piriformis muscle can be considering it has the sciatic nerve running through it. It is absolutely no wonder people suffer from sciatica and it did make me wonder if the size of the muscle has anything to do with risk of sciatic related pain. Getting to look at the hamstring muscles of the leg and the Illeo-Tibia Band were fascinating. The cruciate ligaments of the knee are so small but so strong. Actually holding a knee joint and articulating it and looking at the muscles moving is incredible.

Obviously I was the one interested in feet and to actually start with a muscle such as Extensor Digitorum Longus and follow it up the foot under the Inferior Extensor Retinaculum to its origin three quarters the way up the anterior shaft of the fibula was fascinating. I am sure that should enough people be interested in one of these courses then it could be tailored to lower limb examination. I felt this day was so important, as in our profession although we don’t actually treat above the knee; patients often have biomechanical issues in the feet that cause noticeable problems further up the body. For example a tight muscle or an actual leg length discrepancy may cause an uneven pelvis, there may be other issues such as a lordosis, scoliosis or a dropped shoulder, all of which we check when carrying out a biomechanical assessment.

Each of the cadavers had been carefully prepared with muscle groups being dissected out so you could follow each individual muscle from its origin to insertion.

Many of us regularly deal with Achilles Tendonitis and some patients who have previously ruptured their Achilles tendon. I examined a cross section of an Achilles tendon that had been neatly severed. I have the greatest respect to surgeons who have to repair this tendon- it is as one surgeon once told me “like trying to sew two paintbrushes together”. Each minute fibre in the tendon was clearly visible.

To sum up; The day in the dissection lab is fascinating, surprisingly affordable and will well and truly opens your eyes to the human body. I have the greatest respect for both the people who spend their time preparing these specimens for examination and especially for the people who made the decision to donate their bodies to medical science. I feel indebted to them for making this decision which enables us to continue learning and helping others.

Thank you!

I would thoroughly recommend this day to anyone wishing to update his or her anatomy and physiology knowledge. It is certainly not for the feint hearted but if you feel passionately about private podiatry I would say go for it. It is absolutely fascinating “getting under the skin” For further information on this and other courses contact Jane Johnson at: ask@thelondonmassagecompany.com Or their website www.thelondonmassagecompany.co.uk

7

LECTURE

Continuing Professional Development 2011 TUTOR DATE AND VENUE

BIOMECHANICS 2 DAY SEMINAR Day 1 Introduction to biomechanics, Planes of motion, Basic functional anatomy, Basic terminology, MSK podiatry vs Biomechanics. The evolution of biomechanical theory. An overview of the dominant models in use today. The two tier assessment model. A pragmatic assessment method based on the tissue stress model. Casting and pre fabs.

An introduction to the use of Chairside / pre-fab orthoses and orthotic modification.

Day 2 Sub talar axial location and rotational equilibrium. A review of the pragmatic application of Sub talar axial location and rotational equilibrium for assessment and prescription Kinetic Chain theory. A review of the use of Orthoses for the treatment of proximal complaints (back pain, knee pain etc) Sagittal Plane biomechanics. A review of the pragmatic application of sagittal plane biomechanics, assessment techniques and prescription variables.

Casted orthoses. An introduction to foam box casting techniques, prescription writing and orthoses options.

FOOT MANIPULATION - 2 DAY SEMINAR THE ADJUSTMENT OF THE LOWER LIMB MOBILISATION AND MANIPULATION OF THE LOWER LIMB - The Foot to the Knee - 35 Hours CPD with 2 days handson practical training.

Graduate skills can be viewed at http://www.footandleg.co.uk

MEMBERS ͻ

Sunday Robert Isaacs

£250

th

11 September NON MEMBERS

and

ͻ

Sunday th

£300

18 September

Please email

In Central London

secretary@iocp.org .uk to provisionally book your place.

Numbers are strictly limited

Tom Brett

Sunday October 2

Maximum 15 students

nd

and Sunday

The total fee, including pre course study texts, personal portfolio and refreshments on both practical days

MEMBERS

October 16

This is a comprehensive course and the only course in the UK for podiatrists, which covers treatments for the knee.

th

ͻ£290 NON MEMBERS

Course includes: Pre-course study, Anatomy revision, Manipulation/Mobilisation terms, Demonstrations, Therapeutic principles, Treatment-examination and mobilisation, evaluation and management of foot and ankle disorders and case studies.

Day 1 Part one-Techniques learned on this day can be safely practised in your own surgery prior to embarking on the next level in day 2 Day 2 Includes more advanced concepts VERRUCAE TREATMENTS Includes Cryotherapy and cautery by Hyfrecation which encapsulates the two processes of dessication and fulguration. This course is designed for practitioners who wish to update and expand their knowledge of treatments for these troublesome lesions. This course includes a ͞,ĂŶĚƐ KŶ͟ ƉƌĂĐƚŝĐĂů ƐĞƐƐŝŽŶ and will advise on how to make the techniques affordable that they can be immediately used in private practices.

COST

at

ͻ£340

Peel Hospital, Tamworth

Please email secretary@iocp.org .uk for further information Numbers are strictly limited MEMBERS

Robert Sullivan

ͻ

Sunday th

October 9

£100

NON MEMBERS ͻ£120

at Sheffield

VASCULAR & NEUROLOGICAL ASSESSMENT VASCULAR ASSESSMENT Vascular assessment is a required part of the treatment regimen for any patient. However, with the rapidly increasing number of patients suffering from diabetes mellitus and an ageing population, a systematic approach to the subject is essential. The course will include lecture material and 'hands-on' using doppler and Ankle/brachial indexes. It is designed to be immediately applicable to your practice and to link with the Neurological assessment course.

NEUROLOGICAL ASSESSMENT This course of study has been designed to help you update your knowledge of neurological assessment of the lower limb for foot neuropathy using a neurothesiometer, neuropad, neuropen all for nerve response, testing reflexes etc commencing with theory followed by handson tuition

MEMBERS Bill Liggins

ͻ

Sunday November 6

And

th

£100

NON MEMBERS ͻ£120

at Sheffield

John Patterson

Continuing Professional Development BOOKING FORM Please send your booking, together with a cheque or completed Credit/Debit Card Form to:The Institute of Chiropodists and Podiatrists, 27 Wright Street, Southport, Merseyside PR8 0TL Telephone: 01704 546141 Fax: 01704 500477 Email: secretary@iocp.org.uk Website: www.iocp.org.uk PLEASE COMPLETE IN CAPITAL LETTERS Name:

......................................................................... Branch/Organisation:͙​͙​͙​͙​͙​͙​͙................... Tel No:

..........................................

Address:...................................................................................................................................................................

Seminar/Workshop

Date th

th

Biomechanics 2 day seminar

Sunday, 11 & 18 September 2011

Foot Manipulation 2 day seminar

Sunday, 2 & 16 October 2011

Verrucae Treatments

Sunday, 9 October 2011

Vascular & Neurological Assessment

Sunday, 6 November 2011

nd

th

Postcode: .................................

Venue

London Tamworth

th

Sheffield

th

Sheffield

Rates include VAT @ 20% VAT No: 712 5290 59 Payment 1. Credit Card - Credit card charge of 2% applies and Debit Card charge of 50p applies

Cost

TOTAL ==================

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Switch issue no: ...............

Named Cardholder: ...........................................................͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘ ĂƌĚŚŽůĚĞƌ͛Ɛ ^ŝŐŶĂƚƵƌĞ͗ ͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘ CarĚŚŽůĚĞƌ͛Ɛ ĚĚƌĞƐƐ͗ ͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘................ Postcode.....................................................

2. Cheque I enclose a cheque for £.............................. made payĂďůĞ ƚŽ ͞dŚĞ /ŶƐƚŝƚƵƚĞ ŽĨ ŚŝƌŽƉŽĚŝƐƚƐ ĂŶĚ WŽĚŝĂƚƌŝƐƚƐ͟ * Please note that full payment must be received before confirmation can be sent Please return your completed form with payment to: The Institute of Chiropodists & Podiatrists, 27 Wright Street, Southport, Merseyside, PR9 0TL In the event of insufficient numbers, the management reserve the right to cancel the course.

In this unlikely event fees will be refunded in full.

NORTH WEST AREA COUNCIL 14th ANNUAL SEMINAR at

The University of Central Lancashire, Preston on Sunday, 16th October, 2011 PROGRAMME 9:30 a.m.

Registration Tea, Coffee and Biscuits

10:00 a.m.

Lecture:

11:00 a.m.

11:30 a.m.

Tea, Coffee and Biscuits.

Lecture:

12:30 p.m.

2:00 p.m.

3:00 p.m.

Heart Failure, Wendy Borradale

Parkinson’s disease, another view, its impact on feet.

Dr. Emma Allison MBBs. Hons Lunch, Tea and Coffee and Trade Stands

Lecture:

Lower limb - vasculature, Michelle Weddell, Msc, Dip, Pod M Prize Draw and CPD. Certificate issue and close of seminar

If you plan to attend please send your details and a cheque made payable to: ‘IOCP North West Area Council’ for £65.00 (This includes all refreshments and cooked lunch) Send to: Mr. Bryan Massey, 104, Gillbent Road, Cheadle Hulme, Cheshire, SK8 6NG For more information please contact David Topping (Secretary) 01772 615769 !

!

Booking Form

NWAC 14th ANNUAL SEMINAR 2011 I enclose a cheque for £65 made payable to the IOCP North West Area Council Name:..........................................................................................................................................................

Address: ...................................................................................................................................................... ..............................................................................................

Post Code:................................................

Branch:........................................................................................................................................................

Tel No.: .......................................................................

Email: ................................................................

Please Return to Mr. B. Massey, 104 Gillbent Road, Cheadle Hulme, Cheshire, SK8 6NG

Dear editor Some years ago I wrote an article for the Review on the Weaver Fish which is the only venomous fish living on the coasts around our islands and I thought that, with summer coming, it might be worthwhile bringing it to readers attention again.

The Weaver fish is about 15cm long and lives in the warm shallow waters and pools on our coasts. It lies well hidden under the sand and has venomous spines along its dorsal fin which, when stood upon, inject venom into the foot.

This shows as small red puncture marks surrounded by a bluish ring. The resulting pain is excruciating - I speak from experience! Death is very rare but respiratory failure and gangrene have been reported.

There is no anti-venom available. Treatment is to immerse the foot in water as hot as can be tolerated for about 15 minutes. If this is not possible, hot flannels may be applied, being changed regularly. The heat deactivates the venom and the pain should begin to ease in approximately 30 to 60 minutes. Pain killers such as paracetamol will also help to relieve the pain as may antihistamines. However, walking can be painful and supportive padding and strapping may be used with the help of a stick.

The beach patrol may be able to advise on the danger from these fish in their area and it would be advisable to wear flip-flops or other suitable protective foot wear especially for children.

Beware, Get Your Contracts Sorted!

Members need to be aware that if they work with someone, be it on an employee or associate basis, that they need to have a contract drawn up and signed otherwise you could get yourself into bother. If you have someone working for you and they leave, there is nothing to stop them opening up near you or taking their clients with them unless you have a contract that they have signed to state that they can not. The Board of Ethics is presently working on an Associateship Contract that we hope to have available for download from the Institute Website shortly. I can not stress enough the importance of Contracts to protect both you and your patients

Fred Beaumont Press and Public Relations Officer

Do you want to write for our new Podiatry Review?

Articles - Branch News Human Interest Stories Product Information - Anecdotes All will be considered

Don’t forget!

Writing articles counts towards your CPD portfolio Please email where possible to bernie@iocp.org.uk or send to Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, MerseysidePR9 0TL Please note Podiatry Review copydate is the 1st of the preceding month prior to publication e.g. for the September/October issue copydate is 1st August

1

Chester, North Wales, Staffs and Shrops Branch Silicone Modelling in Practice Workshop Branch members got out of their beds an hour earlier and headed to their Chester meeting place to attend a workshop ‘Silicone Modelling in Practice’ presented by Michelle Weddell from Algeos. She gave a short history of Algeos informing members how the company started and how far the company has grown with offices all over the world. Michelle explained how to use silicone and to be able to adapt it to different foot complications. There are different silicone products and she explained when to use the various types available.

The silicone is available in the following formats: Soft Pipe which is a two part silicone. Each part is used in equal amounts and, mixed together, it sets completely in about 5 minutes. This is a soft material ideal for bunions shields, pressure points etc.

This can be filed with a burr or cut with a scalpel if required.

Sudapex is a two part silicone used for interdigital wedges, toe seperators, dorsal toe protectors and splints. This silicone hardens in five minutes. It comes to two strengths, soft or firm. Ottoform K2 is an impression silicone used for moulding interdigital wedges, seperators, toe protectors and splints. This is mixed together with a small amount of catalyst hardening paste. It remains pliable for about 1-5 minutes to allow the practitioner time to make the shape before setting. Members had the opportunity to throw their socks off and try moulding wedges, toe props, bunion shields using all the silicones.

schedule on a Sunday Morning to attend what turned out to be a very enjoyable training workshop. Members have gone away to their own practices with an additional skill which in turn will add value to their practices and increase income.

Denise Willis, Secretary, Chester, N. Wales, Staffs and Shrops Branch

Michelle was on hand to show us the best way to get the most out of this versatile product and helped members gain confidence in using it. The products were available to purchase on the day at a discount price. Michelle handed pens brochures and freebies to everyone who attended.

This workshop was well attended and was one training workshop that members had requested. Our thanks go out again to Michelle Weddell for taking the time out of her busy

Leicester and Northants Branch Seminar 27th November at Lutterworth Cricket Club Lectures: Lectures: Dementia, how to interact with patients Dementia practicewith patients l Dementia,- effects how toon interact Plantar Fasciitis - excerise and prevention l Dementia effectsto ongive practice Pharmacist- invited drug update.

Refreshments at 9:45 l Plantar Fasciitis - excerise and prevention Autoclave Service by prior arrangement Free Parkinginvited and lunch included l Pharmacist to give drug update.

Cost of the Day £45

l

Refreshments at 9:45

l

Autoclave Service by prior arrangement

l

Free Parking and lunch included

l

Cost of the Day £45

Telephone: David 01455 202224

Practices for Sale BARNSLEY AREA - DOMICILIARY BUSINESS FOR SALE/RENT DUE TO RE-LOCATION – Routine Chiropody Treatment, Friendly Patients, Turnover Approx £28,000 For 3.5 Days - Potential for further expansion.

For more information Telephone: 0786 6332 756

Recruitment

Chiropody Supplies

PODIATRIST/CHIROPODIST NOTTINGHAM Wanted for busy, Private practice in the south of Nottingham. A great opportunity to be part of a leading high street Podiatry practice, offering good rates of pay and a professional environment to help further personel development. Applicants must have minimum of four years experience and be enthusiastic, hard working and motivated. Hours and rates negotiable. Contact 0115 9820100 or Email cv to: info@feetandcohealth.co.uk VACANCY FOR PODIATRIST/CHIROPODIST in Brand New clinic in busy pharmacy Teddington Middlesex. Contact Mrs. Gandhi 07947 806095

www.PODWASTE.co.uk

Chiromart UK ‘WHY PAY MORE?’ Suppliers of Autoclaves and Chiropody Surgery Equipment. Single items to full surgery set ups. Quality used and new. Also your equipment wanted, surgery clearances, trade- ins and part exchange CASH WAITING.... www.chiromart.co.uk Tel: 01424 731432 (please quote ref: iocp)

Classified Advertisements 80p per word - minimum £8.00 Box Number & sending replies: £4.00 extra Classified Advertisements placed by Members: 45p per word minimum £4.50

Trade Classified Advertisements

Discounted rates Any size clinic/practice No long term contracts Full UK coverage Easy payments

(0800 988 7897

Info@podwaste.co.uk

AMBER CHIROPODY SUPPLIES Serving the chiropodist/podiatrist with all the essential daily consumable items for a busy practice, including:

Eighth page (minimum) £85.00 + VAT. The closing date for receipt of Classified Advertisements is the 1st day of the month preceding publication i.e. Jan-Feb issue - 1st Dec.

All Classified Advertisements must be prepaid and sent to:-

Bernie, Chiropody Review, THE ADVERTISING DEPARTMENT, CHIROPODY REVIEW 27 Wright Street, Southport, Merseyside. PR9 0TL. Tel: 08700 110 305 or 01704 546141 Fax 01704 500477 Email: adman@iocp.org.uk

* Instruments & Equipment * Padding & Appliances * Dressings & Adhesives * Biomechanics

* Domiciliary * Sterilization * Diagnostics * Retail Products

To view our website/online store please visit:

www.ambersupplies.co.uk

Diary of Events Western Branch Meeting

July 2011 West Middlesex Branch Meeting 11th July – The Harvester, Croxley Green, Rickmansworth,

4th September at 12:15 p.m. – Seminar Room 1, The Women’s Hospital Liverpool. Lecture: tbc Tel: 01745 331827

Tel: 0208 903 6544

Herts WD3 3RX.

Surrey and Berkshire Branch Meeting 2nd July at 1:30 p.m. – Greyfriars Centre, Reading.

Tel: 0208 660 2822

Sussex Branch Meeting

West of Scotland Branch Meeting and full CPD Day 11th September 9:30 a.m. – Presentation on the Paediatric Foot and Chemical Treatment of Verrucae Express by Holiday Inn, Springkerse Business Park, Stirling FK7 7XH. Tel: 01796 473705

2nd July – The Bent Arms, Lindfield, West Sussex.

Tel: 01273 890570

West Middlesex Branch Meeting 12th September – The Harvester, Croxley Green, Rickmansworth, Herts WD3 3RX. Tel: 0208 903 6544

September 2011 East Anglia Branch Meeting

October 2011

11th September – Haymarket Day Centre.

Tel: 01603 440828

Essex Branch Meeting 18th September – Education Centre, Southend University Hospital, Carlingford Drive Southend-on-Sea. Tel 01702 460890

2nd October at 10:00 a.m. – The Dene Hotel, Hoole Road, Chester CH2 3ND. Tel: 01244 321165

Devon and Cornwall Branch Meeting 9th October 10:00 a.m. – Exeter Court Hotel, Kenford, Exeter EX6 7UX. Tel: 01805 603297

Hants and Dorset Branch Meeting 14th September 7:45 p.m. – Crosfield Hall, Broadwater Road, Romsey, SO51 8GL. Talk: Tax and the small business - Elise Tel: 01202 425568

King HMRC.

Cheshire, North Wales Staffs and Shrops Branch Meeting

Institute of Chiropodists and Podiatrists Executive Meeting Head Office, 27 Wright Street, Southport, PR9 0TL. Tel: 01704 546141

Leicester and Northants Branch Meeting 4th September 10:00 a.m. – Kilsby Village Hall.

CPD Lecture on Padding and Strapping by Chris Leech TBC. Registration and refreshments at 9:45 a.m.

Tel: Sue 01530 469816

Leeds/Bradford Branch Meeting 6th October 10:00 a.m. – The Oakwell Motel, Low Lane, Birstall, Nr. Leeds WF17 9HD. Tel 01924 475338

Midland Area Council 23rd October 10:00 a.m.

Kilsby Village Hall, CV23 8XX.

Tel: 01386 47695

Sheffield Branch Meeting 23rd October – Time to be confirmed SWD Sports Club, Heley Bank Road, Sheffield S2 3GL. Tel: 01623 452711

Surrey and Berkshire Branch Meeting

London Branch Meeting 7th September 7:30 p.m. – Victory Services Club 63-79 Seymour Street, London W2 2HF. Tel: 0208 586 9542

North West Branch Meeting 27th September 7:30 p.m. – St. Joseph’s Community Centre, Harpers Lane, Chorley PR6 0HR. Tel: 0161 486 9234

Southern Area Council Meeting 10th September 1:00 p.m. – Victory Services Club 63-79 Seymour Street, London W2 2HF. Tel: 01992 589063

10th October 7:30 p.m. – Pirbright Village Hall.

Tel: 0208 660 2822

Wolverhampton Branch Meeting 9th October 10:00 a.m. – 4 Selman’s Parade, Selmans Hill, Bloxwich WS3 3RN. Tel: 0121 378 2888

November 2011 Birmingham Branch Meeting 17th November 8:00 p.m. – British Red Cross Centre, Evesham.

Tel: 01905 454116

Diary of Events Essex Branch Meeting

Essex Branch Meeting and A.G.M.

20th November – Education Centre, Southend University Hospital, Carlingford Drive Southend-on-Sea. Tel 01702 460890

29th January – Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea.

Hants and Dorset Branch Meeting

Hants and Dorset Branch A.G.M.

18th November 7:45 p.m. – Our usual ‘Social Occasion of the Year’ dinner out with friends/partners/colleagues. Venue to be arranged.

Tel: 01202 425568

9th January 2011, 7:45 p.m. coffee (meeting 8:00-10:00 p.m.) – Crosfield Hall, Broadwater Road, Romsey, SO51 8GL.

Tel: 01702 460890

Tel: 01202 425568

Leeds/Bradford Branch Meeting 6th November 10:00 a.m. – The Oakwell Motel, Low Lane, Birstall, Nr. Leeds WF17 9HD. Tel: 01924 475338

Leicester and Northants Branch Meeting plus A.G.M. 22nd January 10:00 a.m. – Lutterworth Cricket Club, LE17 4RB. Registration and refreshments at 9:45 a.m.

Tel: Sue 01530 469816

Leicester and Northants Branch Seminar Lutterworth Cricket Club LE17 4RB. Lectures: Dementia: “How to interact with patients” and “effects on practice”, Plantar Fasciitis, Pharmacist invited to give drug up-date - £45 including lunch and free parking, 10:00 a.m. start. Registration and refreshments at 9:45 a.m.

Autoclave calibration by prior arrangement (Max 12).

Tel: David 01455 550111

London Branch Meeting 16th November 7.30 p.m. – Victory Services Club, 63-79 Seymour Street, London W2 2HF. Tel: 0208 586 9542

Sussex Branch Meeting 20th November – The Bent Arms, Lindfield, West Sussex.

Tel: 01273 890570

West of Scotland Branch Meeting 6th November at 11:00 a.m. – Express by Holiday Inn, Springkerse Business Park, Stirling FK7 7XH. Tel: 01796 473705

London Branch A.G.M. 18th January 7:30 p.m. – Victory Services Club, 63-79 Seymour Street, London W2 2HF. Tel: 0208 586 9542

Midland Area Council A.G.M. 29th January 10:00 a.m. – Kilsby Village Hall, CV23 8XX. Tel: 01386 47695

North West Branch A.G.M. and Meeting 15th January 11:00 a.m. – St. Joseph’s Community Centre, Harpers Lane, Chorley PR6 0HR. Tel: 0161 486 9234

Southern Area Council A.G.M. 21st January 1:00 p.m. – Victory Services Club, 63-79 Seymour Street, London W2 2HF. Tel: 01992 589063

West Middlesex Branch Meeting 14th November – The Harvester, Croxley Green, Rickmansworth, Herts WD3 3RX. Tel: 0208 903 6544

Surrey and Berkshire Branch A.G.M. 14th January 1:30 p.m. – Greyfriars Centre, Reading.

December 2011

Tel: 0208 660 2822

Western Branch A.G.M.

Leeds/Bradford Branch Meeting 4th December 10:00 a.m. – The Oakwell Motel, Low Lane, Birstall, Nr. Leeds WF17 9HD. Tel 01924 475338

Tel: 01745 331827

Scottish Area A.G.M.

January 2012

22nd January 10:30 a.m. followed by West of Scotland Branch A.G.M. Express by Holiday Inn, Springkerse Business

Birmingham Branch A.G.M. 12th January 7:30 p.m. – British Red Cross Centre, Evesham.

Tel: 01905 454116

Park, Stirling FK7 7XH.

Tel: 01796 473705

Wolverhampton Branch A.G.M.

East Anglia Branch A.G.M. 29th January – Haymarket Day Centre.

8th January at 12:15 p.m. Meeting at 1:45 p.m.

Seminar Room 1, The Women’s Hospital Liverpool.

15th January 10:00 a.m. – 4 Selman’s Parade, Selmans Hill, Tel: 01603 440828

Bloxwich WS3 3RN.

Tel: 0121 378 2888

National Officers

Branch Secretaries

President Mrs. F. H. Bailey, M.Inst.Ch.P.

Birmingham

Mrs. J. Cowley

01905 454116

Cheshire North Wales

Mrs. D. Willis

0151 327 6113

Devon & Cornwall

Mrs. M. Reay

01805 603297

East Anglia

Mrs. Z. Sharman

01473 830217

Essex

Mrs. B. Wright

01702460890

Hants and Dorset

Mrs. J. Doble

01202 425568

Chairman Board of Education Mr. R Sullivan, M.Inst.Ch.P., B.Sc.(Hons), Dip. Pod. Med,

Leeds/Bradford

Mr. N. Hodge

01924 475338

PGDip, Cert.L.A, FSSCh, FIChPA, MRSM,

Leicester & Northants

Mrs. S. J. Foster

01234 851182

Vice-Chairman Board of Education Mr. M. Harvey, M.Inst.Ch.P., PGCE, B.Sc.

London

Mrs. F. Tenywa

0208 586 9542

North East

Mrs. E. Barwick

0191 490 1234

North of Scotland

Mrs. S. Gray

01382 532247

Standing Orders Committee Mr. M. Hogarth, M.Inst.Ch.P. Mrs. L. Pearson, M.Inst.Ch.P.

North West

Mr. B. Massey

0161 486 9234

Northern Ireland Central

Miss G. Sturgess

0289 336 2538

Secretary Miss A. J. Burnett-Hurst

Nottingham

Mrs. V. Dunsworth

0115 931 3492

Oxford

Mrs. S. Harper

01993 883397

Republic of Ireland

Mr. C. Kerans

00353 1285 3150

Sheffield

Mrs. D. Straw

01623 452711

South Wales & Monmouth

Mrs. J. Nute

02920 331 927

Surrey and Berkshire

Mrs. M. Macdonald

0208 660 2822

Sussex

Mrs. V. Probert-Broster

01273 890570

Teesside

Mr. J. Olivier

01287 639042

Western

Mrs. L. Pearson

01745 331827

West Middlesex

Mrs. H. Tyrrell

0208 903 6544

West of Scotland

Mr. S. Gourlay

0141 632 3283

Wolverhampton

Mr. D. Collett

0121 378 2888

Yorkshire Library

Mrs. J. Flatt

01909 774989

Chairman Executive Committee Mr. W. J. Liggins, F.Inst.Ch.P., F.Pod.A., B.Sc.(Hons) Vice-Chairman Executive Committee Mr. M. Holmes, M.Inst.Ch.P., D.Ch.M., B.Sc. Pod Chairman Board of Ethics Mrs. C. Johnston, M.Inst.Ch.P., B.Sc.(Hons)

Honorary Treasurer Mrs. J. Drane, M.Inst.Ch.P.

Area Council Executive Delegates Midland Area Council Mrs. V. Dunsworth, M.Inst.Ch.P., D.Ch.M. North West Area Council Mrs. M. Allison, M.Inst.Ch.P. Republic of Ireland Area Council Mrs. J. Casey, M.Inst.Ch.P., B.Sc. Scottish Area Council Mrs. A. Yorke, M.Inst.Ch.P. Southern Area Council Mr. D. Crew, OStJ, F.Inst.Ch.P., D.Ch.M., Cert.Ed. Yorkshire Area Council Mrs. J. Dillon, M.Inst.Ch.P.